Inpatient and outpatient outcomes in Missouri's alcohol and drug treatment programs

A comparison of the effectiveness of inpatient and outpatient services for alcohol and drug clients is presented. Controls for program completion and severity of substance use on entry to treatment are included. While inpatients do only as well as outpatients overall, inpatient services show significant advantage for particular classes of clients. Results, though preliminary, suggest that the recent call for a cutback in inpatient services is premature.     

Outcomes of drug and alcohol treatment programs among American Indians in California

OBJECTIVES: We examined differences in substance abuse treatment outcomes between American Indians and their non-American Indian counterparts in California, during 2000 to 2002. METHODS: A total of 368 American Indians and a matched sample of 368 non-American Indians from 39 substance abuse treatment programs in 13 California counties were assessed at multiple time points. Records on arrests, driving while under the influence of alcohol or drugs, and mental health care were obtained 1 year before and 1 year after treatment entry. Differences in pretreatment characteristics, services received, treatment satisfaction, treatment completion and retention, and outcomes were examined. RESULTS: Pretreatment problems were similarly severe among American Indians and non-American Indians. About half in both groups either completed treatment or stayed in treatment more than 90 days; American Indians in residential care had significantly shorter treatment retention. American Indians received fewer individual sessions and out-of-program services, especially for alcohol abuse, but were nevertheless generally satisfied with their treatment. Both groups improved after treatment, with American Indians demonstrating greater reductions in arrests than non-American Indians. CONCLUSION: American Indians benefit from substance abuse treatment programs, although the type and intensity of services offered could be improved.     

Variation in cesarean section rates among hospitals in Washington State.

OBJECTIVES. This study examined hospital characteristics and hospital population risk factors and their associations with hospital-specific cesarean section rates in Washington State. METHODS. Data were obtained from 1987 birth certificates. The study population included all hospitals that had 12 or more singleton live births. RESULTS. Hospital-specific cesarean section rates varied from 0% to 43% and were positively associated with proprietary ownership, size of delivery service, and the proportions of women who had complications or high-birthweight infants. The proportion of women who had late prenatal care was inversely associated with cesarean section rates. Although proprietary hospitals had higher cesarean section rates, their patient populations were lower risk than patients of public or teaching hospitals. CONCLUSIONS. Variation in cesarean section rates among hospitals cannot be fully explained by either hospital or patient population characteristics. A combined strategy may be necessary to lower unjustifiably high cesarean section rates.     

State implementation of the AIDS drug assistance programs.

Acquired immunodeficiency syndrome (AIDS) drug assistance programs (ADAPs) provide access to medications for people who lack other health coverage. In this article, the authors present the results of a 1997 survey identifying how 48 States implemented ADAPs, focusing on the number of beneficiaries, medical and financial eligibility criteria, the administration of waiting lists, and the coverage of drugs including protease inhibitors. Increased funding for ADAPs is necessary to maintain this important part of the public sector safety net for human immunodeficiency virus (HIV) care.     

Fetal alcohol syndrome prevention in Washington State: evidence of success

Fetal alcohol syndrome (FAS) is a permanent birth defect syndrome caused by maternal consumption of alcohol during pregnancy. It is characterised by growth deficiency, central nervous system damage/dysfunction, and a unique cluster of minor facial anomalies. To assess the effectiveness of fetal alcohol syndrome prevention efforts, one must be able to estimate accurately the prevalence of fetal alcohol syndrome over time in population-based samples. With the establishment of the Washington State Fetal Alcohol Syndrome Diagnostic and Prevention Network of clinics, the development of the Fetal Alcohol Syndrome Facial Photographic Analysis Software, the creation of the Fetal Alcohol Spectrum Disorders (FASD) 4-Digit Diagnostic Code, the establishment of the Foster Care Fetal Alcohol Syndrome Screening Program, and the collection of Pregnancy Risk Assessment Management System data on maternal use of alcohol during pregnancy, the tools, methods and infrastructure for assessing the effectiveness of fetal alcohol syndrome primary prevention efforts in Washington State are in place. A cross-sectional study was conducted to determine whether the prevalence of fetal alcohol syndrome among children in a foster care population, born between 1993 and 1998, decreased with the documented decrease in prevalence of maternal use of alcohol during pregnancy from 1993 and 1998 in Washington State. The prevalence of maternal drinking during pregnancy in Washington State declined significantly (P < 0.001) from 1993 to 1998 as did the prevalence of fetal alcohol syndrome among foster children born 1993-98 (P < 0.03). These observations support the likelihood that fetal alcohol syndrome prevention efforts in Washington State are working successfully.     

A model of nonparticipation in alcohol treatment programs

Why do the vast majority of those who suffer harm from drinking fail to obtain treatment? Based on a review of research literature and educational and treatment program materials, a model of nonparticipation in treatment is proposed whereby particular population groups are separated out according to whether or not they exhibit specified characteristics related to both harm from drinking and attitudes towards treatment. Eleven groups have been identified in the model, each of which has different reasons for failing to seek and/or obtain treatment. It is suggested that differing educational program messages should be sent to each group. While the model does not purport to be wholly inclusive of all nonparticipation, it offers a basis for addressing the variety of disparate groups that suffer harm from drinking but do not obtain treatment.     

Learning from clients: an opportunity for sexually transmitted disease programs.

This article summarizes sexually transmitted disease (STD) knowledge, health care-seeking behaviors, and perceived advantages to seeking care from the perspective of 397 STD clinic clients interviewed between 1997 and 1999 in three northeastern cities. More than half reported a prior STD. Mean days delay in seeking treatment was 10.8. Reasons for delay included lack of knowledge especially about symptoms (44%) and inconvenience, especially clinic hours (46%). Major disadvantages to receiving care centered around embarrassment and stress (24%). Programs need to develop more intensive counseling for repeat clients, offer more flexible hours, address sources of stress inherent in their services, and develop better marketing strategies. Successful behavioral interventions, behavioral training, and creative approaches from the popular literature may be helpful.     

Population-based case-control study of amyotrophic lateral sclerosis in western Washington State. I. Cigarette smoking and alcohol consumption

The associations of cigarette smoking and alcohol consumption with the risk of amyotrophic lateral sclerosis (ALS) were investigated in a population-based case-control study conducted in three counties of western Washington State from 1990 to 1994. Incident ALS cases (n = 161) were identified and were matched to population controls (n = 321) identified through random digit dialing and Medicare enrollment files. Conditional logistic regression analysis was used to compute odds ratios adjusted for age, gender, respondent type, and education. The authors found that alcohol consumption was not associated with the risk of ALS. Ever having smoked cigarettes was associated with a twofold increase in risk (alcohol-adjusted odds ratio (OR) = 2.0, 95% confidence interval (CI): 1.3, 3.2). A greater than threefold increased risk was observed for current smokers (alcohol-adjusted OR = 3.5, 95% CI: 1.9, 6.4), with only a modestly increased risk for former smokers (alcohol-adjusted OR = 1.5, 95% CI: 0.9, 2.4). Significant trends in the risk of ALS were observed with duration of smoking (p for trend = 0.001) and number of cigarette pack-years (p for trend = 0.001). The finding that cigarette smoking is a risk factor for ALS is consistent with current etiologic theories that implicate environmental chemicals and oxidative stress in the pathogenesis of ALS.     

Mammography quality assurance in Washington State.

Poor mammography quality control results in the loss of important diagnostic information. Several organizations and agencies recommend or require that mammography quality assurance procedures include the periodic evaluation of equipment. The objective of this study was to assess compliance with published guidelines pertaining to the monitoring of mammography equipment. One hundred eighty-four Washington state mammography facilities were surveyed by mail during late 1989 and early 1990. The response rate was 71%. A large proportion of facilities was not complying with published guidelines concerning the frequency of evaluation of processor parameters and phantom image quality. Results suggest that many facilities were not in compliance with American College of Radiology recommendations concerning annual system evaluation by a physicist. The results of this study reinforce the importance of establishing minimum quality assurance standards and indicate a need for more mammography quality assurance technologist training.     

Healthcare utilisation and disclosure of injecting drug use among clients of Australia's needle and syringe programs

Background : People who inject drugs (PWID) report limited access to healthcare, and may avoid disclosing drug use. Health service utilisation was examined among participants in the Australian Needle and Syringe Program Survey (ANSPS), an annual cross‐sectional sero‐survey of needle syringe program (NSP) attendees. Methods : An anonymous questionnaire was self‐completed by 2,395 NSP clients throughout Australia. Multivariable logistic regressions identified variables independently associated with (i) disclosure of injecting to the most recent healthcare provider; and (ii) recent presentation to emergency departments. Results : Seventy‐eight percent of participants reported accessing healthcare in the preceding 12 months. Reasons for presentation included general health issues (46%); medication seeking (17%); and both (37%). Participants who recently accessed healthcare or had previously visited their most recent provider were more likely to disclose injecting drug use. Participants presenting to a GP or medical centre were less likely than others to disclose injecting. Those accessing emergency departments were more likely to report recent imprisonment. Conclusions : Despite Australia's universal healthcare system and harm reduction policies, NSP‐participants remain reluctant to disclose injecting, potentially hindering appropriate care and highlighting the need for multiple entry points to the healthcare system, including NSPs and opioid substitution therapy clinics.     

Outcomes of pain center treatment in Washington State workers' compensation

BACKGROUND: Injured workers with chronic pain who have failed conventional therapies often receive treatment at pain centers. This study evaluated the effect of pain center treatment on time loss status of Washington State injured workers. The primary hypothesis was that treatment at a pain center would lead to a reduction in the probability of a worker's receiving time loss benefits at a 2-year follow-up. METHODS: A population-based retrospective cohort study was performed on 2,032 Washington State workers' compensation patients who underwent pain center evaluations. Subjects who received pain center treatment were compared to those who were evaluated but not treated with respect to time loss status at 2-year follow-up. RESULTS: Univariate analysis revealed that at 2-year follow-up, 35% of treated subjects were receiving time loss payments vs. 40% of evaluated only subjects (P < 0.05). Subjects who were younger, female, and less chronic were more likely to undergo pain center treatment and were less likely to be on time loss at 2-year follow-up. In multivariate analyses, which statistically controlled baseline differences between the two groups, there was no difference between treated subjects and evaluated only subjects. CONCLUSIONS: There was no evidence that pain center treatment alters 2-year time loss status of already disabled workers.     

Agency and dependency within treatment: drug treatment clients negotiating methadone and antidepressants

This paper explores how drug treatment clients exercise agency while finding their ability to act curtailed by the strictures of treatment itself. Drawing on qualitative interviews with 77 male and female drug treatment clients collected in an Australian study of drug treatment and mental health, the experience of methadone maintenance treatment (MMT) and that of commonly prescribed medications for depression (antidepressants) are examined. The ways that clients engage with MMT and antidepressants are detailed, illustrating how both types of treatment can make clients feel dependent, but can also motivate clients to modify their treatment regimens. These modifications are "tactical" responses generated within the constraints of treatment regulations and can also be against clinical recommendations e.g. stopping treatment. Rather than seeing this as "non-compliance", it is suggested that the negotiation of treatment is an inevitable response of clients trying to adapt to imperfect treatment conditions, who may have understandable anxieties about taking medication. The ways in which treatment providers might better acknowledge the capacities of MMT clients to engage with or modify treatment are discussed, as is the need to acknowledge drug treatment clients' anxieties about dependency and pharmaceutical drugs.     

Return rates and outcomes from ethnicity-specific mental health programs in Los Angeles.

OBJECTIVES. The present study compared the return rate, length of treatment, and treatment outcome of ethnic minority adults who received services from ethnicity-specific or mainstream programs. METHODS. The sample consisted of 1516 African Americans, 1888 Asian Americans, and 1306 Mexican Americans who used 1 of 36 predominantly White (mainstream) or 18 ethnicity-specific mental health centers in Los Angeles County over a 6-year period. Predictor variables included type of program (ethnicity specific vs mainstream), disorder, ethnic match (whether or not clients had a therapist of the same ethnicity), gender, age, and Medi-Cal eligibility. The criterion variables were return after one session, total number of sessions, and treatment outcome. RESULTS. The study indicated that ethnic clients who attended ethnicity-specific programs had a higher return rate and stayed in the treatment longer than those using mainstream services. The data analyses were less clear cut when treatment outcome was examined. CONCLUSIONS. The findings support the notion that ethnicity-specific programs seem to increase the continued use of mental health services among ethnic minority groups.     

Barriers to family planning services among patients in drug treatment programs.

In July 1989, family planning services were integrated into 13 drug treatment programs in Philadelphia. To obtain information on the family planning needs of women in drug treatment programs, baseline interviews were conducted with 599 women. Three-quarters of these women had had a sexually transmitted disease, and although they were in a drug treatment program, 41 percent had injected drugs in the previous month. In addition, 62 percent of the women who were sexually active in the previous month had not used a contraceptive. Twelve months into the program, seven focus groups were conducted with 65 women and men to learn more about their opinions and attitudes related to contraceptives and family planning services in general. The discussions revealed that many of the participants were unsure what family planning services included, saw no need for such services or had had prior negative experiences with health care providers. There was also a great deal of misinformation about contraceptives and the effects they have on health.     

Psychiatric comorbidity measures as predictors of retention in drug abuse treatment programs.

OBJECTIVE: To examine lifetime and current psychiatric comorbidity measures as predictors of drug abuse treatment retention, and to test the generalizability of results across treatment agencies in diverse settings and with varying practices. DATA SOURCES/STUDY SETTING: The national Drug Abuse Treatment Outcome Studies (DATOS), a longitudinal study of clients from 96 treatment agencies in 11 U.S. cities. STUDY DESIGN: The design is naturalistic and uses longitudinal analysis of treatment retention in long-term residential, outpatient drug-free, and outpatient methadone treatment modalities; client background (including psychiatric comorbidity) and program service provision are predictors. Clinical thresholds for adequate treatment retention were 90 days for long-term residential and outpatient drug-free, and 360 days for outpatient methadone. Psychiatric indicators included lifetime DSM-III-R diagnoses of depression/anxiety and antisocial personality, and dimensional measures of current symptoms for depression and hostility. DATA COLLECTION/EXTRACTION METHODS: Data include structured interviews with clients, a survey of treatment program administrators, and program discharge records. PRINCIPAL FINDINGS: Dimensional measures of current psychiatric symptoms emerged as better predictors than lifetime DSM-III-R diagnoses. In addition, the predictive association of hostility with retention varied significantly across treatment agencies, both in the long-term residential and outpatient drug-free modalities. Other notable findings were that on-site mental health services in long-term residential programs were associated with better retention for clients with symptoms of hostility. CONCLUSIONS: Assessment issues and stability of results across programs are important considerations for treatment research and practice.     

Motorcycle helmet use and injury outcome and hospitalization costs from crashes in Washington State.

OBJECTIVES. The incidence, type, severity, and costs of crash-related injuries requiring hospitalization or resulting in death were compared for helmeted and unhelmeted motorcyclists. METHODS. This was a retrospective cohort study of injured motorcyclists in Washington State in 1989. Motorcycle crash data were linked to statewide hospitalization and death data. RESULTS. The 2090 crashes included in this study resulted in 409 hospitalizations (20%) and 59 fatalities (28%). Although unhelmeted motorcyclists were only slightly more likely to be hospitalized overall, they were more severely injured, nearly three times more likely to have been head injured, and nearly four times more likely to have been severely or critically head injured than helmeted riders. Unhelmeted riders were also more likely to be readmitted to a hospital for follow-up treatment and to die from their injuries. The average hospital stay for unhelmeted motorcyclists was longer, and cost more per case; the cost of hospitalization for unhelmeted motorcyclists was 60% more overall ($3.5 vs $2.2 million). CONCLUSIONS. Helmet use is strongly associated with reduced probability and severity of injury, reduced economic impact, and a reduction in motorcyclist deaths.     

Rural adolescent alcohol, tobacco, and illicit drug use: a comparison of students in Victoria, Australia, and Washington State, United States

Purpose: There are inconsistent research findings regarding the impact of rurality on adolescent alcohol, tobacco, and illicit substance use. Therefore, the current study reports on the effect of rurality on alcohol, tobacco, and illicit drug use among adolescents in 2 state representative samples in 2 countries, Washington State (WA) in the United States and Victoria (VIC) in Australia. Participants: The International Youth Development Study (IYDS) recruited representative samples of students from Grade 7 (aged 12 to 13 years) and Grade 9 (aged 14 to 15) in both states. A total of 3,729 students responded to questions about alcohol, tobacco, cannabis, and other illicit substance use (n_VIC= 1,852; n_WA= 1,877). In each state, males and females were equally represented and ages ranged from 12 to 15 years. Methods: Data were analyzed to compare lifetime and current (past 30 days) substance use for students located in census areas classified as urban, large or small town, and rural. Findings were adjusted for school clustering and weighted to compare prevalence at median age 14 years. Findings: Rates of lifetime and current alcohol, tobacco, and cannabis use were significantly higher in rural compared to urban students in both states (odds ratio for current substance use = 1.31). Conclusions: In both Washington State and Victoria, early adolescent rural students use substances more frequently than their urban counterparts. Future studies should examine factors that place rural adolescents at risk for alcohol, tobacco, and illicit drug use.     

Racial distribution of dual-diagnosis clients in public sector mental health and drug treatment settings

This study examined the racial distribution of dual-diagnosis clients in public sector residential mental health and drug treatment settings. In a sample of 179 dual-diagnosis clients, there was a significantly larger proportion of blacks in the drug treatment cohort than the mental health cohort. There were black-white differences in the types of substance use disorders found, but not in the types of mental health disorders. Diagnostic and drug use pattern differences did not account for the differential racial distribution in the two settings. However, the racial distribution was explained by the recent history of service use in the two treatment sectors. In the 2 years after study entry, blacks were less likely than whites to receive mental health treatment and whites were less likely than blacks to receive drug treatment. The implications of these findings regarding the appropriate treatment for dual-diagnosis blacks and whites in the public sector are discussed.