A comparative evaluation of substance abuse treatment: I. Treatment orientation, amount of care, and 1-year outcomes

This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups. The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment. Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up. Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up. These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes. Subsequent papers in this section focus on the proximal outcomes of treatment, patients with psychiatric as well as substance use disorders, patient-treatment matching effects, and the link between program treatment orientation and patients' involvement in and the influence of 12-Step self-help groups.     

A comparative evaluation of substance abuse treatment: II. Linking proximal outcomes of 12-step and cognitive-behavioral treatment to substance use outcomes

This study examines the linkages in the treatment process chains that are thought to underlie two prevalent approaches to substance abuse treatment, traditional 12-Step treatment and cognitive-behavioral treatment. The focus is on the "proximal outcomes" specified by the two treatment approaches and their relation to "ultimate" substance use outcomes assessed at a 1-year follow-up. A total of 2687 men who received treatment in 15 Department of Veterans Affairs substance abuse treatment programs were assessed at treatment entry, at or near discharge, and at a 1-year follow-up. Based on the results of factor analyses, composite proximal outcomes variables were constructed to assess 12-Step cognitions, 12-Step behaviors, cognitive-behavioral beliefs, substance-specific coping, and general coping. Correlation analyses indicated that some of the proximal outcome composites assessed at treatment discharge were linked to 1-year outcomes, but the relationships were weak (r = .09 to .15). At follow-up, the cross-sectional relationships between the proximal outcome composites and two substance use outcomes were stronger, but still modest in magnitude (r = .16 to .39). The weak predictive findings suggest some mechanism is needed to sustain treatment-induced change on proximal outcomes so that positive ultimate outcomes can be achieved more frequently. In this regard, participation in continuing care was associated with enhanced maintenance of treatment gains on proximal outcomes. However, the modest cross-sectional relationships between proximal and substance use outcomes at follow-up suggest that the theories on which 12-Step and cognitive-behavioral substance abuse treatments are based are not sufficiently comprehensive.     

The impact of publicly funded managed care on adolescent substance abuse treatment outcomes

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

Emergency department use of persons with comorbid psychiatric and substance abuse disorders

STUDY OBJECTIVE: This study assesses the relationship between substance abuse comorbidity and emergency department use among patients with psychiatric disorders in a large academic medical center. METHODS: Data were obtained from an administrative database including every patient visit to the ED of a large, academically affiliated county hospital from January 1994 through June 1998. This study focuses on 12,212 patients who were given a diagnosis of a primary psychiatric disorder in the ED. Diagnoses, assigned during ED visits, were made according to the Diagnostic and Statistical Manual of Mental Disorders III-R or IV. RESULTS: Primary psychiatric patients with substance use comorbidity had a significantly higher mean number of ED visits across the span of the study (mean 5.2; SD 7.4) than primary psychiatric patients without substance use comorbidity (mean 2.8; SD 3.9). In multiple logistic regression analyses predicting several categorizations of heavier use of the ED (either 4+, 8+, 12+, 16+, or 20+ visits over the span of the study), psychiatric patients with a comorbid substance use disorder had adjusted odds ratios of 2.8 to 4.9 (reference group was defined as patients with a psychiatric disorder but no substance use disorder; models controlled for age, race, and sex). CONCLUSION: Substance use comorbidity among patients presenting to an ED with a psychiatric disorder is associated with substantially increased ED service use. Improved detection, referral, and treatment of substance use disorders in this population could result in decreased ED use and improved patient outcomes.     

A comparative evaluation of substance abuse treatment: V. Substance abuse treatment can enhance the effectiveness of self-help groups

Affiliation with Alcoholics Anonymous (AA) and other 12-Step self-help groups is becoming more common at the same time as professional substance abuse treatment services are becoming less available and of shorter duration. As a result of these two trends, patients' outcomes may be increasingly influenced by the degree to which professional treatment programs help patients take maximum advantage of self-help groups. The present study of 3018 treated veterans examined how the theoretical orientation of a substance abuse treatment program affects (1) the proportion of its patients that participate in self-help groups, and, (2) the degree of benefit patients derive from participation in self-help groups. Patients treated in 12-Step and eclectic treatment programs had higher rates of subsequent participation in 12-Step self-help groups than did patients treated in cognitive behavioral programs. Furthermore, the theoretical orientation of treatment moderated the outcome of self-help group participation: As the degree of programs' emphasis on 12-Step approaches increased, the positive relationships of 12-Step group participation to better substance use and psychological outcomes became stronger. Hence, it appears that 12-Step oriented treatment programs enhance the effectiveness of 12-Step self-help groups. Findings are discussed in terms of implications for clinical practice and for future evaluations of the combined effects of treatment and self-help groups.     

Public sector managed care: a comparative evaluation of substance abuse treatment in three counties

AIMS: A study of publicly funded substance abuse treatment systems compared MidState, a county that reorganized its treatment system using managed care principles, to two other California counties that took different approaches, NorthState and SouthState. It was hypothesized that MidState would have better outcomes due to its emphasis on quality of care. DESIGN: This natural experiment compared the 'experimental' county, MidState, to two 'control' counties, assessing client outcomes following treatment. Administrative and historical exigencies that may affect system differences were explored in interviews with treatment program managers and staff. SETTINGS: Comparison counties were selected using treatment system and county census data, maximizing similarities to enhance internal validity. PARTICIPANTS: Adult clients (n = 681) were interviewed when beginning treatment and 12 months later (81% response rate). In addition, 50 treatment program managers and staff members across the three counties were interviewed during the year of client recruitment. MEASUREMENTS: Client interviews assessed functioning in the seven Addiction Severity Index domains-alcohol, drug, psychiatric, legal, employment, medical and family/social. FINDINGS: Outcomes (differences between baseline and 12 month composite scores) did not differ between counties in six of seven domains; in the seventh, psychiatric functioning, SouthState had better outcomes than MidState. Staff interviews indicated generally similar treatment strategies across counties, with MidState supplying greater oversight and performance standards. CONCLUSIONS: Managed care in public sector treatment generally did not result in poorer outcomes. Future attention in MidState to the barriers to successful implementation of individualized treatment, and to dual diagnosis treatment, might bring more positive results.     

The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders

AIMS: This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence. DESIGN: Two-group randomized design. SETTING: Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States. PARTICIPANTS: A total of 183 adolescents, ages 12-17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment. INTERVENTION: Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits. MEASUREMENTS: Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. FINDINGS: ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. CONCLUSIONS: ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study     

Chemical dependency patients with cooccurring psychiatric diagnoses: service patterns and 1-year outcomes

BACKGROUND: Improving services and treatment outcomes for individuals with cooccurring alcohol and drug use disorders and psychiatric conditions has been a critical challenge to clinicians and policy makers. This study examined 1-year outcomes for individuals entering chemical dependency (CD) treatment with and without cooccurring psychiatric diagnoses targeted by California parity legislation. Among those with cooccurring conditions (i.e., dual-diagnosis patients), we examined a model including individual characteristics, treatment services, and extratreatment characteristics to understand CD outcome predictors in this population. We hypothesized that longer CD treatment duration and receiving psychiatric services would predict higher abstinence levels. In particular,patterns of psychiatric services (amount of services, receiving a critical dose, or receiving services concurrently with CD treatment) were assessed in relation to outcome. METHODS: We examined abstinence rates 1 year after intake for 747 adults with and without cooccurring conditions. Among dual-diagnosis patients, logistic regression was used to examine predictors of abstinence. RESULTS: At baseline, dual-diagnosis patients (N=104) had higher levels of medical, family, and employment problems than others. They had similar CD retention and received more psychiatric services during the year after intake and had comparable CD outcomes at 1 year. Length of stay in CD treatment, hours of psychiatric services, number of months with concurrent CD and psychiatric services, and number of 12-step meetings attended were independent predictors of abstinence for dual diagnosis patients. CONCLUSIONS: Chemical dependency outcomes in patients with cooccurring psychiatric conditions were positively associated with the number and patterning of services. Receiving psychiatric services concurrently with CD treatment may be beneficial for dual-diagnosis patients. Future studies should examine how best to integrate services to optimize treatment outcomes.     

A comparative evaluation of substance abuse treatment III. Examining mechanisms underlying patient-treatment matching hypotheses for 12-step and cognitive-behavioral treatments for substance abuse

This study examined several hypotheses for matching patients to 12-Step and cognitive-behavioral (CB) treatments in a multisite evaluation of VA inpatient substance abuse programs. A total of 804 male patients in five 12-Step programs, and 1069 male patients in five CB programs completed an intake, discharge, and 1-year follow-up questionnaire. The findings did not support the notion that certain patient characteristics would differentially predict better outcomes after 12-Step and CB treatment This conclusion held when the purest 12-Step and CB programs were used, and when patients who received the full dose of treatment (i.e., treatment completers) were examined separately. Process analyses of the hypothesized mechanisms underlying the patient-treatment matching effects did not yield the expected links among patient characteristics, proximal outcomes, and 1-year outcomes. Our conclusion is that there is no advantage to matching men with substance abuse problems to 12-Step or CB treatments based on the patient attributes measured here.     

Impact of victimization on substance abuse treatment outcomes for adolescents in outpatient and residential substance abuse treatment

This paper considers whether victimization moderates adolescents' outcomes in substance abuse treatment. Adolescents (N=975) in outpatient and residential settings were assessed at intake, three, six, nine, and 12 months. Differential outcomes by gender and degree of victimization were analyzed. Dependent variables were marijuana use and substance-related problems. The residential sample reported higher baseline marijuana use and victimization. Both samples significantly reduced marijuana use and associated problems during treatment. Victimization was significantly related to more substance-related problems at intake and follow-up. More severe trauma histories in residential females were associated with significantly greater persistence in substance-related problems post-discharge.     

Dual diagnosis patients in substance abuse treatment: relationship of general coping and substance-specific coping to 1-year outcomes

Aims. This study examined general and substance-specific coping skills and their relationship to treatment climate, continuing care and 1-year post-treatment functioning among dual diagnosis patients (i.e. co-occurrence of substance use and psychiatric disorders). Design. In a prospective multi-site study, dual diagnosis patients participating in substance abuse treatment were assessed at intake, discharge and at a 1-year follow-up. Setting. Patients were recruited from 15 substance abuse treatment programs, which were selected from a larger pool of 174 inpatient treatment programs in the Department of Veterans Affairs Health Care System. Participants. A total of 981 male dual diagnosis patients participated in the study. Measurements. Assessments included general and substance-specific coping skills, treatment climate, continuing outpatient care, abstinence and clinically significant psychiatric symptoms. Findings. Dual diagnosis patients modestly improved on general and substance-specific coping skills over the 1-year follow-up period. Patients who were in programs with a 'dual diagnosis treatment climate' and who participated in more 12-Step self-help groups showed slightly more gains in adaptive coping. Both general and substance-specific coping were associated with abstinence, but only general coping was associated with freedom from significant psychiatric symptoms. Conclusions. Enhancing general and substance-specific coping skills in substance abuse treatment may reduce dual diagnosis patients' post-treatment substance use and improve their psychological functioning.     

Co-ordination and continuity of care in substance abuse treatment. An evaluation study in Belgium

Considering the complexity of drug dependence and the multiplicity of services for substance abusers, co-ordination and continuity of care are important prerequisites for the quality of substance abuse treatment. However, several shortcomings concerning co-operation, communication and co-ordination have been reported in most European countries. In this study, different aspects of co-ordination and continuity (e.g. first contact, intake, referral, follow-up) have been studied among all services (n = 27) that are addressed by substance abusers in a clear-cut region in Belgium. Structured interviews with key informants show a lack of systematic communication between services and a lack of follow-up of clients. A study of 57 client records in 12 of these 27 centers illustrates that relatively little information is registered concerning the course of the treatment process and that only 10% of all client files contain a treatment plan. Following the introduction of a formalized plan that was regarded as a precondition for systematizing and optimizing communication between services, key informants considered the implementation of a model of case management as an appropriate way of improving co-ordination and continuity of care in this region.     

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.     

Original series of screening, evaluation, and care of adolescent substance abuse

This article presents the proceedings of a symposium held at the meeting of the International Society for Biomedical Research on Alcoholism in Mannheim, Germany, in October 2004. The aim of this symposium was to discuss new and interesting strategies of screening, evaluation and care of adolescent substance abuse developed in various countries. Our speakers have had to explain these strategies and to detail and focus on the more original tools of diagnosis or way of care used in their country. This symposium described two ways for screening and assessment (one developed in France MR, LK and the other in Switzerland LC) and made the point about questionnaires and biomarkers for alcohol problems in adolescents (JPA). The symposium was concluded by the presentation of a cannabis clinic (ES, JP).     

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.     

The primary care therapist and patient needs in substance abuse treatment

The author advocates that a clinician play the role of a primary care therapist (PCT) for substance abusers to assure that appropriate treatment interventions are provided to meet patient needs. In treating substance abusers, the PCT must be concerned about patients' needs for control, containment, contact, and comfort, especially initially, but also in an ongoing way. The PCT functions in direct, coordinating, and monitoring roles in order to optimally provide and combine psychotherapeutic and self-help elements.     

Integrated psychiatric/medical care in a chronic hepatitis C clinic: effect on antiviral treatment evaluation and outcomes

OBJECTIVES: Psychiatric and substance use disorders are common in hepatitis C patients and represent barriers to antiviral treatment. We evaluated the effect of integrating psychiatric and medical care on evaluation for and initiation of antiviral treatment in a cohort of 184 patients with chronic hepatitis C. METHODS: Integrated care consisted of screening for psychiatric problems with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), Beck Depression Inventory (BDI), Urine Drug Screen (UDS), and Primary Care Posttraumatic Stress Disorder (PC-PTSD) screens, referral based on specified cutoff scores to an established mental health (MH) provider, to a colocated psychiatric clinical nurse specialist (PCNS), or both. Data were collected retrospectively by chart review. RESULTS: Most patients (149/184, 81.0%) had at least one positive screen, 25.5% had a positive UDS. Among patients with positive screens, 38.3% had established MH providers, 47.0% had no MH provider and were referred to the PCNS, and 15.0% refused any psychiatric referral. Patients receiving integrated care with a colocated PCNS were significantly more likely to complete evaluation for and start antiviral treatment than other patients with positive screens, and at a rate similar to that of patients with negative screens. Patients with positive screens followed by any MH provider had significantly greater adherence to antiviral therapy than patients without positive screens. CONCLUSION: An integrated MH and medical approach was associated with rates of antiviral therapy recommendation and initiation similar to patients without risks for psychiatric or substance use problems. MH care was associated with improved adherence to antiviral therapy. Integrated care offers promise as an approach for addressing psychiatric comorbidity in this traditionally difficult to treat population.