Evidence-Based Treatment for Opiate-Dependent Clients: Availability,Variation, and Organizational Correlates

The majority of opiate-dependent clients entering substance abuse treatment are referred to “drug-free” (non-methadone) modalities. Given the known challenges of treating these clients in drug-free settings relative to the documented effectiveness of methadone maintenance, these analyses investigate the availability of various clinical and wraparound services for this population among a US sample of addiction treatment programs with and without methadone maintenance services (N = 763). Face-to-face interviews conducted in 2002–2003 gathered data on the number of opiate-dependent clients treated; organizational characteristics, including size, ownership, accreditation, and staffing; treatment practices, including methadone availability, use of other pharmacotherapies, and levels of care; and services offered, including vouchers, transportation, and other wraparound services. Facilities treating proportionately more opiate-dependent clients were significantly more likely to offer a variety of evidence-based services, regardless of methadone availability. Implications for referral linkages and quality of care are discussed.     

Evidence-based treatment for opiate-dependent clients: availability, variation, and organizational correlates

The majority of opiate-dependent clients entering substance abuse treatment are referred to "drug-free" (non-methadone) modalities. Given the known challenges of treating these clients in drug-free settings relative to the documented effectiveness of methadone maintenance, these analyses investigate the availability of various clinical and wraparound services for this population among a US sample of addiction treatment programs with and without methadone maintenance services (N = 763). Face-to-face interviews conducted in 2002-2003 gathered data on the number of opiate-dependent clients treated; organizational characteristics, including size, ownership, accreditation, and staffing; treatment practices, including methadone availability, use of other pharmacotherapies, and levels of care; and services offered, including vouchers, transportation, and other wraparound services. Facilities treating proportionately more opiate-dependent clients were significantly more likely to offer a variety of evidence-based services, regardless of methadone availability. Implications for referral linkages and quality of care are discussed.     

Cost-effectiveness of prize-based contingency management in methadone maintenance treatment programs

AIM: To determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is cost-effective. DESIGN: A cost-effectiveness study of a multi-site clinical trial. Data on the outcome measures came from the original effectiveness trial. Cost data were gathered by clinic survey specifically for this cost-effectiveness analysis. SETTING: Six methadone maintenance community clinics participating in the National Drug Abuse Treatment Clinical Trials Network. PARTICIPANTS: Participants were recruited from six methadone maintenance community treatment programs. The study sample consisted of 388 participants: 190 in the UC condition and 198 in the CM condition. Participants were randomized at each site to either the UC or the CM condition based on the presence of stimulants (cocaine, amphetamine or methamphetamine) and opioids in their baseline urine sample. INTERVENTION: Prize-based contingency management added to usual care. MEASUREMENTS: Longest duration of abstinence (LDA), number of stimulant-negative urine samples and costs of treatment. FINDINGS: Compared to usual care, the incremental cost of using prize-based CM to lengthen the LDA by 1 week was $141 [95% confidence interval (CI), $105-$193]. The incremental cost to obtain an additional stimulant-negative urine sample was $70 (95% CI, $53-$117). CONCLUSIONS: By comparing this study to a companion study, we found that adding prize-based CM to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics.     

What do we get for our money? Cost‐effectiveness of adding contingency management

AIMS: To assess the relative cost-effectiveness of lower versus higher cost prize-based contingency management (CM) treatments for cocaine abuse. DESIGN: Cost-effectiveness analyses based on resource utilization, unit costs and outcomes from a previous CM efficacy trial. SETTING: Two community-based treatment centers. PARTICIPANTS: Patients (n = 120) enrolled in out-patient treatment for cocaine abuse. INTERVENTION: Random assignment to one of three 12-week treatment conditions: standard treatment (STD) alone or two variants of STD combined with prize based CM. In CM, drawing for prizes was available to those submitting drug-free urine samples and completing goal-related activities. There were two levels of pay-out (referred to as $80 versus $240) based on the potential value of prizes won. MEASUREMENTS: Costs per participant associated with counseling utilization, urine and breathalyzer testing, and operation of the prize-drawing procedure were derived from a survey conducted at 16 clinics that had participated in CM studies. The three measures of effectiveness were: (1) longest duration of consecutive abstinence; (2) percentage completing treatment; and (3) percentage of samples drug-free. FINDINGS: The higher magnitude CM produced outcomes at a lower per unit cost than did the lower magnitude prize CM treatment. This was the case for all three outcome measures examined and held across various assumptions in the sensitivity analysis. CONCLUSIONS: Cost-effectiveness analyses can inform policy decisions regarding selection of one treatment model over another. Decisions on adoption of new evidence-based treatments would be aided by more information on society's willingness to pay for incremental gains in effectiveness.     

A Survey of Case Mangagement Practices in Addiction Programs

Although case management is a term increasingly used to define the support provided to persons who have substance abuse problems, little is known about the nature and extent of its . implementation within addictions treatment. This paper presents the results of a survey of addiction treatment programs in Ontario regarding their perceptions of the availability and nature of case management provided by their programs. Services frequently provided as part of case management by different types of addictions programs included addictions education and counselling, counselling for non-addictions problems, detox and relapse support, crisis intervention, and discussing clients with other staff at the same program. Less frequently provided types of case management included seeing clients in other locations, family/ marital counselling, practical help, employment and financial counselling, and liaison/advocacy with other services on the client's behalf. Similarities in case management services were more apparent than were differences among the addictions programs surveyed.     

Similarity of Clients and Treatment Outcome in Outpatient Drug-Free Programs

Client peer groups in drug abuse treatment programs can be expected to impact on the treatment of drug abusers. This ex post facto study explored whether similarity in demographic characteristics and drug use history within client peer groups influences treatment outcome. Subjects were 455 clients in outpatient drug-free treatment. Four aspects of similarity were assessed-age, drug use history, race/ethnicity, and sex. Follow-up data on levels of criminality, nonopiate drug use, and opiate drug use during the first year posttreatment were analyzed using multiple regression analysis. Client similarity was found to influence treatment outcome. While the findings do not warrant substantial changes in the delivery of drug abuse treatment, they suggest that peer relationships and the influence of similarity among clients should be considered in the formulation of treatment plans for individual clients.     

American indians with substance use disorders: treatment needs and comorbid conditions

Background: American Indians and Alaska Natives (AI/ANs) experience significant disparities in health status and access to care. Furthermore, only limited data are available on substance use, mental health disorders, and treatment needs for this population. Addressing such disparities and developing culturally relevant, effective interventions for AI/AN communities require participatory research. Objectives and Methods: The Western States Node of the National Institute on Drug Abuse Clinical Trials Network partnered with two American Indian substance abuse treatment programs: an urban health center and a reservation-based program to assess client characteristics, drug use patterns, and treatment needs. Data collected by staff members at the respective programs from urban (n = 74) and reservation (n = 121) clients were compared. Additional sub-analysis examined patients reporting regular opioid use and mood disorders. Results: Findings indicate that urban clients were more likely to report employment problems, polysubstance use, and a history of abuse. Reservation-based clients reported having more severe medical problems and a greater prevalence of psychiatric problems. Clients who were regular opioid users were more likely to report having a chronic medical condition, suicidal thoughts, suicide attempts, polysubstance abuse, and IV drug use. Clients who reported a history of depression had twice as many lifetime hospitalizations and more than five times as many days with medical problems. Conclusions: Findings from this project provide information about the patterns of substance abuse and the importance of comprehensive assessments of trauma and comorbid conditions. Results point to the need for integrative coordinated care and auxiliary services for AI/AN clients seeking treatment for substance use disorders.     

Which substance abuse treatment facilities offer dual diagnosis programs?

This report examines the distribution of specialized programs or groups for dual diagnosis clients in substance abuse treatment facilities across the United States and the availability of services often needed by this client population at these facilities. Data from the National Survey of Substance Abuse Treatment Services (N-SSATS) were used to assess the geographic distribution and the characteristics of facilities that offer dual diagnosis treatment programs/groups and to examine the other clinical, social, and health services available in these facilities. Overall, 49.9% of all U.S. substance abuse treatment facilities offered dual diagnosis programs/groups. There were no clear regional variations on availability of these services. There were, however, clear variations based on facility ownership and treatment modality. Facilities owned by the federal, state, and local governments, and those offering inpatient treatment were more likely than were other facilities to offer dual diagnosis programs/groups. A large proportion of facilities with specialized dual diagnosis programs/ groups did not offer mental, social, or health services often needed by dual diagnosis clients. It is concluded that specialized programs for dual diagnosis clients are offered in many different substance abuse treatment facilities, attesting to the growing recognition of the special needs of this group of clients. However, dissemination of comprehensive services often needed to meet the special needs of these clients has not kept pace with the spread of specialized programs, highlighting the need for establishing and implementing standard evidence-based guidelines for dual diagnosis treatment programs in these settings.     

Client and provider perspectives of the efficiency and quality of care in the context of rapid scale-up of antiretroviral therapy

Global scale-up of antiretroviral therapy (ART) has focused on clinical outcomes with little attention on its impact on existing health systems. In June-August 2008, we conducted a formative evaluation on ART scale-up and clinic operations at three clinics in Uganda to generate lessons for informing policy and larger public health care systems. Site visits and semistructured interviews with 10 ART clients and 6 providers at each clinic were used to examine efficiency of clinic operations (patient flow, staff allocation to appropriate duties, scheduling of clinic visits, record management) and quality of care (attending to both client and provider needs, and providing support for treatment adherence and retention). Clients reported long waiting times but otherwise general satisfaction with the quality of care. Providers reported good patient adherence and retention, and support mechanisms for clients. Like clients, providers mentioned long waiting times and high workload as major challenges to clinic expansion. Providers called for more human resources and stress-release mechanisms to prevent staff burnout. Both providers and clients perceive these clinics to be delivering good quality care, despite the recognition of congested clinics and long waiting times. These findings highlight the need to address clinic efficiency as well as support for providers in the context of rapid scale-up.     

Formative evaluation of antiretroviral therapy scale-up efficiency in sub-Saharan Africa

With millions in need of HIV antiretroviral therapy (ART) in the developing world, and scarce human and fiscal resources available, we conducted a formative evaluation of scale-up operations at clinics associated with AIDS Healthcare Foundation in Africa to identify lessons learned for improving scale-up efficiency. Site visits were made to six selected clinics in Uganda, Zambia, and South Africa, during which semistructured interviews with key stake-holders and observation of client flows and clinic operations were performed. This evaluation revealed the following lessons related to factors that are critical to efficient ART scale-up: (1) to ensure steady ART uptake, it is important to involve the community and community leaders in outreach, HIV education, and program decision-making; (2) minimizing bottlenecks to smooth patient flow requires efficient staff allocation to appropriate clinical duties, streamlined clinic visit schedule protocols, and tapping clients and the HIV community as a key source of labor; (3) to minimize clients dropping out of care, structures should be developed that enable clients to provide support and a "safety net" for helping each other remain in care; (4) computerized record management systems are essential for accurate antiretroviral inventory and dispensing records, quality assurance monitoring, and client enrollment records and visit scheduling; (5) effective organizational management and human resource policies are essential to maintain high job performance and satisfaction and limit burnout; (6) to maximize impact on social and economic health, it is important for ART programs to develop effective mechanisms for coordinating and referring clients to support service organizations.     

American Indians with Substance Use Disorders: Treatment Needs and Comorbid Conditions

Background: American Indians and Alaska Natives (AI/ANs) experience significant disparities in health status and access to care. Furthermore, only limited data are available on substance use, mental health disorders, and treatment needs for this population. Addressing such disparities and developing culturally relevant, effective interventions for AI/AN communities require participatory research. Objectives and Methods: The Western States Node of the National Institute on Drug Abuse Clinical Trials Network partnered with two American Indian substance abuse treatment programs: an urban health center and a reservation-based program to assess client characteristics, drug use patterns, and treatment needs. Data collected by staff members at the respective programs from urban (n = 74) and reservation (n = 121) clients were compared. Additional sub-analysis examined patients reporting regular opioid use and mood disorders. Results: Findings indicate that urban clients were more likely to report employment problems, polysubstance use, and a history of abuse. Reservation-based clients reported having more severe medical problems and a greater prevalence of psychiatric problems. Clients who were regular opioid users were more likely to report having a chronic medical condition, suicidal thoughts, suicide attempts, polysubstance abuse, and IV drug use. Clients who reported a history of depression had twice as many lifetime hospitalizations and more than five times as many days with medical problems. Conclusions: Findings from this project provide information about the patterns of substance abuse and the importance of comprehensive assessments of trauma and comorbid conditions. Results point to the need for integrative coordinated care and auxiliary services for AI/AN clients seeking treatment for substance use disorders.     

Case Management and Supported Housing in Chicago

The described program provides extended interventions for Chicago adults who abuse alcohol or drugs and also have homeless experience. This program responds to evidence that (I) members of the relevant population cannot easily access either long-term substance abuse treatment or programs that serve other individuals who are homeless. (2) individuals who are both homeless and have substance abuse problems tend to be poorly matched to the programs to which they have access, and (3) a cycle of substance abuse and homelessness occurs as the lack of stable material, residential, and social support inhibits the commitment to recovery. There are two sets of interventions: a case management plus supported housing option that provides individuals with apartments for up to eight months while providing many other types of support, and a case management only option that provides help in locating residences along with the supports. Bothise a "progressive independence" approach which begins by ameliorating immediate tangible needs and builds toward a collaborative relatioship that focuses on other issues. Preliminary information suggests that the programs can be implemented in ways that deal with core client concerns and retain clients in treatment longer than is typical.     

“Hello,May We Help You?” A Study of Attrition Prevention at the Time of the First Phone Contact with Substance-Abusing Clients

The problem of early attrition from treatment is pervasive throughout community mental health and is particularly high for substance-abusing clients. In spite of the severity of this problem and the potential for successful interventions, there have not been many studies that attempt to reduce the dropout rate of drug abusers. The purpose of this research was to test the effectiveness of attrition prevention procedures at the time of the client's first phone contact with the clinic. Callers were either given an appointment or told to come to the clinic the same day. A second variable was the presence or absence of an experimenter-initiated dialogue designed to help subjects predict possible obstacles to attendance and to generate potential solutions to those barriers. Subjects in the same day conditions showed at a higher rate than those given appointments, but the addition of the dialogue had no effect on client behavior. The results are discussed in terms of how mental health professionals can find cost effective interventions that prevent drug abuse treatment dropout.     

"Hello, may we help you?" A study of attrition prevention at the time of the first phone contact with substance-abusing clients

The problem of early attrition from treatment is pervasive throughout community mental health and is particularly high for substance-abusing clients. In spite of the severity of this problem and the potential for successful interventions, there have not been many studies that attempt to reduce the dropout rate of drug abusers. The purpose of this research was to test the effectiveness of attrition prevention procedures at the time of the client's first phone contact with the clinic. Callers were either given an appointment or told to come to the clinic the same day. A second variable was the presence or absence of an experimenter-initiated dialogue designed to help subjects predict possible obstacles to attendance and to generate potential solutions to those barriers. Subjects in the same day conditions showed at a higher rate than those given appointments, but the addition of the dialogue had no effect on client behavior. The results are discussed in terms of how mental health professionals can find cost effective interventions that prevent drug abuse treatment dropout.     

Setting and counselor type as related to program retention

Study was made of the relationship between successful treatment outcome and staff:client ratios in two types of treatment settings. Successful treatment was defined as retention in treatment for at least 6 months and program completion. Using a total sample of 5,405 discharged clients, it was found that there were no differences in outcome between community mental health centers and dedicated drug abuse treatment programs for clients whose primary drug of abuse was either an opiate or a nonopiate exclusive of marijuana. Community mental health centers were significantly more likely to retain minority group marijuana clients 6 months or more to treatment completion while dedicated drug abuse programs were significantly more likely to retain White marijuana clients 6 months or more to treatment completion. No differences in outcome were found for any of the three client groups in relation to program emphasis on advanced-degreed professionals as compared to paraprofessionals.     

HIV risk reduction in outpatient drug abuse treatment: individual and geographic differences.

In the national Drug Abuse Treatment Outcome Studies (DATOS), many clients in outpatient methadone treatment (OMT) and outpatient drug-free (ODF) modalities were admitted with multiple sex and needle-risk behaviors, but they reduced these risks significantly during treatment. Using hierarchical linear model regression analysis, we examined client and treatment program characteristics as predictors of initial risk levels and of reductions over time. Clients who used cocaine frequently before treatment or had antisocial personality disorder entered treatment with elevated risks. In both modalities, cocaine users reduced risky behaviors significantly, but antisocial clients did so only in OMT. Treatment programs located in cities with higher prevalence rates of HIV/AIDS admitted clients with lower baseline levels of risk behavior than found in other cities. OMT programs in lower prevalence cities achieved higher rates of risk reduction than programs in higher prevalence cities. Reduction of sex and needle risks in both the OMT and ODF modalities indicates the importance of outpatient drug abuse treatment to national HIV prevention policy.     

The relationship of drug program environmental variables to treatment outcome

The Moos Community Oriented Program Environment Scale (COPES) was administered to 244 adolescent clients and 131 drug counselors in 30 "drug-free" outpatient drug treatment programs. Four of the COPES factor scores were found to predict significantly to treatment outcome (as measured by reduction in drug use): client ratings of "Spontaneity", and staff ratings of "Personal Problem Orientation", "Practical Problem Orientation", and "Order and Organization". The more positive the ratings of the program environments, the greater the reduction in client-reported drug use from admission to discharge. The "discrepancies" (differences) between staff and client perceptions of the programs on two of the COPES factors ("Autonomy" and "Staff Control") were also found to predict significantly to treatment outcome (as measured by reduction in drug use). The greater the discrepancy, the less successful was the treatment outcome. In the programs in which the clients tended to perceive the staff as less encouraging of client autonomy and as exercising more control over the clients relative to the staff's perceptions of these relationships, the clients tended to have less successful treatment outcomes. One possible interpretation of this finding might be that in the programs which have client populations that are more poorly motivated and more resistant to treatment, the clients will not only tend to have poorer treatment outcomes but will also perceive the program environment more negatively and thus will tend to disagree more with the staff's perceptions of the program.     

Effects of readiness for drug abuse treatment on client retention and assessment of process

Aims. This study examined client motivation as a predictor of retention and therapeutic engagement across the major types of treatment settings represented in the third national drug abuse treatment outcome study (DATOS) conducted in the United States. Design. Sequential admissions during 1991-93 to 37 programs provided representative samples of community-based treatment populations. Based on this naturalistic non-experimental evaluation design, hierarchical linear model (HLM) analysis for nested data was used to control for systematic variations in retention rates and client attributes among programs within modalities. Setting. The data were collected from long-term residential (LTR), outpatient methadone (OMT) and outpatient drug-free (ODF) programs located in 11 large cities. Participants. A total of 2265 clients in 18 LTR, 981 clients in 13 OMT and 1791 clients in 16 ODF programs were studied. Measurements. Pre-treatment variables included problem recognition and treatment readiness (two stages of motivation), socio-demographic indicators, drug use history and dependence, criminality, co-morbid psychiatric diagnosis and previous treatment. Retention and engagement (based on ratings of client and counselor relationships) served as outcome criteria. Findings. Pre-treatment motivation was related to retention in all three modalities, and the treatment readiness scale was the strongest predictor in LTR and OMT. Higher treatment readiness also was significantly related to early therapeutic engagement in each modality. Conclusions. Indicators of intrinsic motivation-especially readiness for treatment-were not only significant predictors of engagement and retention, but were more important than socio-demographic, drug use and other background variables. Improved assessments and planning of interventions that focus on stages of readiness for change and recovery should help improve treatment systems.     

A mobile HIV education and testing program: bringing services to hard-to-reach populations

Few programs exist that offer a range of human immunodeficiency virus (HIV) services to multiple populations (i.e., substance abusers, individuals on probation, sex workers and their clients, court-mandated perpetrators of domestic violence) in multiple settings (i.e., courts, methadone maintenance clinics, residential and outpatient substance abuse treatment programs). The purpose of this article is to describe a model mobile HIV program, highlighting its flexibility in providing services to clients who infrequently present to traditional clinic-based testing sites. This mobile HIV program was developed to provide on-site HIV testing and counseling, education, and linkages to primary care services. The implementation of the program begins with training of agency staff, who then provide preliminary orientation with clients regarding HIV testing. Approximately 3 weeks later, the mobile program staff (HIV nurse specialist and HIV counselors) provide standardized group pretest counseling and education. Clients who decide to be tested meet with mobile program staff for individualized risk assessment and specimen collection. Two weeks later, clients meet with mobile program staff to obtain results and receive posttest counseling; risk reduction strategies are reemphasized at that time. Unique to this program is the provision of referrals for a wide range of primary care services for both seropositive and seronegative clients. Since 1994, the mobile program has been implemented at six sites, and over 1100 clients have been served. Two major outcomes from the program have been observed: 1. With adequate preparation and psychological support, 40% of hard-to-reach populations will elect to be HIV tested. 2. Through social networks of program participants, HIV-positive individuals not previously engaged in care have been referred to a comprehensive HIV primary care program.     

The Relationship of Drug Program Environmental Variables to Treatment Outcome

The Moos Community Oriented Program Environment Scale (COPES) was administered to 244 adolescent clients and 131 drug counselors in 30 “drug-free” outpatient drug treatment programs. Four of the COPES factor scores were found to predict significantly to treatment outcome (as measured by reduction in drug use): client ratings of “Spontaneiety,” and staff ratings of “Personal Problem Orientation,” “Practical Problem Orientation,” and “Order and Organization.” The more positive the ratings of the program environments, the greater the reduction in client-reported drug use from admission to discharge. The “discrepancies” (differences) between staff and client perceptions of the programs on two of the COPES factors (“Autonomy” and “Staff Control”) were also found to predict significantly to treatment outcome (as measured by reduction in drug use). The greater the discrepancy, the less successful was the treatment outcome. In the programs in which the clients tended to perceive the staff as less encouraging of client autonomy and as exercising more control over the clients relative to the staffs perceptions of these relationships, the clients tended to have less successful treatment outcomes. One possible interpretation of this finding might be that in the programs which have client populations that are more poorly motivated and more resistant to treatment, the clients will not only tend to have poorer treatment outcomes but will also perceive the program environment more negatively and thus will tend to disagree more with the staff's perceptions of the program.