Drug abuse treatment process components that improve retention

Background: Longer retention has been the most consistent predictor of favorable drug abuse treatment outcomes, but key therapeutic and patient engagement indicators of treatment process need to be more clearly established. Methods: An integrative model representing treatment dynamics was tested for explaining long-term program retention. It was based on a multisite sample of 527 daily opioid users who remained in methadone maintenance a minimum of 3 months. All had been assigned randomly to a counseling condition at admission (i.e., cognitively enhanced or standard), and information obtained from patient files, as well as periodic assessments completed by patients and their counselors in the first 90 days after admission were the sources of predictors. Results: Counseling enhancements (using node-link mapping, a visual representation tool for improving communication and problem solving) contributed to stronger therapeutic relationships between counselor and patient, which in turn had a positive reciprocal relationship with patient engagement (session attendance). Pretreatment motivation measured at intake was also related to higher engagement. More positive therapeutic relationships (in months 1 and 2) led to lower levels of during-treatment drug use (defined from urinalysis results in months 2 and 3), and better session attendance and therapeutic relationships both predicted longer retention. In addition, lower drug use during treatment was related to longer retention. Conclusions: Major conceptual domains of drug abuse treatment process were identified in community-based programs and their interrelationships with retention specified. As intermediate (during treatment) criteria, they can help guide functional improvements in program effectiveness as illustrated with our counseling enhancements.     

Drug treatment outcomes: investigating the long-term effects of sexual and physical abuse histories

Individuals in drug treatment, particularly women, generally report high levels of past sexual and physical abuse. Although histories of sexual and physical abuse are associated with greater prevalence and severity of depression, anxiety, phobias, and interpersonal difficulties for individuals seeking substance-related treatment, several recent studies failed to show that prior sexual or physical abuse compromised short-term drug treatment outcomes. This study examined the possible effects of sexual and physical abuse on a wide array of behavioral domains over a two-year posttreatment period. The findings indicate few differences between those with and without past histories of such abuse in terms of drug use, drug treatment and 12-Step program participation, criminality, income sources, intimate relationships, family functioning, and psychiatric symptoms. There are specific exceptions, but they apply only to men. Overall, the findings indicate that the impact of sexual and physical abuse histories on relatively long-term treatment outcomes is minimal. Addressing the sexual and physical abuse histories of those seeking treatment for drug abuse may be justified on humanistic grounds, but it will not significantly improve the long-term effectiveness of drug treatment, nor will it substantially enhance the lives of those with histories of abuse.     

Client consensus on beliefs about abstinence: effects on substance abuse treatment outcomes

Organizational culture, as evinced by consensus regarding staff and client beliefs and values, has been shown to affect client engagement in residential substance abuse treatment. The present paper extends this work to treatment outcomes. Secondary analysis of data from a "Beliefs About Abstinence Scale," used in the Drug Abuse Treatment Outcomes Study (DATOS), was conducted for 76 programs, including outpatient methadone treatment, outpatient drug-free, short-term inpatient, and long-term residential programs. Findings show that higher levels of client consensus after 1 month of treatment were associated with less use of drugs and alcohol at 1-year follow-up, after controlling for the mean of the scale score, gender, age, client substance use at baseline and treatment modality. The implications of the results for substance abuse treatment are discussed.     

门诊中心治疗经验谈

１门诊中心治疗模式门诊戒毒中心为澳门特别行政区政府社会工作局防治药物依赖厅辖下特设的“专业治疗中心” ,是唯一由政府提供的戒毒治疗机构 ,主要由戒毒复康处管理。由社工辅导员、临床心理学家、精神科医生和专业护士组成专责治疗小组 ,对自愿求助者的各项困难给予协助。其服务内容主要由社工辅导员为个案作深入的治疗评估 ,制定适合的治疗计划 ,并提供配套治疗 ,包括生理戒断、动机激励、情绪支持和辅导、经济援助、医疗护理、家庭重塑、以及重返社会培训等等。一般而言 ,求助者由社工辅导员接见 ,进行评估 ,再安排具体的医疗戒毒时间…     

Transportation and retention in outpatient drug abuse treatment programs

To determine whether certain types of transportation assistance improve outpatient treatment retention beyond thresholds shown to have therapeutic benefits, we analyzed data from 1,144 clients in 22 outpatient methadone maintenance (OMM) programs and 2,031 clients in 22 outpatient drug-free (ODF) programs in the Drug Abuse Treatment Outcomes Study (DATOS), a national, 12-month, longitudinal study of drug abuse treatment programs. Directors' surveys provided information about provision of car, van, or contracted transportation services or individual vouchers/payment for public transportation. Chart-abstracted treatment retention was dichotomized at 365 days for OMM and 90 days for ODF. Separate multivariate hierarchical linear models revealed that provision of car, van, or contracted transportation services improved treatment retention beyond these thresholds for both OMM and ODF, but individual vouchers or payment for public transportation did not. Future research should validate whether car, van, or contracted transportation services improve retention and other treatment outcomes in outpatient drug abuse treatment.     

Participation and retention in drug abuse treatment services research

We examined potential bias in treatment effectiveness research by studying client characteristics associated with initial participation and subsequent retention in research assessments among clients in substance abuse treatment receiving case management. Six hundred thirty-four residential and 429 outpatient clients were invited to participate. Participants were randomly assigned to one of four conditions. Logistic regression examined the relation between client characteristics and initial participation and retention in follow-up assessments. Females and clients with significant others were more likely to participate and remain in the study. Older persons and criminal justice-referred clients were less likely to participate. Older clients and urban outpatient clients were more likely, and criminal justice-referred clients were less likely, to be retained. Two case management conditions were associated with decreased retention. Client characteristics are important factors in participation and retention in treatment services research. Further, client characteristics may bias estimates of effectiveness generally, or for specific populations.     

Treatment retention and birth outcomes of crack users enrolled in a substance abuse treatment program for pregnant women

This study examined characteristics of pregnant crack users that were associated with their retention in a residential treatment program and the outcomes of their pregnancies. The participant characteristics were assessed when the women were admitted to the program, and were related to their demographic status, physical health, psychological functioning, substance use, and pregnancy. In general, the findings point to the importance of early interventions with this population. Implications and limitations of this study, as well as suggestions for future research, are discussed.     

Predicting retention of adolescents in substance abuse treatment

Because retention of adolescents in substance abuse treatment is critical to treatment effectiveness, factors that predict length of time in treatment were examined among youth (N=173) admitted to five outpatient clinics. At admission, youth received a comprehensive psychosocial assessment. Relevant predictors of length of treatment were determined using Poisson regression analyses. Factors positively associated with treatment duration included use of drugs in addition to alcohol and marijuana, having less deviant peers, absence of substance-caused emotional problems, and viewing counselor's skills more positively. In contrast, pressure to enter treatment was unrelated to treatment duration. Results suggest that the counselor-client relationship and peer influences be explicitly considered in treatment.     

Adolescent tobacco use and substance abuse treatment outcomes

This study investigated the relationship between cigarette-smoking status and 12-month alcohol and marijuana treatment outcomes in a sample of 1,779 adolescents from the Drug Abuse Treatment Outcomes Study for Adolescents. Participants were classified into four groups based on change in cigarette-smoking status from intake to the 12-month follow-up: persistent smokers, nonsmokers, quitters, and smoking initiators. Logistic regression was used to predict likelihood of relapse to alcohol, marijuana, and other drugs after controlling for intake levels and demographic/treatment characteristics. Results found persistent smokers and smoking initiators to have significantly greater odds of alcohol and marijuana relapse compared with quitters. Furthermore, persistent smokers and smoking initiators were also found to have distinctively shorter periods to marijuana relapse at follow-up. Implications for the implementation of tobacco cessation treatment in the context of substance abuse treatment for adolescents are discussed.     

Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes

More than half of substance abusers entering addiction treatment report a history of physical or sexual abuse. It is unclear if such a history impacts treatment outcomes. This one-year follow-up study of 700 substance abusers sought to clarify the relationship between lifetime physical and/or sexual abuse and addiction treatment outcome to help address the specific needs of this population. To achieve this goal, baseline characteristics, no-show for treatment status, post-treatment clinical outcomes, and treatment history were studied for subjects with lifetime history of abuse (47.3%) versus without. Abused subjects, predominantly women, were significantly more impaired at baseline on clinical dimensions including family/social severity and psychiatric severity as measured by the Addiction Severity Index (ASI), and general level of functioning. The two groups endorsed different drugs as primary, with the abused group less frequently endorsing heroin and cocaine in favor of alcohol and polydrug use. Abused subjects reported more prior medical and psychiatric treatments. Abuse history was not a predictor of no-show for treatment. Over the 1-year follow-up, lifetime physical and/or sexual abuse was significantly associated with worse psychiatric status and more psychiatric hospitalizations and outpatient treatment despite receiving similar intensive addiction treatment.     

Client outcomes from rural substance abuse treatment

Several national evaluations have been conducted since the late 1960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short-term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.     

The impact of early trauma and abuse on residential substance abuse treatment outcomes for women

This study examines the impact of early abuse on the functioning and the 12-month treatment outcomes of 146 homeless addicted women who entered residential substance abuse treatment. Sixty-nine percent of the women reported exposure to childhood physical, sexual, or emotional abuse; the majority reported multiple forms of abuse. Comparisons of abused and nonabused women revealed significant differences in childhood, adolescent, and adult functioning, indicative of the pervasive detrimental effects of early abuse. Female survivors of childhood abuse did not improve in treatment as much as their nonabused peers in psychological functioning (p < .001), substance abuse (p < .01), or continuing trauma exposure (p < .01) .The findings suggest the importance of adapting models of residential substance abuse treatment to address concurrent issues related to trauma history. Additional research is needed to identify effective integrated treatment approaches for this population and to explore the independent and interconnected pathways linking trauma history and outcome.     

Physical and sexual abuse history and addiction treatment outcomes

OBJECTIVE: Prior research on patients with substance use disorders has shown that lifetime physical or sexual abuse is associated with more impaired functioning at treatment intake. The present study sought to determine whether physical or sexual abuse also predicted treatment response (posttreatment outcomes) of individuals with substance use disorders. METHOD: Male (n = 19,989) and female (n = 622) veterans with substance use disorders were assessed with the Addiction Severity Index (ASI) early in treatment and reassessed an average of 12 months later. Treatment outcomes were compared for patients who did and did not report prior physical or sexual abuse in the initial ASI interview. RESULTS: Lifetime physical or sexual abuse predicted worse outcomes in six of seven domains of functioning, after controlling for baseline functioning, psychiatric diagnoses and demographic variables. Although women were more likely than men to report being abused, the effect of abuse on treatment outcomes was similar for both genders. Psychiatric problems at baseline mediated the effect of abuse history on outcomes. Abuse history moderated the effect of treatment intensity (contacts per month) on outcomes: More frequent treatment contacts were more beneficial for abused patients than for nonabused patients. CONCLUSIONS: Individuals with substance use disorders who have a history of physical or sexual abuse may have higher risk for problematic treatment outcomes as a result of greater psychiatric problems, deficits in social support and possible difficulties in establishing treatment alliance. Clinicians may consider increasing the duration and intensity of treatment to temper the negative effects of abuse on later functioning.     

Sexual abuse history and treatment outcomes among women undergoing methadone treatment

Women entering drug abuse treatment programs who report a history of sexual abuse are also likely to report poorer psychosocial functioning, more drug-related problems, and more family-of-origin problems. This study investigates outcome differences at follow-up between women with and those without sexual abuse histories who were treated at an outpatient methadone treatment program. Follow-up interviews were conducted with 98 women, 40% of whom reported prior sexual abuse. Those with a history of sexual abuse who reported problems at intake with psychosocial functioning and family support continued to report such problems at follow-up as compared with the women without a history of sexual abuse. However, no difference was found at follow-up between women with and those without sexual abuse histories in terms of drug use, employment, criminality, or HIV-risky behaviors. The findings suggest that sexual abuse history alone cannot predict treatment outcomes for women in methadone treatment. The implications of these findings are discussed in terms of treatment process and services.     

Drug effects on response duration differentiation I: differential effects of drugs of abuse

Rats were trained to respond under a response duration differentiation schedule in which responses on a lever were reinforced if lever press durations were greater than or equal to 1.00 s but were also less than 1.30 s. Dose-effect curves were generated for cocaine, methamphetamine, pentobarbital, phencyclidine, delta-9-tetrahydrocanninabol (⁹-THC), and morphine. All drugs produced dose-dependent decreases in accuracy (the percentage of total response durations that were reinforced); however, the degree to which changes in accuracy were accompanied by changes in response rates varied among drugs. Pentobarbital and morphine affected primarily longer (> 1.3 s) response durations, phencyclidine and ⁹-THC affected primarily shorter response durations, whereas cocaine and methamphetamine affected both shorter and longer response durations. High doses of methamphetamine and cocaine increased the dispersion of response duration distributions with increasing dose, whereas higher doses of pentobarbital, ⁹-THC and morphine did not increase dispersion of response duration distributions as much. These data show that behavior under this novel schedule is differentially sensitive to a number of pharmacologic manipulations, and that the schedule can provide a useful addition to the analysis of drug effects upon behavior.     

Drug abuse treatment on demand in San Francisco: preliminary findings

This article reports on a process and capacity evaluation of San Francisco's Treatment on Demand Initiative, which was launched in 1997 to increase availability of publicly-funded substance abuse treatment. For the process evaluation, data from public documents, interviews with community key informants, and newspaper articles were analyzed. For the capacity evaluation, budget documents and admissions data for publicly-funded substance abuse treatment in San Francisco for fiscal years 1995-1998 were analyzed. Results from the process evaluation document the development of the community-oriented Treatment on Demand Planning Council, and its efforts to not only expand treatment, but to create a continuum of services to address the needs of San Francisco's richly diverse communities, to provide service enhancements, and to prioritize service needs. Process evaluation results also highlight the complexities of implementing treatment on demand, including the difficulty of opening new programs. Results from the capacity evaluation indicate that the San Francisco budget supporting publicly-funded treatment increased from $32 million to $45.2 million over four years. During the same period, the number of persons entering the system in a single year increased by 18%, and the number of admissions in a single year increased by 15%. Implications of these findings are discussed.