Processes and Outcomes of Substance Abuse Treatment Between Two Programs for Clients Insured Under Managed Care

The purpose of this research (N = 160) was to describe and compare substance abuse treatment in two programs under managed care: one residential (RT) and one outpatient (OP). Clients in both settings improved significantly from before to after treatment in relation to substance use and quality of life. However, intensity of treatment (hours of care/week) was much greater in RT and days of sobriety were significantly higher after treatment in RT than in OP (p = .04). Intensity was negatively related to incidents of substance use during treatment (SUdT), which predicted substance use after treatment; SUdT averaged. 2 for RT, and 1.6 for OP (p = .0001). Importantly, treatment was completed by 74 patients (over 90%) from RT, with 8 dropping out, and 53 (almost 70%) of those in OP completed treatment while 25 dropped out. Intensity, as seen in the RT program, rather than duration, was more effective in substance use reduction and treatment completion.     

The Impact of Childhood Maltreatment on Young Adults' Substance Abuse

Designed to establish a causal relationship between childhood victimization and young adults' substance abuse, this study also examined depression's role as mediator in that causal relationship. The study employs child-abuse measures that weigh both the type (sexual, physical) and the persistence of abuse. The study took as its substance-abuse measures the DSM-IV criteria for current alcohol abuse, current marijuana abuse, and current drug abuse. Data from the first 5 waves of the National Youth Survey (NYS) was employed, along with data from its 7th wave, to establish the temporal order needed to determine causal relationship. Childhood physical abuse proved a strong predictor of young adults' current substance abuse, although sexual abuse did not. Depression was shown to mediate the relationship of physical abuse to current alcohol abuse and current drug abuse, but not to current marijuana abuse.     

Adolescent Substance Use Assessment in a Primary Care Setting

Health initiatives suggest that adolescent substance use assessment may be beneficial as part of primary care to screen for early problematic behaviors. To examine the accuracy of such reporting, we compared the anonymous and confidential self-reports of 180 adolescents in a primary care setting. Matching samples to control for demographic variables, we found that adolescents were more likely to report marijuana use and substance use behaviors, such as selling drugs, when reporting anonymously vs. reporting confidentially. These results challenge the accuracy of confidential self-reports within this setting, and suggest further research is needed.     

A Population-Based Study on Substance Abuse Treatment for Adults with Disabilities: Access,Utilization, and Treatment Outcomes

Aims: To examine potential disparities in access to substance abuse treatment services for Medicaid-eligible adults with disabilities, and compare utilization rates and outcomes in outpatient programs. Design: Population-based multi-year cross-sectional study. Setting: State-wide examination of substance-abuse treatment, particularly outpatient. Participants: Medicaid enrollees aged 18–64. Measures: Treatment access and utilization; outcome measures of retention, completion, readmission, and abstinence derived from state treatment and Medicaid databases. Findings: Access and utilization rates for adults with disabilities were about half others' rates; treatment outcomes were generally equivalent across groups. Conclusions: Adults with disabilities are underutilizing substance abuse treatment, suggesting barriers to accessing treatment.     

Indigenous Traditional Knowledge and Substance Abuse Treatment Outcomes: The Problem of Efficacy Evaluation

Background: In the field of substance abuse treatment, American Indian and Alaska Native (AI/AN) communities have routinely incorporated ceremonial practices as one important component in the promotion of recovery and healing. The beneficial effects of such practices are frequently described as plainly apparent by community-based advocates, providers, and professionals alike. In the present era of evidence-based substance abuse intervention, however, indigenous integration of such practices raises questions pertaining to the systematic evaluation of treatment efficacy. Objectives: The focus of this article is outcome evaluation. Although intervention outcome researchers recognize the randomized controlled trial as the “gold standard” against which claims of treatment efficacy are measured, AI/AN efficacy assertions grounded in indigenous traditional knowledge (ITK) reflect different concerns that have emerged in non-Western historical contexts. The interface between scientific and indigenous “ways of knowing” is explored here relative to efficacy claims about substance abuse treatment. Methods: Distinguishing features of both scientific knowing and ITK are summarized and compared. Results: ITK has been described as personal and experiential, reflecting the primacy of autonomous individual knowing. In contrast, intervention scientists are skeptical of personal inference as a basis for efficacy evaluation. The evident divergence between these epistemic paradigms can result in potentially contradictory claims. Conclusion: Proper appraisal of the status and relevance of ITK for determining treatment efficacy requires further exploration of these marginalized approaches to knowledge. Scientific Significance: Intervention scientists who work in AI/AN communities should remain open to the legitimacy and role of ITKs in investigations of substance abuse treatment.     

Assessing the Service Linkages of Substance Abuse Agencies with Mental Health and Primary Care Organizations

Fragmentation of substance abuse treatment represents a major barrier to effective treatment for individuals with cooccurring substance abuse and mental and physical health disorders. Linkages of substance abuse treatment organizations with primary care and mental health agencies are widely considered to be a feasible way to integrate services. In this study, we analyzed information collected from a national sample of 62 outpatient substance abuse treatment units (OSATs) to understand the extent of services linkages in these organizations and to identify facilitators and barriers to service linkages. Results showed that OSATs had limited service linkages with primary care and mental health providers. The cited barriers to linkages included clients' financial problems, managed care restrictions, and limited organizational capacity. Onsite service provision was implemented in some OSATs. The pattern of service linkages in OSATs appeared to reflect the health needs of substance abuse clients.     

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.     

Quality of Life Assessments by Adult Substance Abusers Receiving Publicly Funded Treatment in Massachusetts

Purpose. Quality of life (QOL) has become an important endpoint in clinical trials and studies of medical interventions for many chronic diseases, but has not been widely studied in the substance abuse field. The purpose of this study was to measure QOL in a large sample of adult substance abusers (SA), to compare QOL ratings with those for other chronic diseases, and to assess factors influencing QOL levels in this population.

Methods. Hour-long personal interviews were administered to 570 randomly selected substance abuse clients in six detoxification centers and seven outpatient facilities in Massachusetts. Two QOL instruments—the Multidimensional Index of Life Quality (MILQ) and the SF-12—were used to measure QOL. Substance use problems were measured by the Addiction Severity Index Drug and Alcohol composite scores. QOL scores were compared to those for patients with other chronic diseases. Multivariable regression analysis was used to estimate the influence of demographic characteristics, co-morbidities, and substance use on QOL summary scores.

Results. SA clients reported significantly lower QOL scores than patients about to undergo heart surgery on seven of the nine MILQ domains as well as the MILQ QOL summary index. SA clients also had much lower mean scores than the general population on both the SF-12's Mental Health (ES=?1.80) and Physical Health (ES=?0.58) component scales. SF-12 physical component scores were similar to those for other chronic diseases, but mental component scores were markedly lower and comparable on average to clinically depressed groups. In the regression model, MILQ Index scores were significantly lower for dual diagnosis and detoxification cases. Index scores were negatively associated with ASI drug composite scores, but not with ASI alcohol scores.

Implications. The results of this study suggest that the physical functioning of adult substance abusers is similar to the levels for patients diagnosed with other serious chronic diseases, but that mental functioning is much lower. QOL provides information about functioning and well-being that is not captured by traditional measures of substance use, and may soon begin to play a more prominent role in evaluating the effectiveness of treatment services for substance abusers.     

Arab Americans in Publicly Financed Alcohol/Other Drug Abuse Treatment

Little is known about Arab Americans, a rapidly growing ethnic group, and their involvement in alcohol/other drug abuse treatment. Using fiscal year 2005 Michigan data for all publicly funded alcohol/other drug abuse treatment, Arab American admissions were compared to admissions for American Indian, Hispanic, African American, and Non-Hispanic/Non-Arabic White. Arab Americans appear to account for a disproportionately small percentage of admissions to publicly funded alcohol/other drug abuse treatment. Admission profiles were generally similar across ethnicities, with the exception that Arab Americans were entering treatment after shorter duration of use. These data can inform development of treatment programs and outreach efforts.     

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.     

Advancing American Indian and Alaska Native Substance Abuse Research: Current Science and Future Directions

American Indians and Alaska Natives (AI/AN) have disproportionately high rates of substance abuse yet there is little empirical research addressing this significant public health problem. This paper is an introduction to a special issue that includes cutting edge science in this research area. We identify several areas that require consideration in this field and indicate how the papers in the special issue address these gaps. These overarching areas of need, which should be considered in any substantive research, include attention to heterogeneity within the population, research that has tangible health benefits, continued work on research methods and strategies, increased focus on strength based and community oriented approaches, and the need for strong research partnerships. The special issue marks a major step forward for AI/AN substance abuse research. However, articles also highlight where more work is need to improve public health in AI/AN communities by addressing identified gap areas.     

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.     

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.     

The Relationship Between Substance Abuse Performance Measures and Mutual-Help Group Participation after Treatment

The authors examined the relationship between treatment quality, using during-treatment process measures, and mutual-help group (e.g., Alcoholics Anonymous) attendance after outpatient substance use disorder (SUD) treatment for 739 clients in the Alcohol and Drug Services Study. Logistic regression models estimated any and regular mutual-help attendance after treatment. Clients referred to mutual-help groups were significantly more likely to attend any mutual help after treatment. Results were mixed for facility offered mutual-help groups; treatment engagement and retention were not significant. These findings offer treatment providers further evidence of the importance of referring clients to post-treatment mutual-help groups, an effective, low-cost option.     

Substance Abuse Treatment Readmission Patterns of Asian Americans: Comparisons with Other Ethnic Groups

Background and significance: According to New York statewide substance abuse treatment and discharge data, Asians are a small minority who differ significantly from other racial–ethnic groups on income, primary language, treatment setting, substance abuse, referral source, and discharge status. Objectives: The present study further compares alcohol and substance abuse service utilization patterns of Asians with those of Whites, Blacks, and Hispanics in New York State. Methods: Cox regressions were employed to examine the differences in treatment admission patterns among Asians and other ethnic groups, while controlling a number of demographic, treatment-related, and non-treatment-related factors. A sample of 408,158 clients was selected from the Client Data System of the New York State Office of Alcoholism and Substance Abuse Services for the analysis. Results: While Asians in general are less likely to use treatment services and to have multiple treatment admissions compared with other groups, those Asians with multiple admissions tend to show utilization patterns – the period of greatest risk for readmission, the rate at which readmissions occur, and the likelihood of readmission – similar to the other groups at each subsequent admission. Conclusion: These findings suggest both similarities and differences in treatment readmission patterns between Asians and other clients of substance abuse treatment services. Future research on the cultural and linguistic factors related to Asians’ recovery and service utilization patterns after the initial treatment experience may be particularly important for systems of care seeking to be responsive to Asians’ needs.     

Solution Focused Group Treatment with Publicly Funded Alcohol/Other Drug Abuse Clients in Rural Settings

The unique challenges associated with providing substance abuse treatment in rural settings with publicly funded clients are examined. Solution-focused strategies have proven particularly well suited to these settings. Strategies and techniques discussed include a strong focus on client engagement and use of client feedback, focus on “wellness,” use of the “miracle question,” and exception periods.     

Introducing Evidence-Based Practices into Substance Abuse Treatment using Organization Development Methods

Background: Dissemination of evidence-based practices (EBPs) in addiction settings is a national priority. We tested Organization Development (OD) methods for dissemination. Methods: Using OD in two addiction treatment programs we developed an organization-specific treatment plan using employee work teams with the goals of changes in organizational policies and procedures and improvement in practitioner skills. Results: OD was effectively applied, but EBPs were premature for these addiction programs because they first needed to address more fundamental aspects of client-clinician interaction and agency treatment philosophy. Conclusion: The OD approach in addiction treatment is complementary to other technology transfer efforts by being: (a) “organization-centered,” engaging practitioners at all levels; (b) “needs-focused,” addressing concerns of the particular organization; (c) flexible in its responsiveness to readiness for change; and (d) relatively affordable. However, before absorbing EBPs, substance abuse treatment organizations must develop strengths in delivering fundamental aspects of care.     

The Relationship between Antidepressant Use and Smoking Cessation in Pregnant Women in Treatment for Substance Abuse

Background: Bupropion's efficacy for smoking cessation in pregnant women is unknown. Objectives: To determine if substance-dependent women prescribed bupropion smoked fewer cigarettes/day than those prescribed citalopram/escitalopram or no antidepressant medication. Methods: Comparison of smoking in bupropion (n = 11), citalopram/escitalopram (n = 17), and no antidepressant (n = 28) groups. Results and Conclusions: Trend for greater decrease in smoking for the bupropion vs. citalopram/escitalopram group [?6.4 vs. ?.4 cigarettes/day (p = .276)], although the bupropion decrease was similar to that seen in the no antidepressant group [?5.3 cigarettes/day]. Scientific Significance: Data support continued study of bupropion in depressed pregnant substance-dependent smokers.     

Substance Abuse Treatment as HIV Prevention for Men Who Have Sex with Men

Substance abuse is a prominent risk behavior associated with HIV transmission, particularly for men who have sex with men (MSM) and who engage in sex while using substances. This paper argues that substance abuse treatment has significant value as an HIV-prevention method to the extent that treatment outcome influences sexual risk behaviors for MSM, presumably toward lower risk. We review studies of treatment and HIV risk behaviors for MSM, and describe the current status of effective substance abuse treatments. Clinical issues important to MSM receiving treatment are discussed: gay-specific versus mainstream treatment, gay sexuality issues in substance abuse treatment, gay Alcoholics Anonymous, and ethnicity issues. Based on these arguments, we make the following policy recommendations: (1) develop treatment strategies that target substance use and high-risk sexual behavior simultaneously, (2) recognize treatment as HIV prevention in this population, and (3) educate counselors on cultural and sexual risk issues specific to substance-abusing MSM.