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.     

Spatial accessibility of drug treatment facilities and the effects on locus of control,drug use,and service use among heroin-injecting Mexican American men

BackgroundThis study explores the spatial accessibility of outpatient drug treatment facilities and the potential relationship with drug use-related outcomes among Mexican American heroin users.MethodsSecondary data on 219 current and former heroin-injecting Mexican American men aged 45 and older were drawn from a research study in Houston, Texas. We used geographic information systems (GIS) to derive two spatial accessibility measures: distance from one's place of residence to the closest drug treatment facility (in minutes); and the number of facilities within a 10-minute driving distance from one's place of residence. Exploratory logistic regression analyses examined the association between the spatial accessibility of drug treatment facilities and several drug use-related outcomes: internal locus of control (LOC); perceived chances and worries of injecting in the next six months; treatment utilization; and location of last heroin purchase.ResultsParticipants with greater spatial access to treatment programs were more likely to report a higher chance of injecting in the near future. However, while current heroin users were more worried about injecting in the next six months, greater spatial access to treatment programs seemed to have a buffering effect. Finally, those who lived closer to a treatment programs were more likely to have last purchased heroin inside the neighborhood versus outside the neighborhood. Spatial accessibility was not associated with internal LOC or treatment utilization.ConclusionThe findings showed that the presence of outpatient treatment facilities—particularly services in Spanish—may influence perceived risk of future heroin use and purchasing behaviors among Mexican American men. Implications for future spatially-informed drug use research and the planning of culturally and linguistically responsive drug treatment programs are discussed.     

Identifying United States Substance Abuse Treatment Programs

ABSTRACT

An accurate national listing of substance abuse treatment programs is essential for reporting data about the nation's treatment system and the clients entering that system. The National Survey of Substance Abuse Treatment Services (NSSATS) is thought to provide the most comprehensive list of treatment providers. Therefore, we report a partial test of the concurrent validity of the NSSATS in a single mid-sized city. Using operational definitions of “substance abuse treatment” and “substance abuse treatment programs” derived from prior work by the Center for Substance Abuse Treatment; and working within the defined geographic boundaries of a single, mid-sized city, we compared the NSSATS list with an independently developed compilation of programs from 5 sources: (1) the Yellow Pages; (2) the Internet Infospace Directory; (3) a State directory of licensed substance abuse treatment services; (4) the Office of Applied Studies Directory; (5) the National Master Facility Inventory.

With all sources, including NSSATS, we identified 96 separate listings that met the operational definition of adult treatment within the geographic bounds of the city. The NSSATS identified 70 of those 96 programs (73%), the 5-source compilation identified a sample of 83 (86%). While these findings from a single city cannot be considered a full test of the validity of the NSSATS, the data presented offer at least one partial but promising indication that the NSSATS may be a valid national listing and may serve as satisfactory national frame.     

Global systematic review and ecological analysis of HIV in people who inject drugs: National population sizes and factors associated with HIV prevalence

BackgroundPeople who inject drugs (PWID) are at elevated risk of HIV infection. Data on population sizes of PWID living with HIV are needed to inform the implementation of prevention, treatment and care programs. We estimated national population sizes of people who recently (past 12 months) injected drugs living with HIV and evaluated ecological associations with HIV prevalence in PWID.MethodsWe used national data on the prevalence of injecting drug use and of HIV among PWID, derived from systematic reviews, to estimate national population sizes of PWID living with HIV. Uncertainty was estimated using Monte Carlo simulation with 100,000 draws. We extracted data on sample characteristics from studies of HIV prevalence among PWID, and identified national indicators that have been observed or hypothesised to be associated with HIV prevalence in PWID. We used linear regression to evaluate associations between these variables and HIV prevalence in PWID.ResultsFour countries comprised 55% of the estimated global population of PWID living with HIV: Russia (572,500; 95% uncertainty interval (UI) 235,500–1,036,500); Brazil (462,000; 95% UI 283,500–674,500); China (316,500; 95% UI 171,500–493,500), and the United States (195,500; 95% UI 80,000–343,000). Greater anti-HCV prevalence and national income inequality were associated with greater HIV prevalence in PWID.ConclusionThe countries with the largest populations of PWID living with HIV will need to dramatically scale up prevention, treatment and care interventions to prevent further increases in population size. The association between anti-HCV prevalence and HIV prevalence among PWID corroborates findings that settings with increasing HCV should implement effective interventions to prevent HIV outbreaks. The association between income inequality and HIV among PWID reinforces the need to implement structural interventions alongside targeted individual-level strategies.     

Public Policy Statement on Opioid Antagonist Agent Detoxification Under Sedation or Anesthesia (Oadusa)

Abstract

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.     

The tension between national consistency and jurisdictional professional expansion: The case of pharmacist-administered vaccinations

BackgroundThe COVID-19 pandemic has highlighted the importance of coordinating policies on vaccinations at the national level. In Australia, the regulation and management of pharmacist-administered vaccination programs are the responsibility of each of the eight jurisdictions (six states and two territories), and have been developed independently of each other, leading to substantial variation. Consequently, there are variations regarding which vaccines pharmacists can administer, the minimum age, and whether these vaccines are publicly funded.Objective(s)To identify opportunities for a nationally consistent approach to pharmacist-administered vaccinations in Australia.MethodsThis policy analysis used the Multiple Streams Framework to identify barriers and enablers within the three “streams” of problem, policy, and politics, and how they affected the development of a national approach. Data were drawn from semi-structured interviews with 13 key policy actors and documents (pre-budget submissions and parliamentary inquiry reports). Themes were generated around actor interests, current and proposed pharmacist vaccination programs, and policymaking processes.ResultsFrom the pharmacy sector, there was little clarity around the need for a nationally consistent approach. This issue was linked to their ultimate goal of expanding pharmacist vaccination programs; it was seen as a means for states/territories with smaller programs to ‘catch up’ to other jurisdictions. There was also no unified policy approach from this sector; additionally, decision-makers within jurisdictional health departments faced different service delivery models, policy priorities, agendas, and policy actor relationships. Lastly, there was no federal body that had the capacity to coordinate a national approach. Possible enablers include refining the problem definition and re-framing it to a patient-centric model.ConclusionsCoordination of vaccination policies is an ongoing policy issue with implications for pharmacist vaccination programs and other health policy areas in which a national approach is being considered. This analysis provides insight into how this may be developed in the future.     

Birth outcomes for infants born to women participating in integrated substance abuse treatment programs: A meta-analytic review

Background: Infants born to women with substance abuse issues are at increased risk for prematurity, low birth weight, and impaired physical development. Integrated programs (programs that integrate on-site pregnancy-, parenting-, or child-related services with substance use treatment) have been developed to address these risks, barriers to accessing care, and the unique needs of pregnant women who abuse substances.

Method: To examine the effects of integrated programs on birth outcomes, we compiled a database of 10 studies (N?=?2471) of integrated programs published between 1990 and 2009 with birth outcome data. Data were summarized and meta-analyses were performed.

Results: Compared to women with substance abuse issues not in treatment, women in integrated programs had infants with significantly higher birth weights, larger head circumferences, fewer birth complications, positive toxicology screens, and low birth weight classifications (d's?=?0.42–0.87). Women in integrated programs attended significantly more prenatal visits (d?=?2.20) and had significantly fewer pre-term births (d?=?0.35) than women in non-integrated programs.

Conclusions: This is the first systematic quantitative review of studies evaluating the impact of integrated programs on birth outcomes. Findings suggest that integrated programs may be associated with advantages over non-integrated programs in increasing women's participation in prenatal care and decreasing premature delivery. This review highlights the need for further research with improved methodology, study quality, and reporting to improve our understanding of how best to meet the needs of pregnant women with substance abuse issues.     

Ongoing cocaine and benzodiazepine use: Effects on acquisitive crime committal rates amongst opiate users in treatment

Aims: Research has shown that treatment for opiate use reduces crime, however the extent to which this is maintained is open to question. The objective of this study was to measure the relationship between crime committal rates and ongoing benzodiazepine and cocaine use by clients in opiate drug treatment programs.

Methods: A national, prospective, longitudinal, multi-site drug treatment outcome study was conducted, 404 participants were recruited from inpatient and outpatient settings and 97% were located at 3 years. Drug use and crimes committed were ascertained from the Maudsley Addiction Profile of Marsden et al. [Marsden, J., Gossop, M., Stewart, D., Best, D., Farrell, M., Lehmann, P.,?…?Strang, J. (1998). The Maudsley Addiction Profile (MAP): A brief instrument for assessing treatment outcome. Addiction, 93, 1857–1867].

Findings: Analysis revealed that of those who had not committed an acquisitive crime at intake, those who used cocaine regularly at 1-year were 6.5 times more likely and those that used benzodiazepines regularly were eight times more likely to commit an acquisitive crime at 1-year. Of those who had committed an acquisitive crime at intake, those who used heroin regularly at 1-year were nine times more likely to commit acquisitive crime at 1-year than those who did not use heroin regularly at 1 year.

Conclusions: Treatment must place greater emphasis on reducing substitute drug use if opiate treatment is to effectively sustain crime reduction.     

Evaluating the feasibility of pharmacist-facilitated tobacco cessation interventions in independent community pharmacies in rural Appalachia

BackgroundSmoking rates in the United States are the highest in underserved rural regions. Thus, more points of contact are needed to link smokers to evidence-based cessation programs.ObjectivesThe purpose of this study was to conduct an evaluation to determine the feasibility, acceptability, and interest among rural pharmacists in implementing a pharmacist-facilitated smoking cessation program in independent community pharmacies in rural Appalachian communities in Virginia, North Carolina, Tennessee, and West Virginia.MethodsThis study utilized a complementary sequential mixed-methods approach to explore independent community pharmacists and technicians’ experiences and beliefs about implementing a tobacco cessation program in their pharmacy.ResultsThere were 49 pharmacists or technicians who completed the survey and 7 pharmacists who participated in the interviews. Four main findings emerged from the data: 1) pharmacies can help fill the gap in tobacco cessation services in rural communities, 2) under current practice, tobacco cessation resources when offered by independent community pharmacies are not always formalized, 3) there are known barriers, such as reimbursing for services, that need to be addressed to provide tobacco cessation in an independent pharmacy setting, and 4) the Ask-Advise-Connect model is a feasible tobacco cessation approach in a pharmacy.ConclusionAlthough pharmacists may be ideally situated to build capacity for smoking cessation in rural areas, smoking cessation interventions need to use existing approaches that compensate pharmacists for their time spent counseling patients. Furthermore, simple documentation and billing systems are needed to maximize utilization of tobacco cessation products and services provided in the pharmacy.     

Pharmacogenomics of pediatric acute lymphoblastic leukemia

Importance of the field: Pediatric acute lymphoblastic leukemia (ALL) represents one of the best examples of progress in disease treatment and improved outcome based in part upon the incorporation of the principles of pharmacogenomics. Throughout the past several decades, clinical scientists have continued to refine risk stratification in clinical trials with the understanding that individual patients have different subtypes of pediatric ALL that will respond to therapy in different, but predictable ways.

Areas covered in this review: Discussed in this review are the most significant findings from pharmacogenomic studies of pediatric ALL from 1989 to the present. Pharmacogenomic studies related to the drugs commonly used to treat pediatric ALL are covered in detail, including an emphasis on both genome-wide and candidate gene/pathway approaches.

What the reader will gain: Readers of this paper will acquire a detailed understanding of how pharmacogenomic studies can be integrated into clinical trials, in addition to some of the discrepancies still present in the field.

Take home message: The outcome for children with pediatric ALL has improved greatly, and this is in part due to the successful integration of data from pharmacogenomic studies into clinical trials.     

Does the implementation of evidence-based and culturally competent practices reduce disparities in addiction treatment outcomes?

RationaleResearch is limited on the extent to which implementation of evidence-based and culturally responsive practices reduces outcome disparities in substance use disorder treatment. We examined the role of contingency management treatment (CMT), medication-assisted treatment (MAT), and culturally competent practices on Mexican Americans' rate of successful completion of treatment.MethodsWe analyzed a concatenated dataset from 153 publicly funded substance use disorder treatment programs in Los Angeles County, California, in 2011 and 2013. These data were merged with data from 15,412 adult clients in both periods, of whom we selected only Mexican Americans (46.3%) and non-Latino Whites (53.7%). The outcome was successful treatment completion. The main independent variables were client demographics, drug use severity, mental health issues, and program license and professional accreditation.ResultsLess than half of the programs highly implemented CMT, MAT, and culturally competent practices. CMT and cultural competence were not associated with successful treatment completion. However, Mexican Americans in programs with high degree of implementation of MAT had higher odds of successfully completing treatment compared to non-Latino Whites and programs with low MAT (OR = 1.389; 95% CI = 1.018, 1.897).ConclusionsFindings highlight the role of MAT in reducing the disparity in treatment completion between Mexican Americans and non-Latino Whites. Implications for health policy and the dissemination of MAT are discussed.     

What is low threshold methadone maintenance treatment?

BackgroundLow threshold methadone maintenance (MMT) was developed for clients who do not have abstinence as a treatment goal. We explored how MMT programs in Canada defined low threshold and the challenges they faced.MethodsUsing semi-structured interviews, we collected data from clients (n = 46), nurses/counsellors (n = 15) and physicians (n = 9) at three low threshold MMT programs. All participants were asked to define low threshold MMT and describe how it was implemented in practice. Interviews were taped, transcribed, verified and analysed using an iterative thematic coding technique.ResultsLow threshold MMT was defined by an explicit rejection of abstinence from opiates and other drugs as an over-arching treatment goal. In the absence of guidelines defining a set of practices as low threshold, programs implemented practices they believed would reduce barriers to admission and help retention. There was not always agreement between professional groups or across the programs regarding these practices. For physicians, there was a tension between accepting poly-drug use during treatment as a means to improve retention, with an obligation to do more good than harm for their patients. Missed prescribing appointments generated few to severe consequences and revealed differential focus on reducing barriers versus encouraging client ‘ownership’ of treatment. Differences of opinion regarding appropriate urine drug testing practices revealed power dynamics between medical and non-medical staff.ConclusionOur findings show that there are potentially more ways to reduce barriers to MMT than those presented in the current literature. Our findings are important given the growing number of people with opiate dependence across the world and calls to increase access to MMT. To fully develop the low threshold model, it will be important to evaluate what policies and practices can achieve the goals of reducing barriers to admission and improving retention in treatment.     

Does Concurrent Cocaine Use Compromise 1-Year Treatment Outcomes for Opiate Users?

The current study aimed to determine whether cocaine use compromises treatment outcomes for opiate users. Data were collected from 404 opiate users at treatment intake and 1-year follow-up as part of a national treatment outcome study. Because of higher intake measures, cocaine users improved in more outcomes than nonusers, but comparisons between groups found that cocaine users had more coexisting problems. Regression analysis revealed that those who used cocaine at intake were more likely to use cocaine at 1-year follow-up, to commit crime, and to be homeless. It is concluded that treatment for opiate use “works” even in the presence of concurrent cocaine use.     

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.     

Pharmacotherapy for treatment of retinal vein occlusion

Introduction: Retinal vein occlusion (RVO) is a common vascular condition, which may cause blindness and impaired vision as a result of the development of macular oedema. The management of macular oedema due to RVO is complex and a multidisciplinary approach is required in order to limit disease progression and achieve a better clinical outcome.

Areas covered: An update and a brief review on the current treatment strategies were provided in patients with macular oedema following RVOs. Evidence available from prospective, multicentre clinical studies evaluating the use of VEGF inhibitors and steroids and from a selective literature search is reported.

Expert opinion: For many years, laser photocoagulation has been considered the standard of care for the treatment of branch RVO. However, new treatment modalities have been evaluated through randomised controlled trials. Recently, anti-VEGF agents and corticosteroids have been shown to be efficacious options in the treatment of RVO.     

Cigarette smoking rates among veterans: Association with rurality and psychiatric disorders

AimsCompared to the general U.S. population, military veterans and those living in rural areas disproportionately smoke cigarettes at higher rates, leading to increased health consequences. In the current study, prevalence and severity of cigarette smoking in Iraq and Afghanistan era veterans was assessed across rural and urban areas and comorbid mental health disorders.MethodIraq/Afghanistan era veterans who participated in the Post-Deployment Mental Health study from 2005 to 2017 (N = 3229) were cross-sectionally assessed for the probability of being a current cigarette smoker based on locality status and psychiatric comorbidity. Multivariate logistic and linear regressions, adjusted for demographic characteristics, were used to model the odds of being a current smoker and the severity of nicotine dependence, respectively.ResultsVeterans residing in rural regions, veterans with psychiatric comorbidities, and the interaction of locality and psychiatric disorders were significantly associated with smoking rates. Those veterans living in extremely rural areas and, independently, those living with psychiatric comorbidities were also more severely dependent on nicotine compared to urban veterans and veterans without psychiatric conditions.ConclusionsRural veterans and veterans with psychiatric comorbidities are at increased risk of smoking and are more severely dependent on nicotine than urban veterans. These findings underscore the need to reduce barriers for treatment both for smoking cessation and mental healthcare for veterans residing in the most rural areas.     

Dosage-Related Changes in a Culturally-Responsive Prevention Program for Asian American Youth

SUMMARY

In an effort to provide more responsive modalities to treat and prevent alcohol and other drug (AOD) abuse in under-served communities, intervention programs with an ethnic-specific focus have developed. However, there has been few empirical studies that examine the types of changes associated with participation in these programs. The present study examined the outcome changes associated with participation in the Competence Through Transitions (CTT) program, a prevention intervention specifically designed to serve the diverse needs of Asian American youth from five different Asian ethnic communities. The study identified aspects of the intervention that were related to outcome changes in order to better understand what accounts for the culturally responsive nature of this program. CTT participants were more knowledgeable about drugs and about the negative influences of drugs after completing the program during the school year. Also, there was a significant increase in school-based social comfort following participation in the program. For parents, there was a significant increase in school competence, but no significant change in their perception of family relations. CTT evinced much less effect on youth and family participants when the program was conducted in the summer in that no pre-post outcome changes were found for the summer-based intervention. The outcome differences between the two programs were found to be associated with specific types of curriculum-based dosage differences that were theoretically tied to those outcomes. The investigators discuss the ways in which the dosage differences between the school and summer programs may have contributed to the observed differences in outcomes.