Drinking Goals and Their Association With Treatment Retention and Treatment Outcomes Among Clients in Outpatient Alcohol Treatment

Background: Few studies have compared characteristics of clients entering alcohol treatment who differ in their drinking goal preferences or have investigated the relevance of drinking goals as a predictor of treatment outcomes. Objectives: To investigate associations between baseline drinking goal preferences and client characteristics as well as treatment retention and outcomes among clients in outpatient alcohol treatment. Methods: Secondary data analyses on a longitudinal multicenter study investigating the effectiveness of outpatient alcohol treatment in Switzerland among 805 clients. Assessments were conducted at treatment admission, discharge, and at 6- and 12-month follow ups. At-risk drinking was assessed through the alcohol use disorders identification test. Treatment retention was defined as regular discharge with or without transition into another institution. Results: Clients aiming to abstain from drinking were more likely to be in retreatment, to be assigned to treatment by a health institution, to have no at-risk alcohol use, and to be already alcohol abstinent at the time of admission relative to clients who aimed to control their drinking. Clients without at-risk alcohol use at admission showed higher treatment retention when aiming for controlled drinking than for abstinence, while there was no difference in treatment retention among clients with at-risk use. Clients with at-risk use at admission were more likely to reach not-at-risk alcohol use status when aiming for alcohol abstinence than for controlled drinking. Conclusions: Drinking goals are associated with variables of alcohol use and treatment assignment. They have different effects on treatment retention and treatment outcomes according to alcohol use at the time of admission.     

Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach

Introduction and Aims. Staff interactions with their clients are an important factor in the quality of care that is provided to people in drug treatment. Yet there is very little research that addresses staff attitudes or clients' perceptions of discrimination and prejudice by staff with regard to treatment outcomes. This research aimed to assess whether perceptions of discrimination by staff predict drug treatment completion. Design and Methods. The study used a mixed methods approach. Ninety‐two clients in residential rehabilitation facilities in Sydney were administered a series of quantitative measures assessing drug history, severity of drug use, treatment history, perceptions of staff discrimination and treatment motivation. Clients were followed up regularly until an outcome (dropout or completion) was obtained for the full sample. Results. Perceptions of discrimination were a significant predictor of treatment completion, with greater perceived discrimination associated with increased dropout. Qualitative interviews with 13 clients and eight health‐care workers from these treatment services were then conducted to gain insight into how perceived discrimination may impact on treatment experiences. Clients and staff discussed how they would address the issue of perceived discrimination during the current treatment experience. Discussion and Conclusions. Adopting a mixed methods approach facilitated exploration of the impact of perceived discrimination on treatment from both clients' and health‐care workers' perspectives. This methodology may also enhance interpretation and utilisation of these findings in drug treatment.[Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: Utility of a mixed methods approach. Drug Alcohol Rev 2010;29;491–497]     

The Perceptions of White Clients in a Substance Abuse Program in Which They Are in the Minority

Background: There is a large body of literature regarding the need for culturally-informed practice with non-white populations in substance abuse treatment. Virtually nothing, however, has been written regarding the needs of white clients when they represent a small minority in treatment programs. Objectives: The primary purpose of this study is to compare perceptions of treatment and completion rates between white and nonwhite clients in a substance abuse treatment program where white clients represent a small minority. Methods: In New York City in 2009/2010, at a short-term inpatient program where white clients represented 12% of the population, 611 clients completed surveys that included scales measuring satisfaction, therapeutic alliance, social cohesion, and connection to the program. White and non-white clients were compared regarding results of these scales as well as program completion rates. Furthermore, demographic/background characteristics of the white and nonwhite clients obtained from the surveys were compared. Results: White clients reported lower levels of connection to the treatment program than non-white clients at levels that were statistically significant. However, there were no statistically significant differences between them for the other scales and program completion rates. Although white clients reported greater frequency and number of substances used, they were far less likely to have had felony convictions. Conclusions: Although differences were not extreme, there was evidence that greater sensitivity to the needs of white clients in programs in which they are in the minority is needed. Furthermore, this study demonstrates racial disparities in criminal justice involvement between white and non-white substance users.     

Notes from practice: Methadone prescribing in north central London—doses,compliance, goals and treatment setting

Aims: To examine methadone prescribing in public drug treatment services in inner London; compare levels of methadone prescribing with national guidelines and surveys; investigate whether methadone reduces illicit opiate use; and compare clients treated in specialist clinics with those in shared-care in general practice.

Methods: A cross-sectional survey of four drug treatment services in north central London.

Findings: Data were collected on 715 clients. Mean methadone dose was 57.2?mg but for clients on methadone maintenance, the mean dose was 63.4?mg. Reported heroin use fell from 24.8 days in the last 30 at initial assessment to 11 days (p?<?0.001). Clients on methadone doses greater than 60?mg were more likely than those on lower doses to test negative for morphine on urinalysis (49% vs. 39.4%, p?<?0.01). Clients in GP shared-care were more likely to have been in treatment for less time, be on lower doses of methadone and have stabilization or detoxification as their treatment goal.

Conclusions: Methadone treatment is associated with a reduction in illicit opiate use but not abstinence. Inadequate doses and lack of supervised consumption may in part explain the relatively poor response to treatment. Clients in GP shared-care received substantially different treatment from those in the specialist clinics.     

The Impact of Employment Counseling on Substance User Treatment Participation and Outcomes

The nationally representative Alcohol and Drug Services Study (ADSS, 1996–1999) is used to examine employment counseling's impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N = 988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.     

Repeated Addiction Treatment use in Sweden: A National Register Database Study

Sweden has a free, universal addiction treatment system, yet few studies exist examining utilization of treatment in this country. This study identified predisposing, enabling, and need factors associated with history of number of voluntary addiction treatment episodes for a national sample of 12,009 individuals assessed for an alcohol and/or drug use disorder in Sweden. On average, people reported 4.3 prior treatment episodes. Linear regression methods identified that predisposing factors such as older age and being male were associated with more voluntary addiction treatment episodes compared to younger and female clients; a higher Addiction Severity Index (ASI) employment score (an enabling factor) was associated with more voluntary addiction treatment episodes; and need factors including a history of inpatient mental health treatment, a higher ASI psychiatric score, a higher ASI alcohol score, higher levels of illicit drug use, more compulsory addiction treatment episodes, a lower ASI legal score, and a history of criminal justice involvement were all associated with more voluntary addiction treatment episodes compared to their counterparts.. There were no differences in the number of treatment episodes by education or immigrant status. Implications: (1) Need is a key factor associated with more treatment use. (2) Further studies are needed to identify gender differences in access/use of treatment. (3) Given multiple treatment histories, Swedish addiction treatment policy should reflect a chronic care model rather than an acute care model.     

Individual versus team-based case-management for clients of opioid treatment services: an initial evaluation of what clients prefer

Introduction and Aims. Case‐management is a client‐centred intervention to improve the coordination and continuity of delivery of services for people with complex needs. This service has been incorporated into opioid treatment programs in various ways. This study was undertaken to compare two case‐management models, termed individual case‐management (ICM) and team‐based case‐management (TBCM). This study aims to describe the new TBCM and client attitudes to, and acceptance of, this model compared with ICM. Design and Methods. Clients from two opioid treatment programs, one implementing ICM and one implementing the TBCM, were recruited to undertake a self‐complete survey examining satisfaction with case‐management during dosing hours over 7 months. Surveys took approximately 10 min to complete. Results. One hundred and sixty‐three clients were surveyed (62 ICM, 101 TBCM). Clients were demographically similar, but differed in terms of treatment and drug use characteristics. Significantly higher ratings of case‐management were reported from TBCM compared with ICM clients for help with opiate use (P < 0.001), other drug use (P < 0.001), mental health (P < 0.001), accommodation (P = 0.023), relationships/parenting (P = 0.003) and physical health (P = 0.002) and clinic services in terms of fairness and consistency, safety, respect, staff quality and confidentiality (P < 0.001). Compared with ICM clients, TBCM clients were more likely to report ease of access to case‐management (P < 0.001), wait significantly less time to see a case‐manager (38% vs. 7% seen same day) and 93% and 47% of clients, respectively, reported satisfaction with treatment (P < 0.001). Discussion and Conclusions. These initial data indicate client acceptance and satisfaction with the TBCM model. Further evaluation of the model, including cost‐effectiveness, is warranted.[Day CA, Demirkol A, Tynan M, Curry K, Hines S, Lintzeris N, Haber PS. Individual versus team‐based case‐management for clients of opioid treatment services: An initial evaluation of what clients prefer. Drug Alcohol Rev 2012;31:499–506]     

In Memoriam: Martin C. Doot,MD

Abstract

The purpose of this study was to use administrative records of admissions to substance abuse treatment to construct episodes of care for publicly funded adolescent clients in Washington State, and then to analyze two important outcomes after an index episode: readmissions to treatment and criminal convictions (including felony convictions and any conviction). The study population was youth, ages 14 to 17, who began and ended an index episode in 1997 and 1998 (n = 5903). The youth were followed for 18 months after the end of their episode, and survival analysis techniques were used to determine the treatment correlates of the outcomes. Clients who completed treatment, compared to those who did not, had significantly lower risks of each outcome, while those with treatment episodes longer than 90 days had lower risks of readmission and felony convictions.     

Schizophrenic Patients and Cocaine Use: Antecedents to Hospitalization and Course of Treatment

This study was designed to assess whether cocaine abuse was associated with a different set of antecedents and course for hospitalized schizophrenic patients. Forty-three cocaine-using and 27 non-cocaine-using patients with schizophrenia admitted to a dual diagnosis unit were compared with regard to antecedents to hospitalization such as prior treatment episodes, reliance on drugs for pleasure and tension reduction, and criminal history as well as course of hospital treatment. Cocaine-using patients were more likely to have had a history of prior inpatient drug treatment and to rely on drugs to a greater extent for tension reduction and pleasure. There was a trend for cocaine users to have a history of arrests for violent crimes. Although cocaine-using patients exhibited lower levels of global distress during the first week of hospitalization, they were no different from their counterparts who abused nonpsychostimulant drugs with regard to outcome of hospital treatment. These findings suggest that the lifetime course of illness among schizophrenic patients presenting for hospitalization who abuse cocaine may be characterized by episodes of repeated inpatient drug treatment and impaired impulse control. More rigorous discharge planning and aftercare program monitoring in the community as well as stress management interventions directed to tension reduction are therefore warranted.     

Drinking Goal Trajectories and Their Association with Client Characteristics and Outcomes among Clients in Outpatient Alcohol Treatment

Background: Drinking goal preferences could change over time in alcohol treatment and during follow up. Objectives: To examine the stability of drinking goals over time, types of drinking goal trajectory, and the associations between drinking goal trajectories and baseline client characteristics and treatment outcomes. Methods: We performed secondary analysis of a dataset from a multicenter longitudinal study on the effectiveness of outpatient alcohol treatment (n = 543). Drinking goals (abstinence, controlled drinking, nonrestricted drinking, undecided) and alcohol use were assessed at treatment admission, discharge, and 6- and 12-month follow up. Results: At admission, 32% of the subjects aimed for abstinence and 57% for controlled drinking, while 10% were undecided, and 1% did not want to restrict themselves. The proportions of clients aiming for abstinence and controlled drinking were relatively stable across the four assessments, and the proportion of clients who changed their drinking goal from abstinence to controlled drinking did not differ significantly from the number who changed in the opposite direction. Clients with abstinence-focused trajectories reported higher baseline alcohol use than those focused primarily on controlled drinking. Meanwhile, attaining nonhazardous drinking and reduced alcohol use at 12-month follow up were more likely among clients with abstinence-focused trajectories than those focused on controlled drinking. Conclusions: Since the majority of clients maintain their initially selected drinking goal, counsellors might inform them at treatment admission about the various probabilities of achieving nonhazardous drinking depending on their selected drinking goal.     

Use of Sexual Risk Assessment and Feedback at Intake to Promote Counselor Awareness of Subsequent Client Risk Behavior during Early Treatment

Background: Sexual risk is an important, oft-neglected area in addiction treatment. Objectives: This report examines computerized sexual risk assessment and client feedback at intake as means of enhancing counselor awareness of client risk behavior during early treatment, as well as any clinical impact of that counselor awareness. Methods: In 2009–2011, new clients at both opiate treatment and drug-free treatment programs endorsed in a computer-assisted assessment at intake 90-day retrospective indices for: being sexually active, having multiple partners, having sex under drug influence, and inconsistently using condoms. Clients were randomly assigned in a 2:1 ratio to receive or not receive a personal feedback report, and those receiving a report chose if a counselor copy was also distributed. Ninety days later, retained clients (N = 79) repeated the assessment and their counselors concurrently reported perceptions of recent client risk behavior. Results: Based on client reports, pretreatment risk behaviors were prevalent among men and women and remained so during treatment. A general linear model revealed greater counselor awareness of subsequent client risk behavior with mutual distribution of intake feedback reports to client and counselor, and at the opiate treatment program. A repeated-measures analysis of variance indicated that counselor awareness did not predict change in temporally stable patterns of sexual risk behavior. Conclusions/Importance: Findings document that computerized intake assessment of sexual risk and mutually distributed feedback reports prompt greater counselor awareness of clients’ subsequent risk behavior. Future research is needed to determine how best to prepare counselors to use such awareness to effectively prompt risk reduction in routine care.     

Methadone Maintenance Treatment for Youth: Experiences of Clients,Staff, and Parents

In order to better understand the components of effective treatment for the understudied population of opioid-dependent youth, separate focus groups were conducted in 2006 with clients, clinical staff, and clients' parents (total n = 22) at a novel methadone maintenance program for adolescents and young adults in suburban New York. Focus group sessions were audiotaped, transcribed, and analyzed for common themes. Clients, staff, and parents all reported that effective treatment for opioid addiction among young people is a long-term program, combines pharmacological and behavioral approaches, emphasizes a high degree of individual attention from staff, and incorporates clients' family members. The study's limitations were noted.     

A day treatment program in a therapeutic community setting: six-month Outcomes : The Walden House Day Treatment Program

Although not well represented in the literature, day treatment programs targeting substance abuse problems have increased in both number and acceptability in recent years. This article reports on a day treatment program based on the Therapeutic Community (TC), and on outcomes for a sample of substance abuse clients (n = 66) entering the program. Participants were interviewed early in treatment and 6 months after admission using the Addiction Severity Index (ASI) and other measures. Clients entering day treatment were demographically diverse, with serious substance-abuse problems and psychiatric morbidity. Median retention in day treatment was about 5 weeks, but many clients received a contiguous episode of residential treatment, so that the median for total time in treatment was 18 weeks. Clients located and interviewed at 6-month follow-up (n = 38) showed significant improvement in alcohol and drug use, legal and social problems, and psychiatric symptoms. Findings suggest that day treatment can be used effectively as a precursor to residential treatment and that some clients applying for residential treatment can be treated effectively in day treatment alone.     

Effects of Treatment Type on Alcohol Consumption Partially Mediated by Alcoholics Anonymous Attendance

Background: As insurance coverage, funding sources and venues for drug and alcohol treatment evolve in the United States, it is important to assess how the type of treatment received may impact long-term outcomes. The current study aims were to examine effects of treatment type on alcohol consumption in the year after treatment intake and to test mediators of effects of treatment type on later alcohol use. Methods: Longitudinal data from clients in inpatient and outpatient alcohol treatment programs in California (n = 560) were used in ordinary least squares path analysis adjusting for respondent characteristics typically associated with both treatment completion and alcohol use. The primary outcome was amount of alcohol consumed in the 12 months after treatment entry; hypothesized mediators were treatment duration and participation in Alcoholics Anonymous (AA). Results: Despite higher baseline problem severity and a shorter treatment duration, inpatient clients consumed less alcohol after treatment than outpatient clients (B [95% CI] = ?0.95 [?1.67, ?0.23]). AA involvement was a significant mediator of the relationship between treatment type and alcohol consumption, with inpatient clients being more involved in AA and also drinking less after treatment than outpatient clients; the bias-corrected bootstrap 95% confidence interval for the indirect effect (B = ?0.20) was entirely below zero (?0.43 to ?0.05). Conclusions: Outpatient clients may benefit from customized posttreatment recommendations to identify additional resources to assist in the recovery process during the first year after treatment.     

Evaluating Alternative Treatments for Homeless Substance-Abusing Men:

The present study was designed to explore the relative efficacy of three types of service delivery intervention models for homeless men with alcohol and/or drug problems: integrated comprehensive residential services provided at one site (Group 1); on-site shelter-based intensive case management with referrals to a community network of services (Group 2); and usual care shelter services with case management (Group 3). In addition to assessing the relative efficacy of these approaches in terms of drug and alcohol use, residential stability, economic and employment status, the project also sought to examine what personal factors best predicted successful outcomes for clients. Clients were assessed at baseline and approximately six months following discharge. All three treatment groups improved significantly over time in terms of reduced alcohol and cocaine use, increased employment, and increased stable housing, but no differential improvement was found among groups. Successful outcomes were predicted by lower recent and lifetime substance use, fewer prior treatment episodes, more stable housing at baseline, fewer incarcerations, and less social isolation.     

Delivering trauma-informed treatment in a women-only residential rehabilitation service: Qualitative study

Aim: This article explores the delivery of trauma-informed residential treatment, focussing on factors that affect how it is provided by staff and received by clients, particularly the challenges encountered. Methods: Semi-structured qualitative interviews were conducted with stakeholders (n?=?3), staff (n?=?15) and clients (n?=?19) of a women-only trauma-informed residential rehabilitation service in the UK. Interview data were systematically coded and analysed using iterative categorisation (IC). Findings: Trauma-informed treatment delivery was affected by: “recruiting and retaining a stable and trained staff team”; “developing therapeutic relationships and working with clients”; and “creating and maintaining a safe and stable residential treatment environment”. Clients’ complex needs and programme intensity made trauma-informed working demanding for staff to deliver and for clients to receive. Staff working in the residential service needed sufficient training, support and supervision to work with clients and keep themselves safe. Clients required safety and stability to build trusting relationships with staff and engage with the treatment. Conclusions: Trauma-informed residential treatment seems a valuable way of working with women with co-occurring substance use and trauma. However, it is challenging to deliver and likely to require significant resource investment. These findings appear relevant given increasing international interest in trauma-informed approaches within the addictions.     

Longitudinal Outcomes for Treated Opiate Use and the Use of Ancillary Medical and Social Services

Using an extended Maudsley Addiction Profile, 404 opiate users entering treatment across Ireland were interviewed at intake and at 1 year and 3 years between 2003 and 2006. At 3 years clients were abstinent, in treatment, or relapsed. Analysis of lifetime use of treatment services revealed that greater proportions of those who were drug free at 3 years had counselling in the past. Multiple regression revealed that the number of previous treatment episodes had a significant positive effect on outcomes. Findings are important during times of financial constraint when treatment providers are under pressure to cut back to core services.     

Predicting readmission to substance abuse treatment using state information systems. The impact of client and treatment characteristics

The purpose of this study was to use administrative records of admissions to substance abuse treatment to construct episodes of care for publicly funded clients in Washington State, and then to analyze readmissions to treatment after an index episode. The study population was those clients who began and ended an index episode in 1995 (N = 10,284). The population was divided into two groups, which were separately analyzed based on programs run by the Washington State Division of Alcohol and Substance Abuse (DASA) [Alcohol and Drug Abuse Treatment and Support Act (ADATSA) and Non-ADATSA, named for legislation defining these programs]. Clients in each program were followed for 13 months, and proportional hazards regression was used to estimate the relationship between our treatment measures and readmission, controlling for several covariates. We compared clients based on several aspects of treatment, but our primary interest was in comparing clients that completed the index episode with those that did not complete it. For both ADATSA and Non-ADATSA clients, those completing their episode of treatment had significantly lower risks for readmission. Females and those arrested in the year prior to treatment had increased risks of readmission, while males and those receiving a combination of inpatient and outpatient treatments had lower risks of readmission. The discussion concludes with suggestions for improving statewide systems of care.     

Preliminary analysis of the Northern Territory's illicit drug court diversion program highlights the need to examine lower program completion rates for indigenous clients

Introduction and Aims. Court drug diversion programs are now available in all jurisdictions in Australia, but there is increasing evidence that such programs have differing success rates for certain client populations, including indigenous clients. This study investigates client characteristics, program completion rates and factors associated with retention, for all 484 clients admitted to the Northern Territory's Court Referral and Evaluation for Drug Intervention and Treatment 12 week illicit drug pre‐sentence court diversion program between July 2003 and December 2008. Design and Method. Client data were collected by court clinicians as part of the face‐to‐face assessment interview and treatment outcomes were recorded. Results. Multivariate logistic regression analysis showed that indigenous clients were significantly less likely to complete their treatment than non‐indigenous clients, as were clients who were younger, male, had an educational level of Year 10 or less, were unemployed, had a previous custodial order and used drugs other than cannabis. Discussion and Conclusions. The lower program completion rates for indigenous clients are consistent with findings from other Australian studies and highlight the need to further explore and address factors contributing to this result.[Rysavy P, Cunningham T, O'Reilly‐Martinez R. Preliminary analysis of the Northern Territory's illicit drug court diversion program highlights the need to examine lower program completion rates for indigenous clients. Drug Alcohol Rev 2011;30:671–676]     

Impact of early telephone contact on 3-month follow-up rates following residential drug and alcohol treatment: A randomized controlled trial

Background: Routine outcome monitoring (ROM) is an important component of service provision and qualitity assurance procedures. However, a major logistical and financial challenge for organizations is successfully following up participants once they have left residential alcohol and other drug treatment. The aim of the current study was to assess the impact and effectiveness of an “early” follow-up contact and brief interview on subsequent 3-month ROM follow-up success. Methods: Participants were 800 clients attending specialist residential alcohol and other drug treatment provided by The Salvation Army. As part of routine outcome assessment procedures, all people attending these programs are asked to complete a 3-month follow-up assessment. Participants were randomly allocated either to the early contact condition (i.e., “early” 2-week follow-up contact prior to the 3-month follow-up assessment) or to the control condition (i.e., no “early” 2-week follow-up prior to the 3-month follow-up assessment). The primary outcomes were the proportion of participants who were followed up and surveyed at 3?months. Results: There were significantly higher follow-up rates at 3?months post discharge for participants in the early contact group (55.6%) compared with the control condition (46.1%). Although there were higher rates of 3-month follow-up for participants in the early contact group, rates of successful survey completion were not significantly different between the 2 groups. Conclusions: Including an early 2-week telephone call prior to the 3-month assessment increased the number of participants we were able to follow up at 3?months post discharge but did not improve the rate of survey participation at 3?months. The additional costs associated with this activity and the modest increase in follow-up rates need to be considered prior to organizations investing in these follow-up enhancement activities.