Drug and alcohol offenders coerced into treatment: a review of modalities and suggestions for research on social model programs.

Outcome studies on drug and alcohol offenders coerced into treatment by the criminal justice system were reviewed. Positive outcomes were found for therapeutic community, methadone maintenance, and unspecified residential and outpatient programs. No outcome studies were found for court-mandated clients coerced into social model recovery programs. When developing studies, researchers should consider how clients perceive legal mandates and whether they are receiving pressures to enter treatment from other sources, such as family members, employers, friends or the welfare system. Use of the Social Model Philosophy Scale (SMPS) is suggested to correlate program characteristics and processes with outcome.     

Reflections on LSD – Ten Years Later

Abstract

An increasing number of individuals are being referred to alcohol treatment programs under coercion from the criminal justice system. While a substantial number of investigations have addressed coercive treatment for illicit drug-related offenses, fewer studies have focused on mandated treatment for alcohol-related problems. This article examines the treatment of two subgroups of clients coerced into alcohol treatment from criminal justice institutions. The article begins with an overview of the literature on clients coerced into treatment as a result of “driving under the influence” (DUI) charges. The characteristics of a subgroup that has received less attention are then described: lower socioeconomic clients who are coerced into alcohol treatment from the courts for non-DUI offenses, such as public inebriation, disorderly conduct, trespassing, assault, and theft. This subgroup of non-DUI coerced-treatment offenders depends primarily upon underfunded public services, although their treatment requires careful assessment and triage for multiple problem areas. The article addresses some potential political and economic roadblocks to comprehensive treatment and closes with questions and recommendations for further research.     

Consequences and costs of shutting off methadone

In the face of rising fiscal conservatism, many states and localities with sizable addict populations have reduced or eliminated public funding for methadone maintenance (MM) programs and permitted private-fee-for-service programs to replace them. The social and economic costs of these changed funding policies with reference to the California experience were analyzed. A two-and-a-half year follow-up of a sample of San Diego MM clients (195 men, 129 women) terminated from a public subsidized program compared outcome results to clients from publicly funded MM programs in Orange, Riverside and San Bernardino counties (129 men, 131 women). In a secondary analysis, San Diego clients who transferred into private (fee-for-service) treatment programs were compared with those who did not transfer. Major adverse consequences were found for clients unable or unwilling to transfer to private programs: higher crime and dealing rates, more contact with the criminal justice system, and higher rates of illicit drug use were demonstrated by nontransfer clients. Moreover, the savings resulting from a reduction of MM program costs were nearly offset by increased direct costs for incarceration, legal supervision, and other government-funded drug treatment. Indirect costs were not assessed.     

The relationship of legal coercion to readiness to change among adults with alcohol and other drug problems

Prior research on legally coerced treatment for substance abuse tends to find no difference between coerced and non-coerced clients with respect to treatment retention and treatment outcomes. There is less known about the relationship between coercion and a client's motivation to change. We considered the relationship of legal coercion and readiness to change among 295 consecutive admissions to five publicly funded outpatient treatment programs. A logistic regression analysis indicated that legal coercion was associated with greater readiness to change after controlling for addiction severity, prior treatment history, and gender. Persons entering treatment due to legal coercion were over three times more likely to have engaged in recovery-oriented behavior in the month preceding admission. Entering treatment more prepared to benefit from the experience could contribute to outcomes that are more positive.     

Criminal recidivism in three models of mandatory drug treatment

Although research has generally been supportive of compulsory treatment programs for drug abusers, findings remain mixed, and few studies have assessed the impacts of different coercive program elements. This study compared criminal recidivism outcomes of 350 clients mandated to the same long-term residential treatment facilities from three different legal sources. On several measures of recidivism, including long-term re-arrest rates that controlled for time at risk, clients mandated from two highly structured programs were found to recidivate at less than half the rate of comparison group clients. This group effect was upheld in multivariate models that controlled for pre-treatment differences and other factors related to recidivism. Combined with results of a previous retention study involving these clients, the findings provide support for the use of structured protocols for informing clients in mandatory programs about legal contingencies of participation and enforcing contingencies through frequent contact between legal agents and treatment staff.     

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.     

The value of acupuncture detoxification programs in a substance abuse treatment system

Our purpose is to compare baseline characteristics and detoxification readmission rates of clients treated at outpatient acupuncture programs and at short-term residential programs, two options available to persons seeking substance abuse detoxification. This was a retrospective cohort study using data on clients discharged from publicly funded detoxification programs in Boston between January 1993 and September 1994. Multivariate models were used to examine the effect on 6-month detoxification readmission rates of treatment at residential detoxification programs (used by 6,907 clients) versus at outpatient acupuncture programs (used by 1,104 clients) after adjusting for baseline differences. Acupuncture clients were less likely to be readmitted for detoxification within 6 months (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.53–0.95). Similar results were found when the analysis was performed on a subsample of clients that were relatively similar in terms of baseline characteristics (OR 0.61, 95% CI 0.39–0.94). We determined that acupuncture detoxification programs are a useful component of a substance abuse treatment system.     

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.     

Therapeutic communities: AIDS/HIV risk and harm reduction

The limited survey data available suggest that therapeutic communities have increasingly organized themselves to develop HIV prevention programs and to integrate HIV-infected and AIDS clients into the treatment community while providing specialized program as necessary. Nonetheless, there remains a need for a comprehensive survey of the response of therapeutic communities to AIDS and the risk of HIV infection. There is need as well for studies that can build on findings linking retention in the therapeutic community to strategies that focus on clients' motivation or readiness for treatment. In addition, therapeutic community programs can ally with outreach programs both to provide priority admission to seropositive clients, women with children, adolescents, and criminal justice clients, and to provide harm reduction services to those unwilling to enter treatment while also taking incremental steps to engage those clients in ever increasing behavior change initiatives.     

Modified therapeutic community for co-occurring disorders: a summary of four studies

This article summarizes results from four research studies (n = 902) that examined the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring disorders (most with severe mental disorders). Significantly better outcomes for MTC were found across four experimental versus control comparisons on 23.1% (12 of 52) of primary outcome measures of substance use, mental health, crime, HIV risk, employment, and housing. Study limitations included the potential for selection bias, limited measurement of program fidelity, and insufficient examination of the relationship between treatment dose and outcome. Future research should emphasize clinical trial replications, multiple outcome domains, and further development of continuing care models. Given the need for research-based approaches, the MTC warrants consideration when program and policy planners are designing programs for co-occurring disorders.     

Relationship between time spent in treatment and client outcomes from therapeutic communities

Research found that therapeutic communities and other types of residential programs are effective in reducing drug use, unemployment, and criminal behavior and that length of time spent in treatment is an important predictor of client outcomes from programs. Studies vary considerably, however, in terms of the amount of time they found clients need to stay in treatment to produce those outcomes. Data collected for the Treatment Outcome Prospective Study (TOPS) were analyzed to explore the relationship between time spent in treatment and client outcomes from therapeutic communities and other types of residential drug treatment programs. The analysis took into account client characteristics and whether clients received drug treatment during the follow-up year. The results indicate there is a stronger relationship between time spent in treatment and client outcomes from therapeutic communities than was suggested in earlier analysis of TOPS data.     

Outcomes for clients of public substance abuse treatment programs before and after Medicaid managed care

Following conversion of Medicaid substance abuse treatment programs in Oregon from fee-for-service to managed care, there were suggestions of poorer outcomes. This project interviewed cohorts of Medicaid and non-Medicaid substance abuse treatment clients before and after the 1995 implementation of Oregon's Medicaid capitated payment system. Subjects were 553 adults (59% male, average age 35, 64% white). Forty-three percent were Medicaid clients and 60% were treated during the fee-for-service era. All clients were interviewed with the Addiction Severity Index at baseline and at 6 and 12 months thereafter. Multilevel, multivariate analyses examined baseline and outcome differences between the Medicaid and Non-Medicaid groups; between the fee-for-service and managed care conditions; and their interactions. After adjustment for covariates, most analyses were not statistically significant. It does not appear that Medicaid managed care had an adverse impact on outcomes for clients with substance abuse problems.     

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.     

The impact of motivational interviewing on substance abuse treatment retention: a randomized control trial of women involved with child welfare

Previous studies have supported the efficacy of Motivational Interviewing (MI) in increasing treatment engagement and retention among people with substance abuse disorders. However, few studies have assessed the impact of MI with coerced populations, particularly women referred to drug abuse treatment by child welfare due to prenatal drug use. Seventy-one such women who used drugs during pregnancy were randomly assigned to either receive three MI sessions or to watch two educational videos and participate in a home visit. Treatment retention group attendance and random urine analysis results were evaluated in these women during the first 8 weeks of treatment. No differences were found between the two conditions on these variables. Possible reasons for these negative findings are discussed, as are ideas for future research with coerced populations.     

Family and client characteristics as predictors of outpatient treatment outcome for adolescent drug abusers

Adolescent drug abuse clients (N = 176) and their mothers, in six different outpatient drug-free programs, were assessed at admission and at follow-up, 15 months after initiation of treatment. Family therapy sessions were offered in all six programs in addition to individual and group counseling. The pretreatment assessment procedures, and thus also the variables analyzed for prediction of treatment outcome, emphasized family measures (including the Family Environment Scale, the Family Adaptability and Cohesion Scale, the Parent-Adolescent Communication Inventory, and other information about the family and the parents).Multiple regression analysis determined which of three demographic variables and 39 other independent pretreatment predictor variables had a significant relationship with each of the six outcome criteria (dependent variables). Four of these outcome criteria were based on client information, and two were based on information provided by the mother.The more positively the family's functioning and relationships were described by the client at pretreatment, the more client improvement was reported by either client or mother at follow-up. Eleven of the 12 predictor variables that were found to be significantly related to any of the treatment outcome criteria were measures, at pretreatment, either of the client's perceptions of family functioning, or of his or her relationship with parents, particularly with the mother. These findings show the power of the family factors as indicators of prognosis.The predictor variable that was found to have the largest number of significant relationships, predicting three of the six outcome criteria, was the “family independence” dimension of the FES (i.e., “The extent to which family members are encouraged to be assertive, self-sufficient”). It appears that the FES instrument may be quite effective for predicting improvement in the behavior of adolescent drug-abusing clients.     

A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders

Substance use disorder is the most common and clinically significant co-morbidity among clients with severe mental illnesses, associated with poor treatment response, homelessness and other adverse outcomes. Residential programs for clients with dual disorders integrate mental health treatment, substance abuse interventions, housing and other supports. Ten controlled studies suggest that greater levels of integration of substance abuse and mental health services are more effective than less integration. Because the research is limited by methodological problems, further research is needed to establish the effectiveness of residential programs, to characterize important program elements, to establish methods to improve engagement into and retention in residential programs and to clarify which clients benefit from this type of service. [Brunette MF, Mueser KT, Drake RE. A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders. Drug Alcohol Rev 2004;23:471-481]     

Comparative Treatment Effectiveness: Effects of Program Modality and Client Drug Dependence History on Drug Use Reduction

This study examined treatment outcome as a function of program modality, clients’ lifetime patterns of drug dependence, and their interaction, controlling for current level of drug use at treatment intake. Data were based on 2,966 clients who were interviewed at intake and at 1-year follow-up as part of the Drug Abuse Treatment Outcome Study (DATOS), which included programs of four major modalities. Subjects’ lifetime patterns of drug dependence were classified into nine groups according to Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association; 1987) diagnostic criteria and time of onset of drug use career. Outcome measure was the reduction of heroin use or cocaine use at follow-up from levels at intake. The results showed that rates of lifetime drug dependence and current drug use at DATOS admission were highest among methadone maintenance clients and lowest among outpatient drug-free clients. Drug use reduction was observed for all modalities. The presence of dependence diagnosis was associated with less improvement when current use level at intake was controlled. Clients dependent on heroin but not currently daily users benefited most from inpatient and residential programs. Methadone programs were also relatively ineffective in reducing cocaine use. Characteristics of the client’s drug dependence history, in addition to the current or presenting drug problem, should be assessed to guide treatment planning. The high rate of cocaine dependence among methadone clients, most of whom were dependent on heroin, poses considerable challenge to contemporary opiate substitution treatments. Published by Elsevier Science Inc.     

A case for addressing cigarette use in methadone and other opioid treatment programs

Most persons attending drug treatment smoke cigarettes. They will eventually experience predictable, but devastatingly high, tobacco-related mortality. Recent studies indicate that many clients are ready to quit smoking and that quitting does not threaten progress made in treatment. Methadone and other opioid treatment providers are in an excellent position to address tobacco use among their clients. The present paper describes the prevalence of smoking among methadone clients, reviews promising interventions, and describes how programs can implement a systematic approach to smoking cessation that includes creating a cue system for identifying smokers, providing brief on-site intervention, and arranging follow-up or more intensive treatment.     

Modified Therapeutic Community for Co-Occurring Disorders: Single Investigator Meta Analysis

ABSTRACT

This paper presents the results of a meta-analysis for a single investigator examining the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring substance use and mental disorders (COD). The flexibility and utility of meta-analytic tools are described, although their application in this context is atypical. The analysis includes 4 comparisons from 3 studies (retrieved N = 569) for various groups of clients with COD (homeless persons, offenders, and outpatients) in substance abuse treatment, comparing clients assigned either to an MTC or a control condition of standard services. An additional study is included in a series of sensitivity tests. The overall findings increase the research base of support for the MTC program for clients with COD, as results of the meta-analysis indicate significant MTC treatment effects for 5 of the 6 outcome domains across the 4 comparisons. Limitations of the approach are discussed. Independent replications, clinical trials, multiple outcome domains, and additional meta-analyses should be emphasized in future research. Given the need for research-based approaches, program and policy planners should consider the MTC when designing programs for co-occurring disorders.