Mental Health Indicator Interaction in Predicting Substance Abuse Treatment Outcomes in Nevada

Background: Indicators of co-occurring mental health and substance abuse problems routinely collected at treatment admission in 19 State substance abuse treatment systems include a dual diagnosis and a State mental health (cognitive impairment) agency referral. These indicators have yet to be compared as predictors of treatment outcomes. Objectives: 1. Compare both indices as outcomes predictors individually and interactively. 2. Assess relationship of both indices to other client risk factors, e.g., physical/sexual abuse. Methods: Client admission and discharge records from the Nevada substance abuse treatment program, spanning 1995–2001 were reviewed (n = 17,591). Logistic regression analyses predicted treatment completion with significant improvement (33%) and treatment readmission following discharge (21%). Using Cox regression, the number of days from discharge to treatment readmission was predicted. Examined as predictors were two mental health indicators and their interaction with other admission and treatment variables controlled. Results: Neither mental health indicator alone significantly predicted any of the three outcomes; however, the interaction between the two indicators significantly predicted each outcome (p < .05). Having both indices was highly associated with physical/sexual abuse, domestic violence, homelessness, out of labor force and prior treatment. Conclusions and Scientific Significance: Indicator interactions may help improve substance abuse treatment outcomes prediction.     

Gender and Racial/Ethnic Disparities in the Impact of HIV Prevention Programming in Substance Abuse Treatment

Objective: The objective of the study was to evaluate the capacity of HIV prevention programs offered in substance abuse treatment to reduce HIV-related risk behavior for women and men and for Black, Latino, and White groups. Methods: Prospective data was collected at intake, discharage, and 12 months post-treatment from 1992 to 1997 for the National Treatment Improvement Evaluation Study with a sample consisting of 3,142 clients from 59 service delivery units: 972 females, 1,870 males, 1,812 Blacks, 486 Latinos, and 844 Whites. Results: Study findings show that receipt of HIV prevention programming as part of substance abuse treatment services resulted in reductions in HIV-related risk behavior for the sample overall and for women as well as men. However, although Blacks received more prevention services than Latinos and Whites, the significant positive effect of HIV services on reduced HIVrisk behavior held only for Whites. Conclusions: Racial/ethnic disparities exist in the capacity for HIV prevention programming offered as part of substance abuse treatment to reduce HIV-risk behavior. The findings highlight the need for the development of culturally competent service delivery strategies to enhance the impact of these services for all groups.     

Improving Health and Social Outcomes with Targeted Services in Comprehensive Substance Abuse Treatment

Background: Improved life functioning along with substance use reduction is increasingly recognized as the definition of effective addiction treatment. Objectives: To assess whether targeted health and social services contribute to improved physical/mental health and employment. Methods: This study used data from the National Treatment Improvement Evaluation Study (N = 3027) and modeled the improvement in physical/mental health and employment at discharge or 12 months after discharge compared with intake measures as a function of receipts of matched services. Results: Receiving matched medical service improves physical health only at treatment discharge; receiving matched mental health services improves mental health at discharge and 12 months after discharge; receiving matched vocational services improves employment only 12 months after discharge. Conclusions: Need–service matching contributes to improved health and social outcomes when longitudinal assessments of treatment outcomes are used to evaluate treatment effectiveness. Scientific Significance: Study findings document the value of targeted services for achieving success in health and social functioning in comprehensive 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.     

Substance Use and High Risk Sexual Behaviors among Women in Psychosocial Outpatient and Methadone Maintenance Treatment Programs

Objectives: The purpose of the present study was to assess the association between substance use/diagnosis and sexual risk behaviors among women enrolled in both psychosocial outpatient (PS) and methadone maintenance (MM) treatment and involved in a HIV prevention intervention study within the National Institute for Drug Abuse Clinical Trials Network. Methods: 515 sexually active women reported on unprotected sexual occasions (USO), anal sex, sex trading, sex with drug occasions, and multiple male sex partners at the baseline assessment. Results: Within the PS sample, cocaine use diagnosis was associated with more than twice the risk of having multiple partners, trading sex for drugs, having anal sex, or having sex with drugs; alcohol or opioid use diagnosis was associated with fewer risk behaviors. Within the MM sample, cocaine use, alcohol use and opiate use diagnoses were each associated with one to two risk behaviors. Associations between sexual risk and substance using days were less frequent in both samples. Conclusions: These findings highlight the need for integration of HIV sexual prevention interventions that address the relationship between sexual risk behavior and substance use diagnoses into substance abuse treatment programs.     

The Effectiveness of Seeking Safety on Reducing PTSD Symptoms in Clients Receiving Substance Dependence Treatment

An evaluation of the Seeking Safety (SS) program was conducted in a 28-day substance abuse treatment facility. The evaluation included 12 male and 28 female participants with a mean age of 33 years. The Trauma Symptom Checklist-40 was utilized as an outcome measure to statistically compare posttest to pretest group means. Results showed significant decreases, from pretest to posttest, on the total score and on several subscales of the measure. Effect sizes were large (d < 0.80) across all scales with the exception of Male Sexual Problems (d = .46). Overall, results suggest that incorporating SS as an adjunct to treatment as usual can help lower trauma symptoms in those receiving substance dependence treatment.     

Drug Abuse Treatment Outcome Study of Adolescents: A Comparison of Client Characteristics and Pretreatment Behaviors in Three Treatment Modalities

Objectives: The present study presents background and pretreatment characteristics of adolescent substance abuse treatment clients, and it provides a mechanism for describing perhaps the largest research sample of adolescents who were in drug treatment in this decade. Methods: The sample was 3382 subjects who presented for treatment from 1993 to 1995 in 37 programs in Pittsburgh, Pennsylvania; Miami, Florida; Minneapolis, Minnesota; Chicago, Illinois; Portland, Maine; and New York City, New York. Informed permission for the youth to participate was obtained from the subject's custodial parent/guardian, and both the youth and the youth's parents or guardians provided informed assent if they agreed to participate as subjects. Adolescents then were interviewed privately and confidentially by a trained professional interviewer who was independent of the treatment programs. The interviews queried subjects about their background, including education and employment; physical and mental health; use of tobacco, alcohol, and other drugs; sexual experiences; legal problems; religious beliefs; and treatment experience. Results: The long-term residential treatment modality was the least gender balanced of the modalities and had the most African-American and Hispanic clients. This modality was distinguished by the proportion of clients who were referred to treatment by the juvenile or criminal justice system. Compared with other clients in other modalities, short-term inpatient clients were more likely to be female and white. Inpatient clients also reported more indicators of psychiatric impairment. Outpatient clients were slightly younger than clients in the other modalities, and more of them were attending school at the time of admission to treatment. Outpatient clients had the least criminally involved lifestyles, their rates of (regular daily or weekly) drug use were also the lowest of the three modalities for all drugs assessed, and they had the least drug treatment experience. Conclusions: These results merit several recommendations. One is the need for more community-based adolescent substance abuse treatment programs. An additional recommendation is for more substance abuse treatment programs in facilities that serve incarcerated youth. Finally, and perhaps most critically, it is recommended that programs be designed to address such specialized issues as comorbid substance abuse and psychiatric problems, family dysfunction, physical and sexual abuse, gender and ethnic differences, and academic performance.     

The Impact of Publicly Funded Managed Care on Adolescent Substance Abuse Treatment Outcomes

This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hundred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care enrollment status. One hundred forty two (56%) adolescents were in the managed care group and 113 (44%) comprise the comparison group. Substance use outcomes include a count of negative consequences of substance use, days of alcohol use, days of cannabis use, and days of any substance use in the previous 30 days. Repeated measures analysis of covariance (ANCOVA) was used to assess change with time of measurement and managed care status as main effects and the interaction of time and managed care included to measure differences between the groups over time. Although several changes across time were detected for all four outcomes, we found no evidence of an impact of managed care for any of the outcomes. The results of our study do not support the fears that behavioral managed care, by imposing limits on services provided, would substantially reduce the effectiveness of substance abuse treatment for adolescents. At the same time, the results do not support those who believe that the continuity of care and improved resource utilization claimed for managed care would improve outcomes.     

The impact of 9/11 on patients in New York City's substance abuse treatment programs

OBJECTIVES: This article assesses the impact of the attacks on 9/11 in New York City on drug use, relapse, and mental health from the perspective of drug users and patients in substance abuse treatment programs. METHODS: Structured interviews were conducted with 16 administrators and 75 randomly selected patients at 15 substance abuse treatment programs in New York City from December 2002 to April 2003. RESULTS: Drug use and relapse was a significant issue on and after 9/11. While Post Traumatic Stress Disorder was related to drug use, other preexisting mental health problems were not. Men were more likely to relapse than women; however, women were more emotionally affected by events following 9/11. CONCLUSIONS: The attacks on 9/11 may have contributed to relapse among drug users and exacerbated existing mental health problems among patients with a history of concurrent drug use and mental illness.     

Patients with Substance Use and Personality Disorders: A Comparison of Patient Characteristics,Treatment Process,and Outcomes in Swiss and U.S. Substance Use Disorder Programs

Background: Cross-cultural comparisons may increase our understanding of different models of substance use treatment and help identify consistent associations between patients’ characteristics, treatment conditions, and outcomes. Objectives: The aim of the study was to compare matched samples of substance use disorder (SUD) patients with personality disorders (PD) in Swiss and the United States (U.S.) residential SUD treatment programs and examine the relationship of program characteristics to 1-year outcomes. Methods: A prospective, naturalistic design was used to compare 132 demographically matched Swiss and U.S. male patients drawn from a sample of 10 Swiss and 15 U.S. public treatment programs. Patients completed comparable inventories at admission, discharge, and 1-year follow-up. Results: Compared to Swiss SUD-PD patients, U.S. SUD-PD patients had more severe substance use and psychosocial problems at admission and follow-up. More intensive treatment and a stronger emphasis on patients’ involvement were related to better outcomes for both Swiss and U.S. SUD-PD patients. Conclusion: There may be some cross-cultural consistency in the associations between treatment characteristics and SUD-PD patients’ outcomes. Scientific Significance: Treatment evaluation findings from representative programs in one country may apply elsewhere and contribute to our overall knowledge about how to improve SUD-PD patients’ outcomes.     

The Impact of Therapeutic Case Management on Participation in Adolescent Substance Abuse Treatment

Establishing the efficacy of case management in substance abuse treatment has been confounded by the lack of attention given to assessing the fidelity of case management implementation. The current study measured the fidelity of case management implementation and used fidelity information to examine the impact of therapeutic case management on attrition in an adolescent, outpatient, group, substance abuse treatment program. Ninety adolescent women enrolled in substance abuse treatment were randomly assigned to receive or to not receive case management. Treatment fidelity was measured using the Case Management Quality Inventory. Cox regression analyses revealed that higher fidelity of case management implementation predicted a decreased risk of dropping out of the substance abuse treatment program (RR = ?11.21, p < 0.02). Higher proportions of total case management time spent on case management core functions predicted a decreased risk of dropping out of treatment (RR = 4.32, p < 0.03). This study confirms that programs need to first demonstrate that the case management model has been implemented faithfully before its efficacy in reducing attrition in the substance abuse treatment program can be fairly evaluated. It also suggests that core case management functions may have a greater influence on attrition in substance abuse treatment than does intensity.     

Characteristics of Treatment Completers versus Treatment Noncompleters in a Targeted Capacity Expansion and HIV/AIDS Education Program for Adolescents with Substance Use Disorders

This study examines and presents outcome analyses of characteristics of treatment completers versus treatment noncompleters in a Targeted Capacity Expansion (TCE) and HIV/AIDS Education Program for adolescents with substance use disorders, using a two-group nonrandomized design. The treatment completion rate was 47%, exceeding the national average of 40% for outpatient clients. These results suggest the importance of utilizing comprehensive assessments, providing linkages to assertive continuing care, and developing curricula to meet cultural, developmental, and gender-specific needs of adolescent clients. The TCE and HIV/AIDS Education Program appears to be an effective program for reducing and eliminating substance abuse among adolescents.     

The Impact of Expressions of Treatment Efficacy and Out-of-pocket Expenses on Patient and Physician Interest in Osteoporosis Treatment: Implications for Pay-for-performance Programs

BACKGROUND Clinical practice guidelines (CPGs) are increasingly used as the basis for pay-for-performance (P4P) programs. It is unclear how support for guidelines varies when treatment efficacy is expressed in varying mathematically equivalent ways. OBJECTIVES To assess: (1) how patient and provider compliance with osteoporosis CPGs varies when pharmacotherapy efficacy is presented as relative risk reduction (RRR) versus absolute risk reduction (ARR) and (2) the impact of increasing out-of-pocket drug expenditures on acceptance of guideline concordant therapy. DESIGN Cross-sectional survey of patients and physicians. SUBJECTS AND SETTING Female patients age >50 years and providers drawn from academic and community outpatient clinics. MEASUREMENTS Patient and provider acceptance of pharmacotherapy when treatment efficacy (reduction in hip fractures) was expressed alternatively in relative terms (35% RRR) versus absolute terms (1% ARR); acceptance of pharmacotherapy as patient drug copayment increased from 0% to 100% of the total drug costs. RESULTS Compliance with CPGs fell significantly when the expression of treatment benefit was switched from RRR to ARR for both patients (86% vs 57% compliance; P < .001) and physicians (97% vs 56% compliance; P < .001). Increasing drug copayment from 0% to 10% of total drug cost decreased patient compliance with CPGs from 80% to 57% (P < .001) but did not impact physician compliance. With increasing levels of copay, both patient and provider interest in treatment decreased. LIMITATIONS Respondents may not have fully understood the risks and benefits associated with osteoporosis and its treatment. CONCLUSION Patient and provider interest in CPG-recommended treatment for osteoporosis is reduced when treatment benefit is expressed as ARR rather than RRR. In addition, minimal increases in drug copayment significantly decreased patient, but not provider, interest in osteoporosis treatment. Designers of P4P programs should consider details including expressions of treatment benefit and patients’ out-of-pocket costs when developing measures to assess quality-of-care. Dr. Sinsky presented this work at the 2006 national SGIM meeting in Los Angeles.     

冠心病患者白细胞膜黏附分子CD11b/CD18表达的研究

目的探讨冠心病患者中性粒细胞和单核细胞膜黏附分子CD11b/CD1s的表达.方法对60例冠心病患者(冠心病组)采用流式细胞仪直接免疫荧光法与20例正常者(正常组)比较检测中性粒细胞和单核细胞膜黏附分子CD11b/CD18的表达.结果冠心病组中性粒细胞和单核细胞膜黏附分子CD11b/CD18表达较正常组均增加,有显著性差异(P＜0.05),环磷酸腺苷葡胺对不稳定性心绞痛患者干预后,其表达显著增高,有极显著性差异(P＜0.01).结论冠心病患者中性粒细胞和单核细胞膜黏附分子CD1tb/CD18表达明显增加,其增加程度与心肌缺血的类型有关.     

The effect of matching comprehensive services to patients' needs on drug use improvement in addiction treatment

AIMS: To examine whether need-service matching in addiction treatment leads to improvements in drug use, and whether treatment duration mediates those improvements. DESIGN, PARTICIPANTS, MEASUREMENTS: This analysis utilizes prospective data from a US cohort of addiction treatment patients who reported service needs beyond core rehabilitative services (n = 3103). 'Drug use improvement' is the difference between the patient's peak drug use frequency (in days per month) in the year before intake and in the year after treatment. Overall and primary use of the major illicit drugs (heroin, powder or crack cocaine and marijuana) are considered separately. 'Need-service match' means that a patient rated a service as important at intake and reported its receipt during treatment. 'Percentage of needs matched' indicates the proportion of five service domains (medical, mental health, family, vocational and housing) so matched. FINDINGS: In mixed regression models controlling for multiple factors, a greater percentage of needs matched tended to improve primary (beta = 0.028, P = 0.09) and overall (beta = 0.049, P = 0.05) drug use in the follow-up year. Exclusion of treatment duration as a covariate doubled the magnitude of these coefficients. The benefits of matching were concentrated among the half of patients reporting needs in four to five rather than one to three domains, and were strongest among patients in long-term residential facilities. Addressing vocational and housing needs exerted the greatest effects. CONCLUSIONS: Matching comprehensive services to needs is a useful addiction treatment practice, especially for high-need patients. Treatment duration might partially mediate its effect.     

罗格列酮对2型糖尿病合并颈动脉粥样硬化患者血清基质金属蛋白酶-9及C-反应蛋白的影响

目的探讨罗格列酮(Rosiglitazone)的抗炎、抗动脉粥样硬化(AS)作用及其机制。方法应用彩色多普勒超声测量颈动脉内中膜厚度(IMT)及斑块情况以判定颈动脉粥样硬化,将2型糖尿病颈动脉粥样硬化患者随机分为罗格列酮治疗组和非罗格列酮治疗组。采用酶联免疫吸附(ELISA)法测定血清基质金属蛋白酶-9(MMP-9)、C-反应蛋白(CRP)水平,观察罗格列酮治疗前后MMP-9、CRP水平变化及与非罗格列酮治疗组之间变化的差别。结果应用罗格列酮治疗组治疗2周时的血清MMP-9、CRP水平分别为[397.3(282.4~600.9)]μg/L、[3.54(1.68~8.48)]mg/L,较治疗前水平[600.3(467.1~836.2)]μg/L、[5.98(3.90~10.92)]mg/L明显下降,且较非罗格列酮治疗组下降更加明显,而空腹血糖(FPG)在两治疗组间无显著性差异。罗格列酮治疗12周时的血清MMP-9、CRP水平较治疗2周时明显下降,分别为[259.3(136.0~495.2)]μg/L,[1.71(1.01~4.63)]mg/L。结论罗格列酮具有抗炎及独立于降糖之外的抗AS作用,且在一定时期内具有时间依赖性。     

替米沙坦对体外培养THP-1源性巨噬细胞MMP-9与CD40/CD40L表达的影响

目的:通过观察替米沙坦对体外培养的THP-1源性巨噬细胞基质金属蛋白酶9(MMP-9)及白细胞分化抗原CD40/CD40L表达的影响,揭示替米沙坦抗炎作用的可能机制,同时明确替米沙坦的心血管保护作用。方法:用一定浓度的血管紧张素Ⅱ(AngⅡ)(10 000 nmol/L)诱导体外培养的巨噬细胞,与不同浓度的替米沙坦共同孵育,以MMP-9和CD40/CD40L为指标,应用RT-PCR方法分别检测MMP-9和CD40/CD40L mRNA表达。结果:替米沙坦可同时下调AngⅡ刺激后的MMP-9、CD40和CD40L mRNA的表达,有剂量依赖性。替米沙坦100 nmol/L、1 000 nmol/L、10 000 nmol/L时,MMP-9mRNA的表达与AngⅡ组相比分别下降24%、42%及62%;CD40、CD40LmRNA的表达与AngⅡ组相比分别下降24%、39%、55%、16%、32%及40%。结论:替米沙坦体可下调外培养巨噬细胞MMP-9的表达,从而具有抗炎及稳定斑块作用,其作用机制与抑制CD40/CD40L通路有关。