Co-occurring disorders in substance abuse treatment: issues and prospects

This article explores the epidemiology of co-occurring disorders (CODs) with an emphasis on the implications of study findings for the functioning and potential of substance abuse treatment. Severity of disorder is discussed as an issue that may have particular significance for the selection of specialized as opposed to traditional substance abuse treatment forms. Exploration is made, as well, of the resources currently available to substance abuse treatment, especially the human resources available, and the implications of resource availability for undertaking initiatives specific to COD. Findings from standard and enhanced treatment for comorbid individuals are examined in an effort to clarify areas of need for specialized and typical treatment personnel. Issues are raised for consideration by the clinical research and treatment provider communities in terms of assessment and diagnosis, manpower and training, and response to the challenge of relapse in this population.     

Co-occurring disorders in the adolescent mental health and substance abuse treatment systems

This article explores the rates of co-occurring disorders in two large federally-funded programs that target youth. In the mental health treatment system, the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) supports the Comprehensive Community Mental Health Services for Children and Their Families Program. SAMHSA's Center for Substance Abuse Treatment (CSAT) supports a number of grant programs providing substance abuse treatment for adolescents. The data from these programs underscores the need for the use of systematic, validated, biopsychosocial assessment instruments for all youth entering either the substance abuse or mental health treatment systems. The current evidence base for models of co-occurring treatment for youth is discussed and recommendations made for future activity related to adolescent co-occurring treatment.     

Enhancing adolescent substance abuse treatment engagement

Trends in adolescent drug use are encouraging and suggest the importance of preventative programs for youth. Yet, among those who become involved with illicit substances and seek treatment, only a fraction report positive outcomes. This article describes an approach to enhance adolescent participation in substance abuse treatment. Aspects of the transtheoretical model are integrated into a treatment program designed to meet the unique developmental needs of adolescent alcohol and marijuana abusers. The result is a treatment that better engages adolescents in participation, thereby increasing the likelihood for treatment success.     

Family functioning following adolescent substance abuse treatment

Reciprocal influences of substance abuse and family functioning have been hypothesized from diverse theoretical perspectives. The longitudinal study presented here investigated the relationship between adolescent alcohol and drug use outcome and family functioning following adolescent substance abuse treatment. Consistent with predictions, long-term improving teens (n = 17) experienced better family relations, and less conflict-related behavior within the family, than did teens who returned to an abuse pattern of drug use (n = 37). Two years following treatment, families of improvers demonstrated greater cohesion and expressiveness, and less conflict, than did families of relapsers. Findings highlight a gradual process of adaptation in relations among families of teens treated for alcohol and drug abuse.     

Characteristics of relapse following adolescent substance abuse treatment

Historically research has focused on the characteristics of adults who relapse following treatment for alcohol or drug dependence. The circumstances of adolescent relapse, however, have largely gone unattended. The present study investigated the relapse rates and characteristics of adolescent posttreatment drug relapse. Seventy-five teens and their parents were interviewed while participating in an adolescent chemical dependency treatment program and at three and six months following treatment. Results indicate that a number of characteristics of adolescent relapse, including rates, are comparable to those of adults. In contrast to adult relapse, adolescent relapses occur most commonly in the presence of social pressure to drink. Situational characteristics of initial relapse experiences were different for transient or minor relapses and adolescent relapses which lead to a return to abusive drinking and drug use patterns.     

Parental consent in adolescent substance abuse treatment outcome studies

No systematic review has focused on parental consenting procedures used in adolescent substance abuse treatment outcomes research. To address this gap, we examined parental consenting procedures in adolescent outcome studies (n = 34) published between 1980 and 2007. Although parental consent was required in 89% of adolescent treatment outcome studies we reviewed, consenting procedures were not routinely reported. We argue that parental consenting procedures should be routinely reported as a methodological feature of adolescent treatment outcome studies and, given concerns about sample bias in adolescent risk behavior research when parental consent is required, encourage outcomes researchers in this area to prospectively study the impact of consenting procedures on both the study participation rates and substance use reporting.     

Delay discounting predicts adolescent substance abuse treatment outcome

The purpose of the current study was to identify predictors of delay discounting among adolescents receiving treatment for marijuana abuse or dependence, and to test delay discounting as a predictor of treatment outcome. Participants for this study were 165 adolescents (88% male) between the ages of 12 and 18 (mean age = 15.8 years; standard deviation = 1.3 years) who enrolled in a clinical trial comparing three behavioral treatments for adolescent marijuana abuse or dependence. Participants completed a delay discounting task at treatment onset for $100 and $1,000 of hypothetical money and marijuana. Overall, smaller magnitude rewards were discounted more than larger magnitude rewards. Delay discounting rates were concurrently related to demographic variables (socioeconomic status, race). Delay discounting of $1,000 of money predicted during treatment abstinence outcomes among adolescent marijuana abusers, over and above the effects of type of treatment received. Teens who show higher levels of discounting of the future may be an important subgroup to identify at treatment onset. Youth with a greater tendency to discount the future may require different intervention strategies that address their impulsivity (e.g., targeting executive function or inhibitory control) and/or different schedules of reinforcement to address their degree of preference for immediate rewards.     

Factors that predict adolescent motivation for substance abuse treatment

Many adolescent substance abusers enter treatment because of external pressures and thus lack motivation to change their behavior and engage in treatment. Because an understanding of adolescent motivation may contribute to improved treatment, an investigation of factors that predict motivation was undertaken with youth admitted to an adolescent outpatient substance abuse treatment program (N=196). At admission, these subjects received a comprehensive biopsychosocial assessment. Using multiple regression analysis, factors considered to potentially predict motivation were assessed. Of the factors examined, those that involved experiencing various negative consequences of substance use emerged as important predictors of motivation, whereas severity of substance use did not. Diminished awareness of negative consequences of use was consonant with lower motivation, suggesting the importance of interventions to help youth recognize negative consequences of their substance use. Interventions to enhance motivation are likely to become more important as the juvenile justice system increasingly refers troubled youth to treatment.     

Gambling behavior in adolescent substance abuse

This study assessed the prevalence and correlates of gambling behavior (GB) in adolescent substance abusers (N = 97) consecutively admitted to an outpatient treatment program. Thirty‐four percent of the cohort had never gambled; 57% were classified as social/nonpathological gamblers; 8% were labeled as in transition gamblers; and only 1% met criteria for pathological gambling. A significant finding was that males are more likely to gamble and to have a higher severity score than do females. A younger age of GB onset is seen for girls than boys and is correlated with a history of suicide attempts, diagnosis of depression, number of symptoms of oppositional behavior, cluster B personality disorders, and a higher need for psychiatric treatment. None of the gambling youths was ever referred for GB counseling. Increased awareness for and additional studies of adolescent gambling are required.     

Ethical issues in substance use intervention

This essay offers an overview of some of the ethical questions raised by governmental and medical interventions into drug use. With respect to the former, it begins with the liberal assumption that constraints on free action are to be justified by reference to its deleterious impact on others, but then qualifies that assumption by noting the social requisites of free action. With respect to medical interventions, it focuses on the codes that have been developed for treatment providers and their clients, and explores the ethical underpinnings of several of their central provisions--informed consent, privacy, confidentiality, nondiscrimination, professionalism, and accountability.     

Developing adaptive treatment strategies in substance abuse research

For many individuals, substance abuse possesses characteristics of chronic disorders in that individuals experience repeated cycles of cessation and relapse; hence viewing drug dependence as a chronic, relapsing disorder is increasingly accepted. The development of a treatment for a chronic disorder requires consideration of the ordering of treatments, the timing of changes in treatment, and the use of measures of response, burden and adherence collected during treatment to make further treatment decisions. Adaptive treatment strategies provide a vehicle through which these issues can be addressed and thus provide a means toward improving and informing the clinical management of chronic substance abuse disorders. The sequential multiple assignment randomized trial (SMART) is particularly useful in developing adaptive treatment strategies. Simple analyses that can be used with the SMART design are described. Furthermore, the SMART design is compared with standard experimental designs.     

Adult ADHD and substance abuse: diagnostic and treatment issues

Attention deficit hyperactivity disorder (ADHD) is a neurobehavioral, developmental disorder most often diagnosed during childhood, marked by the core symptoms of inattention, hyperactivity, and impulsivity that results in social, academic, and occupational underachievement. Although the disorder has a prevalence of 3-9% in the general childhood population and 1-5% in the general adult population, it affects between 11 and 35% of "substance-abusing" adults, oftentimes complicating treatment response. The present review discusses diagnostic assessment issues, prevalence, comorbidity, pharmacotherapy, and psychological interventions in substance-abusing adults with ADHD.     

Level of analysis issues in assessing treatment beliefs in substance abuse clinics

The current study applies the growing literature in the organizational sciences regarding levels of analysis issues to the analysis of substance abuse treatment beliefs. Research on clinicians' beliefs in substance abuse treatment is often based on the assumption that the beliefs are sufficiently shared by clinicians within a clinic and sufficiently vary across clinics that they can be treated as a group-level phenomenon. Further, efforts to introduce new innovations are often focused at the group or clinic level without testing this assumption, which can lead to failure to adopt or to successfully implement the innovation. We tested the assumption of sharedness by examining if there was sufficient agreement about treatment beliefs within clinics, within groups of clinics or within groups of clinicians to justify treating these aggregations as meaningful groups. Using three statistical approaches to examining level of analysis (Within and Between Analysis (WABA I), Intraclass Correlation Coefficients (ICC(1)), and r(wg)), we found that variability in treatment beliefs largely occurred at the individual rather than at the tested aggregate levels of analysis. These findings serve as an example of the importance of testing the assumption of shared perceptions in future research.     

Using ethnographic methodology in substance abuse treatment outcome research

The purpose of this article is to argue for a greater inclusion of ethnography as an adjunctive methodology within the context of traditional substance abuse treatment outcome studies. First we describe what is meant by "ethnographic methodology," then discuss the various methodological elements of ethnographic research that are relevant to substance abuse research. A number of suggested applications of ethnographic research pertaining to a substance abuse treatment outcome context are then presented. The article concludes with a discussion about how ethnographic methods can enhance and broaden our understanding of important questions relating to substance abuse treatment processes and outcomes.     

Gender issues and the pharmacotherapy of substance abuse

In the last 25 years, the different disciplines and professions that are involved in managing the issue of substance abuse have recognized that gender-linked factors influence patterns of substance abuse and response to treatment. In 2007, the US National Institute on Drug Abuse (NIDA) concluded that studies of substance abuse should routinely address gender issues. In the field of drug development, gender issues historically have not been an issue of high priority. By outlining the types of evidence that underpin the view of the NIDA and providing evidence of the widespread existence of gender-linked effects from pharmacotherapies (both those marketed and under development), this feature review proposes that drug developers should embrace the opinion of the NIDA regarding gender and substance abuse. To avoid false conclusions, the issue of gender should become a higher priority during the collection and analysis of data on pharmacotherapies. Some gender differences will have more clinical significance than others, but any difference related to gender has the potential to complicate clinical trials and other studies.     

Training substance abuse treatment staff to care for co-occurring disorders

Although co-occurring disorders have been associated with poorer substance abuse treatment outcomes and higher costs of care, few individuals with co-occurring disorders receive appropriate mental health care. This article describes the design and implementation of an intervention to improve the quality of mental health care provided in outpatient substance abuse treatment programs without requiring new treatment staff. The intervention focuses on individuals with affective and anxiety disorders and consists of three components: training and supervising staff, educating and activating clients, and linking with community resources. We evaluated three treatment programs (one intervention and two comparison) for the first component by having program staff complete both self-administered questionnaires and semistructured interviews. Staff knowledge and attitudes about co-occurring disorders, job satisfaction, and morale all indicated an improvement at the intervention relative to the comparison sites. The evaluation is still under way; results for implementation of the other two components and for outcomes will be reported later.