Patient Predictors of Irregular Discharge From Inpatient Substance Abuse Treatment

The authors conducted a controlled cohort study to determine the characteristics of patients irregularly discharged from inpatient substance-abuse treatment and to derive and validate an instrument to predict such early discharge. The sample was 220 subjects (110 consecutive patients who were discharged early and 110 matched control patients) admitted to a voluntary substance abuse treatment unit of a general hospital. Structured chart audits were used to collect demographic and clinical data. Hierarchical logistic regression identified only three predictors of irregular discharge: predominant heroin use, failure to complete high school, and age younger than 30 years. These three items were used to derive and validate an instrument for predicting completion of treatment. Readily available information on age, education, and psychoactive substance history is useful in identifying the risk of early discharge from inpatient substance abuse treatment.     

Smoking Cessation Treatment among Patients in Community-Based Substance Abuse Rehabilitation Programs: Exploring Predictors of Outcome as Clues Toward Treatment Improvement

Background: Predictors of smoking cessation (SC) treatment outcome were explored in a multisite clinical trial of SC treatment at community-based, outpatient, substance abuse rehabilitation programs affiliated with the National Drug Abuse Treatment Clinical Trials Network. Objectives: To explore baseline demographic and clinical predictors of abstinence during treatment. Methods: Cigarette smokers from five methadone maintenance programs and two drug and alcohol dependence treatment programs were randomly assigned to SC treatment as an adjunct to substance abuse treatment as usual or to substance abuse treatment as usual. SC treatment consisted of group counseling (weeks 1–8) plus transdermal nicotine patch treatment (21 mg/day, weeks 1–6; 14 mg/day, weeks 7–8). Demographic and clinical predictors of smoking abstinence were evaluated among those patients assigned to the active SC condition (N = 153) using logistic regression. Results: Abstinence during treatment was positively associated with younger age, Hispanic or Caucasian (as opposed to African American) ethnicity/race, employment or student status, fewer cigarettes per day at baseline, lower severity of the primary substance problem at baseline, and higher methadone doses (among the subsample in methadone treatment). Conclusions and Scientific Significance: During future efforts to improve SC treatments among drug- and alcohol-dependent patients, consideration should be given to adequate treatment to reduce the severity of the primary drug or alcohol problem, tailoring treatments for patients with greater severity of smoking and of the primary substance problem, and culturally sensitive interventions. Analysis of predictors of outcome may be a useful tool for treatment development.     

Retention in Substance Abuse Treatment

The authors investigated the association between psychiatric symptom severity and subsequent treatment retention among substance abusers. The Symptom Check List-90-R was administered, after admission to an addiction treatment facility, to 308 male and 106 female clients with moderate-to-severe substance abuse problems. Mean scores on nine symptom and three summary scales were computed. Controlling for other sociodemographic and treatment variables, somatization was significantly associated with dropout from specialized outpatient and inpatient treatment programs. This study, however, suggests that psychopathologic symptom severity at admission has only limited utility in predicting subsequent treatment retention among substance abusers with overall moderate levels of psychological distress.     

Adolescent Substance Abuse Treatment

The authors evaluated the level of agreement between unit staff and patients (treatment completers and noncompleters) regarding their perception of the efficacy of treatment modalities in a program for adolescent substance abusers. The results indicate statistically significant and clinically meaningful differences in perception of the value of three modalities: 1) individual treatment contracting, 2) therapeutic community meeting, and 3) educational counseling. The three groups did not differ on seven other variables. The authors hypothesize that the magnitude of agreement between staff and patients on the efficacy of treatment variables is associated with the likelihood of completing treatment among adolescent substance abusers.     

Treatment Outcome for Hospitalized Alcoholics:

Treatment outcome for hospitalized alcoholics was assessed two years after their first hospitalization for alcholism. Results indicated hospitalization to have been an effective mode of treatment in terms of relapse to the hospital, patient's perception of treatment, and patient's functioning at home and at work. Eighty-seven percent of the patients did not relapse during the first six months; 79% did not relapse after one year; 75% did not relapse after 18 months; and 72% did not relapse two years after hospitaliztion. Nearly three-fourths of the patients indicated that their lives had improved since hospitalization.     

Can Management by Outcome Invigorate Substance Abuse Treatment?: Microincentives and the Quality of Care

Given the rapid changes in health care, the economic consequences of substance abuse and the contemporary problems of substance abuse treatment must be acknowledged and addressed. These problems include poor treatment outcomes, difficulty of recruiting and retaining treatment staff, and failure of treatment programs to adopt effective research innovations. The authors suggest that these problems result from the incentives of the current payment system. To correct this, they propose an outcome-based incentive system to improve treatment outcome. This system is designed to enhance both treatment- and cost-effectiveness while being flexible and sensitive to local community circumstances. (American Journal on Addictions 1996; 5:281–291)     

Substance Abuse Treatment Among American Indian Children

Alcoholism is the number one killer among American Indians. Accordingly, the death rate for Indians ages 15 to 44 is over 300 percent that of the total U.S. population. This paper addresses this phenomenon from both the socio/legal and psycho/cultural perspectives. Alternative Indian-specific modalities are discussed and a successful proactive, preventative program-begun on the Qualla Reservation in 1972-is illustrated. Lastly, we warn against wellmeaning and other ethnocentric interventions presented under the guise of such programs as the "Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (PL 99-570)."     

Characteristics of Opinion Leaders in Substance Abuse Treatment Agencies

Objective. This study was part of a larger effort to test the effectiveness of technology transfer approaches related to evidence‐based treatment of co‐occurring substance abuse and mental health disorders. Specifically, this study examined characteristics of “opinion leaders” as technology transfer agents. Method. A network analysis was conducted within four large substance abuse treatment agencies to identify individuals that other counselors sought out for consultation on co‐occurring issues. The identified opinion leaders were then compared with other counselors on demographic variables, education and experience, and attitudes and knowledge about working with individuals with co‐occurring disorders. Results. The analyses demonstrate that opinion leaders differed from other counselors in competency‐related characteristics including more postgraduate education, relevant professional credentials, and years of experience in mental health treatment. They also had greater knowledge of the dynamics and treatment of co‐occurring disorders as well as a greater willingness and confidence in working with such clients. Conclusion. These results suggest that opinion leaders are used within agencies for information and consultation regarding treatment issues. Therefore, opinion leaders may provide an important vehicle for dissemination and adoption of evidence‐based treatment practices in community treatment settings.     

A Measure of Readiness for Substance Abuse Treatment

The Recovery Attitude and Treatment Evaluator-Research (RAATE-R) scale is a structured interview that assesses readiness for substance abuse treatment in five subscales: resistance to treatment, resistance to continuing care, biomedical acuity, psychological acuity, and environmental/social problems. Psychometric properties, based on an inter-rater reliability analysis of 23 raters and administration of the scale to 116 cocaine-dependent outpatients, included high interrater reliability, high internal consistency, independence of subscales, and a factor structure that partially supports the scale's original design. The authors discuss limitations of these conclusions and the lack of concurrent validity with a self-report measure of therapy readiness.     

Treatment Outcome Predictors for Cocaine Dependence

Over the past decade, a large number of potential medications have been examined in clinical trials for cocaine dependence. Unfortunately, no effective pharmacotherapies for cocaine dependence have been found to date. Although effective treatments for cocaine dependence are still being investigated, a few variables have been found to significantly predict cocaine treatment response. These variables include cocaine use variables, such as days of cocaine use in the month before treatment, baseline urine cocaine results, and cocaine withdrawal symptoms. Comorbid depression and alcohol use have also been shown to be risk factors for relapse. Among personality variables, impulsivity and similar personality traits may predict treatment response. Initial promising findings with genetic polymorphism, brain activation, and stress response have also been found and need to be replicated in future studies.     

Evaluation of Provider Profiling in Public Sector Substance Abuse Treatment

Few evaluations of provider profiles and performance measurement in publicly funded substance abuse treatment exist. This study examined a 7-year period in which the Connecticut Department of Mental Health and Addiction Services alternately implemented, suspended, and reintroduced profiling of treatment agencies. The profiles contained quarterly statistical reports indicating the agency's performance and peer comparison on percentages of clients connecting to lower levels of care and readmitted to higher levels of care. Neither measure changed during the first profiling period, but both improved during the second. Although adjustment for concurrent initiatives may be incomplete, profiling proved somewhat beneficial.     

Substance Abuse in Pregnancy

Staff collected urine samples anonymously on 100 consecutive pregnant women in a women's clinic and simultaneously on 100 admissions to the “labor deck.” Urines were tested for cocaine, opiates, methadone, benzodiazepines, and THC. Nine percent of the urines were positive in the clinic setting, and 15% were positive on the labor deck; the incidence of cocaine- and opiate-positive urines was significantly higher on the labor deck. The authors discuss the significance of these results. (American Journal on Addictions 1996; 5:351–353)     

Meeting the Treatment Needs of Veterans with Substance Use Disorders

Substance use disorder (SUD) treatment staff from the Brooklyn Veterans Administration Hospital and Samaritan Village describe current practices and challenges in treating the increasing Veteran population with SUD. Article addresses best practices for treating Veterans with SUDs, posttraumatic stress disorder, and traumatic brain injury complications; military sexual trauma; combat versus noncombat status; significance of period served (WW II, Korea, Vietnam, Kuwait/Iraq I, Iraq II, Afghanistan); active service obligations; treatment interventions for trauma survivors; gender treatment differences; medically assisted treatments, especially for those with pain issues; family involvement; benefit seeking; self-help Step 1’s “surrender” and “powerlessness” terms; access to treatment issues; returning home adjustment; and coordinating interdisciplinary treatment services.     

Mortality Rates and Predictors of Mortality Among Late-Middle-Aged and Older Substance Abuse Patients

This study describes mortality rates and predictors of mortality among late-middle-aged and older (55+) substance abuse inpatients ( n = 21, 139) in Department of Veterans Affairs (VA) Medical Centers in the 4 years after an index episode of care. A total of 24% of the patients died; this mortality rate was 2.64 times higher than expected. Predictors of earlier mortality included older age and nonmarried status, alcohol psychosis and organic brain disorder diagnoses, and several medical diagnoses, including neoplasms, liver cirrhosis, respiratory, endocrine and metabolic, and blood system disorders. Three proxy indicators of illness severity also predicted mortality: more prior inpatient and outpatient medical care and an index episode in an extended care unit. In contrast, more prior outpatient mental health care and remitted status predicted lower mortality. These diagnostic and treatment indicators can be used to identify patients at heightened risk for premature mortality. Moreover, they show that intensive mental health aftercare and remission of substance abuse may delay mortality, even among older patients who have longstanding substance abuse problems.     

Predictors of Treatment Outcome in Outpatient Cocaine and Alcohol Dependence Treatment

We examined the ability of several baseline variables to predict treatment outcome in a pharmacotherapy trial that included 164 participants who were both cocaine‐ and alcohol‐dependent and were selected for a randomized, double‐blind, placebo‐controlled study. Predictor variables included results from the baseline Addiction Severity Index (ASI), initial Urine Drug Screen results, cocaine and alcohol craving and cocaine and alcohol withdrawal symptoms at the start of treatment. Successful treatment was defined as four continuous weeks of self‐reported cocaine abstinence verified by urine drug screens. In respect to demographic characteristics, there were no significant differences between patients who achieved four weeks of abstinence from cocaine and those who did not. Baseline variables that most consistently predicted cocaine abstinence included initial urine drug screen (UDS) results, the initial Cocaine Selective Severity Assessment (CSSA) scores, and initial self‐reported cocaine use in past 30 days, whereas cocaine craving, cocaine composite scores, alcohol craving, alcohol withdrawal symptoms, and alcohol composite scores did not. The results of this study suggest that cocaine dependence severity in general, and initial UDS results, the CSSA scores and frequency of recent cocaine use in particular, have a significant impact on treatment outcome in the treatment of cocaine‐dependent patients with comorbid alcoholism. Initial UDS results and CSSA scores are very useful predictors of treatment outcome and could be used as stratifying variables in outpatient cocaine and alcohol medication trials.     

Outcome of Trauma Patients After Brief Intervention by a Substance Abuse Consultation Service

The Substance Abuse Consultation Service (SACS) at the University of Maryland Medical System (UMMS) conducts assessments and brief interventions for patients at the University Hospital and the Shock Trauma Center of the UMMS. This project examined a 10-week sample of trauma patients (N = 30) seen by the SACS, for whom consultations and recommendations (including participation in formal treatment programs as well as 12-step meetings) were provided. The authors used medical record reviews for background information and telephone interviews for follow-up. Of 22 subjects reached by telephone, 6 reported that they had followed the SACS recommendations completely or partially, and 16 subjects reported they had not. Of the latter group, a majority reported self-imposed abstinence or decreased use. No relationships existed between demographic characteristics or patterns of substance abuse and whether or not subjects acted upon SACS recommendations.     

Predictors of Flexibility in Social Identity Among People Entering a Therapeutic Community for Substance Abuse

One of the key aspects of recovery from substance dependence is making a transition from a social network supportive of substance use to one that supports recovery. This study assessed this transition in social identity in an adult therapeutic community (TC) at baseline and 2 weeks into treatment. Where residents increased identification with the TC, and reduced social identification with using groups, retention in treatment improved. As retention is a proxy measure of positive outcomes, this pilot suggests that facilitating residents' positive identification with the community in the first weeks of treatment may be central to retaining residents and improving treatment outcomes.     

Opening Move in Substance Abuse Therapy: Appropriateness of Treatment Assignment

This study examines the relationships between pretreatment severity of six problem areas commonly affected by addiction and type of discharge from inpatient substance abuse treatment. Subjects were 531 male veterans from five different inpatient substance abuse programs at the Veterans Administration Hospital, Coatesville, Pennsylvania. A comparison of patients in the five programs showed different patterns of problem severity, and different variables emerged as correlates or discriminators of discharge status. Results of multiple discriminant analyses were useful in predicting those patients who received an unfavorable discharge from treatment, although the analyses were not as successful in identifying those patients who received favorable discharges. Based on this data, some approaches to improving the match between patients and programs are discussed.