The Washington Circle continuity of care performance measure: Predictive validity with adolescents discharged from residential treatment

This study examined the predictive validity of the Washington Circle (WC) continuity of care after long-term residential treatment performance measure, as well as the impact of assertive continuing care interventions on achieving continuity of care. This measure is a process measure that focuses on timely delivery of a minimal floor of services that are necessary to provide sufficient quality of treatment but should not be construed to be the optimal continuity of care after residential treatment for any specific adolescent. Participants included 342 adolescents who were admitted to long-term residential treatment and randomly assigned to either standard continuing care or an assertive continuing care condition. Overall, results provide initial support for the WC continuity of care after residential treatment performance measure as a useful predictor of 3-month recovery status. In addition, assignment to an assertive continuing care condition was found to significantly increase the likelihood of achieving continuity of care.     

Promoting recovery in an evolving policy context: What do we know and what do we need to know about recovery support services?

As both a concept and a movement, “recovery” is increasingly guiding substance use disorder (SUD) services and policy. One sign of this change is the emergence of recovery support services that attempt to help addicted individuals using a comprehensive continuing care model. This paper reviews the policy environment surrounding recovery support services, the needs to which they should respond, and the status of current recovery support models. We conclude that recovery support services (RSS) should be further assessed for effectiveness and cost-effectiveness, that greater efforts must be made to develop the RSS delivery workforce, and that RSS should capitalize on ongoing efforts to create a comprehensive, integrated and patient-centered health care system. As the SUD treatment system undergoes its most important transformation in at least 40 years, recovery research and the lived experience of recovery from addiction should be central to reform.     

Predictors of engagement in continuing care following residential substance use disorder treatment

BACKGROUND: Patients in intensive SUD programs who subsequently participate in continuing care for a longer interval have better outcomes than those who participate for a shorter interval. We sought to identify patient and program factors associated with duration of engagement in SUD continuing care after residential/inpatient treatment. METHODS: Patients (n=3032) at 15 geographically diverse SUD residential treatment programs provided data on demographics, symptom patterns, recovery resources, and perceptions of treatment environment. We identified patient characteristics associated with the number of consecutive months of engagement in continuing care. We then consolidated and classified risk factors into an integrated model. RESULTS: Being African American, having more SUD and psychiatric symptoms, more resources for recovery, and perceiving the treatment staff as being supportive were associated with longer engagement in continuing care. African Americans' engagement in continuing care was 17% longer than Caucasians'. The positive effect of being African American was partially mediated by having taken actions toward changing use, and by the presence of psychotic symptoms. CONCLUSION: These results extend previous research on the predictors of continuing care engagement after residential SUD programs. Clinicians can use information about characteristics that put patients at risk for shorter engagement in continuing care to target patients who might benefit from interventions to increase engagement in continuing care.     

Leveraging technology to enhance addiction treatment and recovery

Technology such as the Internet and mobile phones offers considerable promise for affecting the assessment, prevention, and treatment of and recovery from substance use disorders. Technology may enable entirely new models of behavioral health care within and outside of formal systems of care. This article reviews the promise of technology-based therapeutic tools for affecting the quality and reach of addiction treatment and recovery support systems, as well as the empirical support to date for this approach. Potential models for implementing technology-based interventions targeting substance use disorders are described. Opportunities to optimize the effectiveness and impact of technology-based interventions targeting addiction and recovery, along with outstanding research needs, are discussed.     

Comparison of Black Student Enrollment in US Schools and Colleges of Pharmacy,Medicine, and Dentistry

Objective. Promoting equity and diversity in health care must include increasing the population of minority health care professionals. The purpose of this study was to: evaluate changes in Black professional student enrollment in schools and colleges of pharmacy, medicine, and dentistry; determine whether significant differences exist in Black professional student enrollment among these schools; and rate schools on how well Black professional student enrollment reflects state populations and compare ratings between 2010 and 2019 (for purposes of this study, professional student refers to students enrolled in Doctor of Medicine [MD], Doctor of Pharmacy [PharmD], or Doctor of Dental Medicine [DMD]/Doctor of Dental Surgery [DDS] degree programs).Methods. Enrollment data were obtained through the American Association of Colleges of Pharmacy, Association of American Medical Colleges, and American Dental Association for fall 2010 through fall 2019. The average percentage of Black students enrolled and the rate of change over time was determined. Schools were rated on their percentage of Black students relative to the percentage of Black residents in their state. Kruskal-Wallis H test, Wilcoxon signed rank tests, and chi-square tests were performed to quantify differences in enrollment and college ratings.Results. Schools of pharmacy and medicine experienced a significant increase in Black student enrollment between 2010 and 2019, but schools of dentistry did not. Pharmacy and medical schools also had significantly greater Black student enrollment in 2019 compared to dentistry. The proportion of schools of pharmacy and medicine with failing ratings decreased between 2010 and 2019.Conclusion. To facilitate improved access and limit health and health care disparities, it is important that health professions schools and colleges reflect the diversity of the patient populations they serve. Serious and intentional efforts toward diversification, inclusivity, and equity are necessary to improve Black student enrollment.     

持续性护理干预对骨折术后肢体功能恢复的效果观察

目的探讨持续性护理干预对骨折术后肢体功能恢复的效果观察影响。方法120例髋部骨折患者根据护理参与的不同分为治疗组与对照组各60例,对照组在术后采用常规护理方法,治疗组在此基础上给予积极的持续性护理干预措施。结果护理后治疗组的Harrishipscore（Harris）评分明显高于对照组,对比差异明显（t--5．214,P〈0．05）。护理后治疗组在生活质量的总分与四个领域的得分都明显高于对照组U）〈0．05）。结论持续性护理干预应用老年髋部骨折术后有利于肢体功能恢复与生活质量的提高,值得推广应用。     

Outpatient continuing care after residential substance use disorder treatment in the US Veterans Health Administration: Facilitators and challenges

Background: In the U.S. Veterans Health Administration (VHA), residential treatment programs are an important part of the continuum of care for patients with substance use disorders (SUDs). Outpatient continuing care after residential treatment helps maintain early recovery and treatment gains. Knowing more about the drivers of variation in continuing care practices and performance across residential programs might inform quality improvement efforts. Methods: Metrics of continuing care were operationalized and calculated for each of VHA's 63 SUD Residential Rehabilitation Treatment Programs (SUD RRTPs) and 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track in fiscal year 2012. Management and frontline staff of these programs were then interviewed to learn what factors might contribute to high or low program performance on the metrics compared with national averages. Results: Among SUD RRTPs, the mean rate of outpatient SUD/MH continuing care was 59% within 7 days and 80% within 30 days, and the mean rate of SUD continuing care was 63% within 30 days. Among MH RRTPs with a SUD track, these rates were 56%, 75%, and 36%, respectively. There was substantial variability in continuing care rates across the 97 programs: 21%–93% for SUD/MH care within 7 days, 36%–100% for SUD/MH care within 30 days, and 4%–91% for SUD care within 30 days. Interviews with representatives of 44 programs revealed key facilitators of continuing care: accountability of program staff, predischarge scheduling, predischarge introductions to continuing care providers, strong patient relationships, accessibility, and persistent emphasis. Key challenges included inadequate program staffing, lack of program staff accountability, and poor accessibility. Conclusions: Wide variation in continuing care rates across programs and identification of common facilitators at high-performing programs suggest substantial opportunity for improvement for programs with lower performance.     

Effects of 12-step mutual support and professional outpatient services on short-term substance use outcomes among adults who received inpatient treatment

BackgroundContinuing care is increasingly prioritized in the treatment of substance use disorders (SUDs). Ongoing engagement in continuing care, including mutual support (e.g., 12-step groups) and/or professional outpatient services, may enhance treatment outcomes and facilitate recovery.ObjectiveThis study investigates how engagement in 12-step mutual support and professional outpatient services is associated with short-term substance use outcomes in a sample of patients who completed inpatient SUDs treatment.MethodsAs part of the Recovery Journey Project – a longitudinal cohort study – participants completed questionnaires upon admission to an inpatient SUDs treatment program, and at 1- and/or 3-months post-discharge (n = 379). Baseline data were collected by self-administered, electronic questionnaires. Follow up data were collected by phone or email. Analyses involved multivariate Generalized Estimating Equations separately modelling self-reported abstinence and percent days abstinent (PDA) over the three time periods.ResultsOverall, rates of self-reported abstinence and PDA increased significantly from baseline to 1- and 3-months follow up. Engagement in 12-step activities (i.e., attended 30 meetings in 30 days, had a home group, had a sponsor, did service work) and professional outpatient substance use support were each significantly associated with abstinence and PDA. Participants who reported a higher degree of 12-step involvement (defined as engagement in more 12-step activities) were also more likely to report being abstinence and greater PDA.ConclusionsEngagement in continuing care, including 12-step activities and professional outpatient substance use support, was highly associated with substance use. Clinical teams should encourage participation in such activities to optimize treatment outcomes.     

Struggling to achieve a ‘normal life’: A qualitative study of Vietnamese methadone patients

Background:Methadone maintenance treatment, initially introduced in Vietnam for HIV harm reduction, has marked a significant switch in the country’s drug policy – from addiction as a moral issue to addiction as a brain disease. After the some initial outstanding achievements, the programme is facing a high dropout rate that threatens both goals of HIV prevention and drug treatment. This sociological study, as part of an HIV intervention research project, explores the challenges and opportunities that individuals who use drugs are faced with in relation to addiction treatment.Methods:A qualitative study among drug users with and without methadone maintenance treatment experiences recruited by peer outreach workers. We conducted 58 in-depth interviews and 2 focus groups between 2016 and 2017.Results:The start of treatment brought about significant feelings of success as heroin use was no longer compulsive. However, being in treatment programmes is also challenging with respect to continuing the recovery process. Barriers to retention include a popular fear of methadone as another harmful drug, a feeling of dependence related to the current practices of methadone treatment programmes and a poor therapeutic relationship. In the face of such challenges, the two major motivations that keep patients in care come from the desire to completely break up with heroin and the pursuit of family happiness.Conclusion:The current practices of methadone programmes pose challenges to patients’ recovery efforts from addiction and threaten treatment retention. Prompt interventions are needed to help Vietnam attain its objective of providing better care for larger vulnerable populations.     

Extending residential care through telephone counseling: initial results from the Betty Ford Center Focused Continuing Care protocol

There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the "real world". This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described.     

Perceptions about Recovery Needs and Drug-Avoidance Recovery Behaviors among Youth in Substance Abuse Treatment

Abstract

Objective: This study used mixed methods to explore youth attitudes about recovery-related needs and important drug-avoidance behaviors after treatment. Method: Focus groups were conducted with 118 substance using youth in treatment (four residential and 10 outpatient settings) throughout Los Angeles County. Results: The average age was 17.4 (SD?=?2.9); 78.3% were male, 66.1% Latino; and most were in treatment for primary marijuana (40.9%) or methamphetamine (30.4%) abuse. Quantitatve results from the drug-avoidance activity survey identified the following factors youth rated as important to their recovery after treatment: lifestyle improvement activities (95.7%); changing personal drug behaviors (89.6%); drug environment/culture change activities (82.5%); with the least important being therapeutic activities (78.5%). Qualitative findings from focus groups that asked what youth think are important for recovery programs to address after treatment revealed the following four areas: (1) recovery promotion to developmentally appropriate activities (95%); (2) facilitating the use of coping skills to deal with stress (85%); (3) offering alternative recovery support options (not just abstinence only) (75%); and (4) continuing to provide substance use education (65%). Conclusion: Findings highlight essential aspects of recovery in terms of need and drug-avoidance behaviors considered important to youth in treatment. Such information will help to better address clinical and recovery support models aimed at relapse prevention to ensure that the perceived problems of substance-abusing youth are adequately met.     

The Evolving Role of Historically Black Pharmacy Schools in a Changing Environment

Objective. To provide a comprehensive review of the contributions of historically Black colleges and universities (HBCUs) to creating a diverse pharmacist workforce and identify opportunities for future contributions. This was accomplished by comparing enrollment at HBCUs to overall US enrollment of African American pharmacy students and then comparing those numbers to national enrollment of pharmacy students, analyzing contributions of HBCUs to underrepresented pharmacy student enrollment, evaluating overall changes to pharmacy school enrollment and impact on enrollment at HBCUs, and identifying areas of opportunity to enhance the future contributions of HBCUs.Findings. There are six HBCU pharmacy schools in the United States. Although HBCU pharmacy schools made up only 4% of the total number of US pharmacy schools, they accounted for an average of 22.8% of the total African American student enrollment in pharmacy schools over a five-year period (2015-2019). An average of 13.8% of the total population of underrepresented people of color (UPOC) enrolled in US pharmacy schools from 2015-2019 attended an HBCU pharmacy school.Summary. Historically Black colleges and universities have consistently made significant contributions to the total pharmacy school population of African Americans, as well as that of Native Hawaiian and other Pacific Islanders and American Indian and Alaska Natives. These institutions have an opportunity to enhance their impact and serve in graduating the diverse pharmacy workforce needed in the future. Historically Black colleges and universities can achieve this goal by making significant efforts to recruit LatinX pharmacy students and by increasing their recruitment of African Americans, Native Hawaiian and other Pacific Islanders, and American Indian and Alaska Natives.     

Reinforcement-based therapy: 12-month evaluation of an outpatient drug-free treatment for heroin abusers

This controlled study examined the efficacy of reinforcement-based therapy (RBT) for producing enhanced abstinence outcomes over 12 months in opioid-dependent patients exiting a brief residential detoxification. Patients were randomly assigned upon completing their medically managed taper (i.e., detoxification) to RBT (N=66) or usual care (N=64) referral to community treatment programs. The 6-month RBT program offered an array of abstinence-based incentives including rent payment for recovery housing, program-led recreational activities and skills training for procuring employment. RBT produced significantly higher self-report and urinalysis-confirmed rates of abstinence from opioids and cocaine relative to usual care at 1 (42% versus 15%) and 3 (38% versus 17%) months during treatment but not at 6 or 12 months after enrollment. The RBT but not the usual care group showed significant increases in the number of days worked and the amount of legal income earned at 3, 6 and 12 months. The results of this randomized study suggest that an intensive reinforcement-based therapy that includes abstinence-based recovery housing is a promising approach; however, further research is needed to determine the role of treatment intensity and the specific efficacy of RBT's component parts.     

Drug test results as a predictor of retention among patients using buprenorphine in a comprehensive outpatient treatment program

The study examined the relationship between continued non-medical drug use and treatment retention for patients receiving buprenorphine maintenance treatment in a comprehensive addiction treatment program. The participants were 106 newly admitted patients and 103 continuing patients in treatment for an average of 9.4 months at the start of the study. Retrospective chart reviews were used to determine for each group whether the use of illicit, non-prescribed drugs during a 3-month baseline period was associated with lowered rates of treatment retention over the following 14 months. The New Admissions group was divided into 4 subgroups based on the percentage of urine drug tests that were positive during baseline: 0, 1–33, 34–67, or 68–100%. Because only 16 (15%) of the continuing patients had positive drug tests during baseline, the continuing group was divided into just 2 subgroups—no positives and any positives. Newly admitted patients testing positive for drugs more than 33% of the time were significantly more likely than those with less frequent or no positive tests to withdraw from treatment within 2 months. Continuing patients with at least 1 positive drug test left treatment 6 months sooner, on average, than those with no positive tests and were twice as likely to leave without completing continuing care (87 to 42%). Non-prescribed drug use during buprenorphine maintenance treatment is strongly correlated with lowered retention and risk of early treatment termination for new and continuing patients. Actions taken to monitor and reduce drug use during buprenorphine maintenance treatment may improve retention and enhance long-term recovery outcomes.     

Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment

In many treatment systems, adolescents referred to residential treatment have the most serious alcohol or other substance use disorders and are at high risk of relapse. Upon discharge, these adolescents are typically referred to continuing care services, however, linkage to these services is often problematic. In this study, 114 adolescents (76% male) who stayed at least 7 days in residential treatment were randomly assigned to receive either usual continuing care (UCC) or UCC plus an assertive continuing care protocol (ACC) involving case management and the adolescent community reinforcement approach. ACC participants were significantly more likely to initiate and receive more continuing care services, to be abstinent from marijuana at 3 months postdischarge, and to reduce their 3-month postdischarge days of alcohol use. Preliminary findings demonstrate an ACC approach designed for adolescents can increase linkage and retention in continuing care and improve short-term substance use outcomes.     

Continuing care research: What we have learned and where we are going

In the field of addiction treatment, the term continuing care has been used to indicate the stage of treatment that follows an initial episode of more intensive care. This article reviews controlled studies of continuing care conducted over the prior 20 years. The results indicate that continuing care interventions were more likely to produce positive treatment effects when they had a longer planned duration, made more active efforts to deliver treatment to patients, and were studied more recently. However, there was considerable variability in patient response and room for improvements in participation rates and effectiveness. It is possible that the effectiveness of continuing care interventions could be further improved by the use of adaptive algorithms, which adjust treatment over time based on changes in patients' symptoms and status. The use of alternative service delivery methods and care settings may also lead to greater engagement and retention in continuing care, particularly among the large numbers of individuals who do not want traditional, clinic-based specialty care.     

Perceptions of the importance of physical setting in substance abuse treatment

Research indicates that architectural design can provide therapeutic effects. Six setting characteristics are considered of primary importance in health-care facilities: comforts and conveniences, safety, attractiveness, size, privacy, and arrangement/location. This study presents the perceptions regarding these and other setting features held by female clients and staff from a substance abuse treatment facility. Results support the importance of these six setting characteristics in influencing clients' treatment goals. Four other setting variables emerged as important to women's recovery: participation in a residential, drug-free, gender-specific program that provides on-site child care. Attention to these variables may provide facilities with an advantage in today's competitive market for clients.     

One-year outcomes of telephone case monitoring for patients with substance use disorder

Background

Many patients treated for substance use disorder (SUD) do not achieve lasting recovery from a single episode of treatment and require continuing care. The current randomized clinical trial investigated whether in-person continuing care as usual (CCAU) following intensive outpatient SUD treatment leads to better SUD outcomes when compared with telephone case monitoring (TCM).

Method

This study randomized 667 intensive SUD outpatients to telephone case monitoring versus face-to-face continuing care as usual at two sites. Patients completed data at baseline, 3 and 12 months with telephone interviews. Data of interest include self-report of substance use, psychiatric symptoms, quality of life, and treatment satisfaction. We also evaluated potential interaction effects for distance to VA provider, SUD severity, and presence of co-morbid psychiatric disorder.

Results

Participants randomized to the telephone case monitoring condition substantially engaged with face-to-face continuing care resulting in cross-over contamination. We addressed this issue by using randomization as an instrumental variable to evaluate the impact of telephone case monitoring (contamination adjusted, intent to treat analysis). Instrumental variable analyses indicated significant benefit of telephone case monitoring for drug and alcohol percent days abstinent and psychiatric symptom outcomes at 3-months follow-up, but not at 12-month follow-up. No interaction analyses were significant.

Discussion

Participants receiving telephone case monitoring achieved better short term outcomes in terms of substance use and psychiatric symptoms. The “on treatment” effects suggests the need for future studies to investigate consumer (patient) perspectives on the optimal duration of telephone case monitoring and use of alternative monitoring methods such as text messaging.