An Argument for Choice: An Alternative Women’s Treatment Program

Current substance abuse treatment strategies tend to be relatively narrow and not empirically based. This is a result of a general failure on the part of practitioners to keep abreast of current research, which would direct them toward more effective models. Substance abuse treatment, usually based on a “one size fits all” philosophy, is often not particularly effective. Substance abuse research is often limited to the measurement of a single outcome—abstinence—and research on alternative models is scarce. This article argues for more flexible models of treatment that are based on research. A substance abuse treatment program that uses an empirically based model is described. The program incorporates broader outcomes research, which is yielding encouraging results. The suppositions that directed the research are discussed.     

Substance abuse prevention: moving from science to policy

Substance abuse exacts tremendous social and economic costs in the United States, making a response to this problem a priority for policy makers at all levels of government. Although little argument exists about whether government should play a role in substance abuse control, considerable debate has been generated about exactly what that role should be. Currently, the United States spends about twice as much on supply reduction as demand reduction strategies. Supply reduction strategies, such as law enforcement and interdiction, are often harsh and based on little or no scientific evidence that demonstrates efficacy. As a demand reduction strategy, drug treatment has been demonstrated to be cost-effective. Substance abuse prevention, however, has failed to establish a critical body of research with which to make its case. This paper suggests several direct ways in which prevention science can influence public policy and thus move prevention science to more effective substance abuse prevention policy.     

Treating adolescents for substance abuse and comorbid psychiatric disorders

Recent research has identified a cluster of standardized approaches that effectively treat adolescents with substance abuse disorders. Many of these approaches share elements that may be adopted to improve outcomes in substance treatment programs. In adolescents, treatment goals should be informed by a comprehensive assessment that includes the adolescent patient's developmental history and evaluation of psychiatric comorbidity. Treatment for behavioral, psychosocial, and psychiatric problems should be integrated with substance abuse interventions. The author describes practical clinical guidelines, grounded in current research, for providing integrated treatment services. Special emphasis is given to strategies for integrating the treatment of comorbid psychiatric disorders with substance use disorders in adolescents.     

Counseling substance abuse clients infected with human immunodeficiency virus

Some of the barriers to effective dual treatment of substance abuse and AIDS-related diagnoses have been detailed in this article, and some practical strategies to improve the response of treatment providers in caring for this difficult population of patients have been offered. While there are many problems associated with the dual diagnosis of substance abuse and AIDS, health care providers and substance abuse treatment professionals can intervene effectively by first recognizing how their own values and anxieties impact on treatment approaches. Next, they can accept substance abuse as a problem that can be treated and the diagnosis of AIDS as one issue of many that needs to be addressed. Finally, they can stay informed about community resources to help them make accurate assessments and to develop effective treatment strategies.     

Integrating skills training and motivational therapies. Implications for the treatment of substance dependence.

Two well-articulated models of substance abuse treatment, skills training and motivational enhancement, have received considerable research attention in recent years. Skills training treatments operate on the underlying rationale of correcting skills deficits, whereas motivational strategies are based on affecting clients' willingness to use skills they already possess. Skills training and motivational enhancement are typically described as distinct treatments and have recently been constructed as different treatments within a large multisite trial in the United States (Project MATCH). This article explores how treatments for substance abuse can draw from and integrate skills training and motivational strategies. Recovery from addictive patterns of behavior often requires learning over time and typically involves slips, relapses, and multiple quit attempts. Therapeutic support for change in addictive behavior, in particular attempting to prevent and minimize relapse, requires assessment and support of both why one might pursue change (motivation) and how one can best be successful (skills).     

Single versus multiple drug focus in substance abuse clinical trials research

Complex patterns of multiple substance use pose clinical and methodological challenges for substance abuse clinical trials research. To increase measurement precision and internal validity, the modal approach has been to target both treatment interventions and outcome assessment to a single class of abused substance. This strategy warrants reconsideration because it entails limitations in recruitment feasibility and generalization of study findings. This report reviews pros and cons of single versus multiple targeted drugs, suggests guidelines for choosing between these strategies and outlines methods for broadening the scope of substance abuse clinical trails to take abuse of multiple substances into account. We recommend that investigators consider moving away from a single drug focus in three ways. First, include systematic assessment of a wide range of psychoactive substance use throughout the trial and evaluate the impact of study treatments on use of all classes of drugs. Second, except where contraindicated, include patients who use and abuse multiple classes of substances even in trials evaluating treatment of a single targeted drug. Third, consider inclusion of polysubstance abusers or those who primarily abuse multiple classes of substances in the same clinical trial. Although many treatment efficacy questions can best be answered by single focus studies, we recommend that such designs be adopted only after less restrictive designs are first considered.     

Psychosocial and psychopathology differences in hospitalized male and female cocaine abusers: a retrospective chart review.

While considerable amounts of psychological and pharmacological data have been collected on male substance abusers in public treatment facilities, relatively little information is available about the psychosocial characteristics of men in private treatment settings and of women presenting for substance abuse treatment. The present study reviewed the records of 100 male and female cocaine abusers admitted to a private substance abuse treatment program between 1987 and 1989. Patterns of cocaine use and levels of impairment were found to be similar for men and women, with male cocaine abusers more likely to abuse additional substances. Male cocaine abusers were employed more frequently than women and held higher status jobs despite equivalent levels of education. Female cocaine abusers were more likely to be diagnosed with concurrent psychiatric disorders and were more likely to report family histories of substance abuse. Both groups produced elevations on MMPI scales indicating depression, anxiety, paranoid features, and acting-out tendencies. These data suggest that while male and female cocaine abusers show similarities on some measures, there are significant gender differences that may have implications for both research and treatment.     

The need for evidence-based research ethics: a review of the substance abuse literature

Participants in substance abuse research may be vulnerable for multiple reasons. International research ethics guidelines and policy statements require that researchers provide extra protections when conducting research with vulnerable subjects, but it is uncertain which measures best protect vulnerable individuals. Concerns about vulnerability have been translated into only the vaguest regulatory requirements, and very little empirical data exist to guide researchers and ethics review committee members who want to protect participants. This article reviews two bodies of substance abuse research ethics literature. First, "normative" articles, that is, articles that discuss ethical issues that may arise in substance abuse research, are discussed. The resulting taxonomy of ethical issues then guides a review of empirical studies on issues like the informed consent process and the use of financial incentives in substance abuse research. While the ethical issues in substance abuse research are numerous and well-documented, the evidentiary base for addressing these issues is inadequate. If any one major theme emerged from the existing studies, it is that many well-intentioned, protectionist concerns--about recruitment incentives, consent comprehension, and drug administration studies--are not supported by empirical data. While these findings are at best tentative, they suggest how research on research ethics might ultimately benefit participants.     

Treatment of substance abuse by relaxation training: a review of its rationale, efficacy and mechanisms

The efficacy of relaxation training as a treatment for alcohol and drug abuse is reviewed, and directions for future research derived. Such use of relaxation procedures, notably progressive muscular relaxation and meditation, has been widespread and is premised on the assumptions that substance abuse is causally linked to anxiety and that anxiety can be reduced by relaxation training. However, the evidence suggests that such precipitating anxiety is limited to interpersonal-stress situations involving diminished perceived personal control over the stressor, and that alcohol and other drugs are often consumed for their euphoric rather than tranquilizing effects. Consequently, the empirical support for the effectiveness of relaxation training as a treatment for substance abuse in general is equivocal. As well, the existing outcome studies suffer from numerous methodological and conceptual inadequacies. In cases of demonstrated effectiveness, increased perceived control is a more plausible explanation than is decreased anxiety.     

The adoption of medications in substance abuse treatment: associations with organizational characteristics and technology clusters

Despite growing interest in closing the "research to practice gap", there are few data on the availability of medications in American substance abuse treatment settings. Recent research suggests that organizational characteristics may be associated with medication availability. It is unclear if the availability of medications can be conceptualized in terms of "technology clusters", where the availability of a medication is positively associated with the likelihood that other medications are also offered. Using data from 403 privately funded and 363 publicly funded specialty substance abuse treatment centers in the US, this research models the availability of agonist medications, naltrexone, disulfiram, and SSRIs. Bivariate logistic regression models indicated considerable variation in adoption across publicly funded non-profit, government-owned, privately funded non-profit, and for-profit treatment centers. Some of these differences were attenuated by organizational characteristics, such as accreditation, the presence of staff physicians, and the availability of detoxification services. There was some evidence that naltrexone, disulfiram, and SSRIs represent a group of less intensely regulated medications that is distinct from more intensely regulated medications. These types of medications were associated with somewhat different correlates. Future research should continue to investigate the similarities and differences in the predictors of medication availability across national contexts.     

Utilizing dissemination findings to help understand and bridge the research and practice gap in the treatment of substance abuse disorders in Hispanic populations

This article focuses on the gap between research and practice in substance abuse treatment, identifies some of the key findings in the technology transfer literature, and discusses their relevance to the adoption of new technology among Hispanic serving agencies and counselors. In organizing the material we present information within the categories of: (1) evidence, (2) context, and (3) facilitation. When considering the "evidence" for empirically supported substance abuse treatments for Hispanics, there is great concern about the shortage of treatments that have been adequately tested with Hispanics. In this article, we analyze the strengths and weaknesses of strategies recommended to address this problem. In terms of the "context" in which evidence-based practices will be implemented, we consider counselor characteristics and organizational structures that may facilitate or hinder the adoption of these practices and discuss how these may impact Hispanic-serving agencies. Finally, the mechanisms necessary for "facilitation" of evidence-based practices in Hispanic-serving agencies are described. Given the dearth of dissemination research with Hispanics, as well as other minorities, each area described in this article presents unique challenges that can benefit from a field-wide discussion.     

Substance abuse treatment and HIV services: Massachusetts' policies and programs

States and communities use many strategies and policies to facilitate the integration of HIV and AIDS services with alcoholism and drug abuse treatment and prevention programs. Massachusetts' policy initiatives that promoted collaboration between substance abuse programs and AIDS services are outlined. The review begins with an overview of the HIV epidemic in Massachusetts and reflects on the initial challenges of building system capacity so that HIV and substance abuse services could become more closely integrated. The discussion summarizes specific policy strategies implemented to encourage system development and to develop program and staff skills for working with men and women with HIV/AIDS and at risk of infection. The initiatives included integration of alcoholism and drug abuse treatment programs, expansion of Medicaid reimbursement for substance abuse treatment, training and skills development for counselors, and coordinated service development and advocacy for substance abuse and AIDS/HIV services.     

Guidelines for Investigating Alcohol Problems and Developing Appropriate Responses

Abstract

This analysis is based on a follow-up study of 48 White male young adults who had been former youth multiple drug abuse patients in day-care treatment. For the most part, these respondents came from middle-class homes. As youthful offenders, many had been sent into treatment as an alternative to incarceration. Approximately six years after terminating their day-care treatments, interview data were collected when most were in their middle twenties. Consistent with previous research, those consuming more drugs were found to be more likely to have resisted treatment, to have trouble with the law, to have poorer work histories and diminished educational attainments, and they showed evidence of poorer psychological health. Surprisingly, the data also indicated that high-volume drug users were more likely to be living in their parental homes, compared to those whose drug use patterns were more moderate. It is suggested that the pattern of taking up residence with one's parents while drug dependent may be encouraged by parental enabling. The implications of these findings for guiding efforts in substance abuse treatment are discussed.     

Efficacy of acupuncture for treating cocaine addiction: a review paper

Acupuncture is being used in more than three hundred treatment facilities for treating substance abuse including cocaine addiction. Previous review papers could not evaluate the role of acupuncture for treating cocaine addiction because of lack of clinical trials at the time. Since then, several important studies were conducted in the field. This paper reviews existing clinical trials using acupuncture to treat cocaine addiction. The existing evidence fails to document the benefit of acupuncture in treating cocaine addiction as the sole treatment. Further efforts to document the efficacy of the NADA protocol to treat cocaine addiction as the sole treatment should be re-evaluated. There is a limited amount of evidence showing possible benefits of acupuncture when used as an adjunctive therapy to complement existing substance abuse treatment program. Future efforts should concentrate on systematic studies investigating the role of acupuncture as an adjunctive treatment for cocaine addiction. In addition, more formative research exploring the efficacy of different types and protocols of acupuncture treatments for cocaine addiction should be thoroughly investigated.     

Gender differences among prisoners in drug treatment

Purpose: Nearly all prison-based substance abuse treatment programs have been designed with male prisoners in mind. Administering these male-oriented programs to women prisoners has been the standard correctional practice. Recently, this practice has received considerable criticism. Critics argue that female prisoners have special needs that are not met by programs originally designed for male prisoners. However, most of the empirical support for the existence of such special needs rely on two inappropriate samples: prisoners who are not in treatment and treatment participants who are not incarcerated. Findings from these two different groups may not be generalizable to the population of prisoners in treatment. Methods: This paper directly addresses this generalizability problem with an examination of gender differences among 1326 male and 318 female federal prisoners who were enrolled in a substance abuse treatment program. Results: Women used drugs more frequently, used harder drugs, and used them for different reasons than men. Women also confronted more difficulties than men in areas linked to substance abuse such as educational background, childhood family environment, adult social environment, mental health, and physical health. Conclusion: We find support for the argument that substance abuse treatment programs which were originally designed for men may be inappropriate for the treatment of women.     

Alexithymia in Egyptian Substance Abusers

Alexithymia is thought of as a trait that predisposes to drug abuse. Moreover, it is suggested to be related to type of the substance abused, with the worst-case scenario including a worse prognosis as well as tendency to relapse or even not to seek treatment at all. To address this important subject in Egyptian patients, a sample of 200 Egyptian substance abusers was randomly selected from inpatients in the Institute of Psychiatry, Ain Shams University, Egypt. The study also included 200 group-matched controls. DSM-IV criteria were used for assessment of substance use disorders, and toxicologic urine analysis was used to confirm the substances of abuse. Toronto Alexithymia Scale (TAS)—Arabic version was used for assessment of alexithymia. It was found that alexithymia was significantly more prevalent in the substance use disorders group as compared to healthy controls. It was also found that among the substance use disorders group, alexithymics reported more polysubstance abuse, more opiate use (other than heroin IV), lower numbers of hospitalizations, lower numbers of reported relapses, and a lower tendency to relapse as a result of internal cues compared to patients without alexithymia. Statistically significant associations were also found between alexithymia and more benzodiazepine abuse and nonpersistence in treatment. The results suggest that alexithymia should be targeted in a treatment setting for substance use disorders.     

Alexithymia in Egyptian substance abusers

Alexithymia is thought of as a trait that predisposes to drug abuse. Moreover, it is suggested to be related to type of the substance abused, with the worst‐case scenario including a worse prognosis as well as tendency to relapse or even not to seek treatment at all. To address this important subject in Egyptian patients, a sample of 200 Egyptian substance abusers was randomly selected from inpatients in the Institute of Psychiatry, Ain Shams University, Egypt. The study also included 200 group‐matched controls. DSM‐IV criteria were used for assessment of substance use disorders, and toxicologic urine analysis was used to confirm the substances of abuse. Toronto Alexithymia Scale (TAS)—Arabic version was used for assessment of alexithymia. It was found that alexithymia was significantly more prevalent in the substance use disorders group as compared to healthy controls. It was also found that among the substance use disorders group, alexithymics reported more polysubstance abuse, more opiate use (other than heroin TV), lower numbers of hospitalizations, lower numbers of reported relapses, and a lower tendency to relapse as a result of internal cues compared to patients without alexithymia. Statistically significant associations were also found between alexithymia and more benzodiazepine abuse and nonpersistence in treatment. The results suggest that alexithymia should be targeted in a treatment setting for substance use disorders.     

The federal role in drug abuse technology transfer: a history and perspective

The past 30 years have seen a focus on substance abuse research in association with the creation of federal agencies specifically mandated to guide that effort. While research has been well supported and largely productive, there has been increasing concern with the slow pace of adoption of the findings from that research. The history of those efforts suggests a long-standing concern with knowledge development, and a continuing reliance on print media to achieve knowledge application. Nonetheless, evidence from other human service fields, and increasingly from the substance abuse field, indicates interpersonal strategies are dramatically more effective in achieving the individual and organizational behavior change needed to achieve technology transfer. Argument is made that the federal government remains the best, if not the only resource for promoting technology transfer. A paradigm is described to further federal efforts in this area, and structural elements suggested for the achievement of technology transfer goals.     

The moderating role of substance abusers’ personal attributes in predicting relapse and partner persuasiveness

In relationships where one partner is dependent on substances, the non-dependent, or “functional” partners use a variety of strategies to stop the abuse and prevent relapse. Inconclusive research results on the effectiveness of these strategies can be partially explained by the failure to consider personal characteristics of the substance abusers that may make them more or less receptive to their partners’ attempts at assisting them in their sobriety. This work explores the substance abusers’ anger, over-controlled hostility, and ego-strength as moderating factors influencing both the types and amounts of persuasive strategies used by the significant other. The sample was composed of 67 married or cohabitating couples with one functional and one substance-abusing partner (as assessed by the chemical use, abuse, and dependence (CUAD) scale). Participants’ personality variables were tested using the Minnesota Multiphasic Personality Inventory (MMPI), followed by videotaped interviews where they were independently asked about their own and their partner's behavior. Contrary to predictions, as the abusers’ anger and ego-strength increased so did their partners’ use of punishment and the consistency of the substance-abusing behavior. Finally, as the abusers’ ego-strength increased and over-controlled hostility decreased the partner presented more reinforcement of the substance abuse. These findings encourage a systems approach to the treatment of substance abuse, and provide insight into appropriate and effective strategies used by the functional partner in this system.     

A longitudinal analysis of factors associated with morbidity in cocaine abusers with psychiatric illness.

We conducted a study to characterize a population of cocaine users who were referred to a state psychiatric institution, identify treatment problems including reasons for relapse, and develop strategies to improve treatment outcome. Using a data base system from a tertiary-care hospital emergency department, we identified a sample of 80 patients with a cocaine-related presentation who came to the emergency department and were referred to the psychiatric facility. Forty-six percent had consumed crack cocaine, and 65% reported ingesting cocaine with other drugs, half of them with alcohol. Suicidal ideation or attempt was the most common reason for referral. A retrospective review of 58 of the 80 referrals to the psychiatric facility showed that over half of the patients were given a concurrent psychiatric diagnosis and required hospitalization on an acute-care psychiatric unit. Sixty-two percent of those admitted had prior hospitalizations at the psychiatric facility, yet only five patients had received treatment for substance abuse. Seventy-four percent were readmitted to the psychiatric facility within 1 year of their index episode, with a higher rate of relapse among persons with dual diagnoses compared to cocaine users without dual diagnoses (p less than 0.05). Possible reasons for relapse included lack of referral for substance abuse treatment, nonintegrated treatment of psychiatric illness and substance abuse, lack of psychosocial support, and unresolved financial or job-related stressors. The data support increased funding to facilities that treat persons with dual diagnoses, and suggest the need to develop comprehensive treatment approaches involving a multidisciplinary team to address issues of mental illness and substance abuse concomitantly, and to identify and resolve stressors leading to relapse.