Observations On The Phenomenology Of Consciousness Change

Abstract

Several national evaluations have been conducted since the late 1960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short-term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.     

Associations between spirituality and substance abuse symptoms in the Baltimore Epidemiologic Catchment Area follow-up, 1993-1996

Prior studies on substance abuse treatment programs have provided some evidence that participants who embrace some facet of spirituality during recovery may have greater success in maintaining sobriety. Several plausible associations exist between spirituality and sobriety; this paper posits that spirituality has consistently negative associations with substance abuse symptoms in models with 'substance abuse symptoms' as the outcome. The data come from the Baltimore Epidemiologic Catchment Area (ECA) study. In 1993, ECA researchers surveyed 1,920 of the original 3,841 participants, all household residents in East Baltimore. Multiple logistic regression analyses show that strong spiritual beliefs within this population are negatively associated with current substance abuse symptoms [OR = 0.53; 95%CI = 0.35-0.80, p = 0.002]. Homeownership is also negatively associated, while positively associated characteristics include suffering from income- related stress and having a history of substance abuse treatment. This population-based study confirms findings from clinical studies, and the results support continued emphases on spirituality in substance abuse recovery programs.     

Financing and cost of standard and enhanced methadone treatment

Although some national surveys of drug-abuse treatment have examined cost and financing issues, our study is one of the first to rigorously analyze the costs and financing of methadone treatment at the program level. Our findings are similar to those found at the national level for treatment cost but deviate significantly from the National Drug and Alcoholism Treatment Unit Survey (NDATUS) findings on funding sources. In addition to examining financing and total cost, we grouped resources into particular categories and examined variations at the client, program, regimen, and setting levels. Our specific findings show that public funding sources overwhelmingly support the programs examined; the average annual cost per client for standard methadone treatment was between $3,750 and $4,400; the marginal cost of providing enhanced treatment was between 5% and 6% of the total annual cost of standard treatment; and the average annual cost at the freestanding community-based programs was significantly different from the average annual cost at the hospital-based treatment program. Our results provide a treatment cost methodology along with a financial profile of treatment operations at three clinics that can be compared across programs and settings.     

Correlates of participation in peer recovery support groups as well as voluntary and mandated substance abuse treatment among rural and urban probationers

This study explores the correlates of probationers' participation in 12-step programs, voluntary treatment, and mandated treatment, with respect to the geographic location of where the services are being provided as the primary covariate of interest. Data were derived from face-to-face interviews with rural and urban probationers (N = 1,464). Results of the three logistic regression models suggested that even when all the covariates are taken into account, urban probationers were significantly more likely to have been involved in 12-step programs, voluntary treatment, and mandated treatment over their lifespan. Despite high levels of self-reported substance use among all participants, treatment services were underused by rural probationers. These data suggest that individuals residing in rural communities may face additional barriers to receiving treatment services and that criminal involvement is associated with participation in peer recovery support groups and treatment. Future studies can investigate criminal involvement as an avenue to enhance recovery and how to overcome treatment barriers in rural areas.     

The incidence of drug use and associated factors in two small towns: a community survey.

The article reports the results of a 1974 drug survey in two rural municipalities in the Pacific Northwest. Drug use in these towns was found to be similar to drug use in urban areas. It appears that towns size 2,500 to 50,000 have been absorbed into the national drug culture while only farmers and people living in very small towns still experience relatively low rates of drug use. Other findings include attitudes toward and needs met by drug use, the effect of parental drug use on perceived children's drug use, and the relationships between drug use and age, sex, and general health. In the past few years, articles have appeared describing adult drug use in the United States as a whole, or in selected urban populations. The most comprehensive study is a national survey of a representative sample of 2,552 adults completed in 1971 (1-3). Among the regional reports are studies carried out in California (4,5) and New York (6,7). What these studies have in common is the absence of data on rural or small town drug use as compared with urban drug use. A national study by Cahalan, Cisin, and Crossley (8) does analyse rural-urban differences, but only for alcohol use. No comprehensive treatment of this topic exists in the literature. The research reported in the present article represents an attempt to begin to fill in this void data on small town drug use in a rural setting.     

Intelligent noncompliance with special emphasis on the elderly

Intelligently noncompliant patients alter their prescribed therapy on a rational basis that often represents advanced therapeutic principles. The literature contains many examples of patients who alter their medication but still have good treatment outcome. Doses are altered to avoid adverse effects or because the dose was excessive or inconvenient. When compliance studies are done in a large heterogeneous group, the rates for different age groups are almost always similar. Health professionals have devised compliance-ensuring strategies such as educational programs and modification of the regimen. Use of compliance-ensuring strategies, however, opposes the current trend which advocates a more direct, active patient participation in treatment decisions.     

Parental stress and child behavioral outcomes following substance abuse residential treatment. Follow-up at 6 and 12 months

Residential treatment programs specifically designed for alcohol/drug-addicted women and their children have become a popular treatment modality across the United States. Outcome evaluation of these programs are beginning to show promising results. In this article, outcome data from a study of a residential substance abuse treatment program for women and young children in rural South Carolina will be presented. Data from 35 women and 23 children in the area of addiction severity, parenting and child emotional and behavioral development at 6 and 12 months following discharge from a substance abuse residential treatment program is examined. Results showed that women who completed treatment had better scores on addiction severity and parental stress, and their children had improved behavioral and emotional functioning at 6 and 12 months after discharge from the program. These results suggest that residential treatment has benefits for mothers and their children. This data adds to the growing body of evidence supporting intensive and inclusive care for certain groups of individuals with substance use disorders during critical periods.     

Relating counselor attributes to client engagement in England

Client functioning and treatment engagement were examined in relation to staff attributes and organizational climate across a diverse sample of drug treatment and outreach programs in England. Self-rating assessments were obtained from 1,539 clients and 439 counselors representing 44 programs, and results were interpreted using comparable data from studies of treatment programs in the United States. Client scores on treatment participation and counseling rapport in England were directly related to their higher levels of motivation and psychosocial functioning, as well as to staff ratings of professional attributes and program atmosphere. By linking records from English clients with their counselors in each program, findings also indicate these relationships are rooted in the personal interactions between clients and their counselor. Standardized assessments of treatment structure, process, and performance used across therapeutic settings and national boundaries show there is generalizability in the pattern of clinical dynamics, including the relationships between organizational functioning and quality of services.     

Alcohol and drug treatment outcome studies: new methodological review (2005–2010) and comparison with past reviews

Objective

Several methodological reviews of alcohol treatment outcome studies and one review of drug studies have been published over the past 40 years. Although past reviews demonstrated methodological improvements in alcohol studies, they also found continued deficiencies. The current review allows for an updated evaluation of the methodological rigor of alcohol and drug studies and, by utilizing inclusion criteria similar to previous reviews, it allows for a comparative review over time. In addition, this is the first review that compares the methodology of alcohol and drug treatment outcome studies published during the same time period.

Method

The methodology for 25 alcohol and 11 drug treatment outcome studies published from 2005 through 2010 that met the review's inclusion criteria was evaluated. The majority of variables evaluated were used in prior reviews.

Results

The current review found that more alcohol and drug treatment outcome studies are now using continuous substance use measures and assessing problem severity. Although there have been methodological improvements over time, the current reviews differed little from their most recent past counterpart. Despite this finding, some areas, particularly the continued low reporting of demographic data, needs strengthening.

Conclusions

Improvement in the methodological rigor of alcohol and drug treatment outcome studies has occurred over time. The current review found few differences between alcohol and drug study methodologies as well as few differences between the current review and the most recent past alcohol and drug reviews.     

Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program

A sample of 200 patients who had been treated for alcoholism in a multimodal inpatient program that used aversion therapy as a treatment component was selected for outcome evaluation. One hundred sixty (80%) were located. A minimum of 13 months had elapsed since treatment (mean 20.5 months) collateral reports were used to verify self-reports in 36% of the cases. Abstinence status was determined for the first 12 months since treatment, the entire elapsed time since treatment (range 13 to 25 months, mean 20.5 months), and "current abstinence" (last 6 months). The abstinence rate for the first 12 months was 71.3%; for the total period since treatment, the rate was 65% (mean 20.5 months); the current abstinence rate was 78.1%. The data was also viewed from other perspectives. The findings of this study suggest that a multimodal alcoholism treatment program utilizing aversion conditioning is at least as acceptable to patients as counseling centered programs and can be expected to yield favorable abstinence rates.     

Promoting new practices to increase access to and retention in addiction treatment: an analysis of five communication channels

Addiction treatment programs adopt evidence-based practices slowly, in part because adopting a new practice is a process, not an event. Using different communication channels may have a different effect at different points in the process. This paper reports the effectiveness of five communication channels in getting substance abuse treatment programs to adopt new business practices. In this study, national trade media coverage produced the greatest interest among programs and the greatest number of decisions to adopt. Conference presentations produced fewer decisions to adopt than national media, but were the most effective channel when compared to the number of programs they reached. Peers were the greatest influence in moving clinic staff from the decision to adopt to implementation. These findings give preliminary evidence for using different communication channels at different times during an effort to promote the adoption of best practices.     

The role of African-American clergy in providing informal services to drug users in the rural South: preliminary ethnographic findings

To date, no ethnographic studies of the role of African-American clergy in providing informal services to drug users in the rural South have been reported. We use qualitative interviews with 15 African-American ministers and 26 African-American drug users in Arkansas' Mississippi River Delta region to explore this issue. All drug users reported significant religiosity, and 9 had discussed drug problems with clergy. Every minister had provided assistance to at least one drug user or their family during the previous year, including: direct counseling; referrals to treatment programs; aiding negotiations with formal institutions; and providing for basic needs. Ministers stated that clergy are not well-prepared to address drug problems, and most acknowledged a need for professional training. They also discussed barriers to education. The findings contribute to understanding rural informal drug treatment resources. They suggest that professional treatment providers should investigate the potential benefits of improving outreach efforts to assist African-American ministers engaged in drug abuse issues.     

Introduction to the special issue: treatment process in DATOS

Several important findings from the drug abuse treatment outcome studies (DATOS) are presented in this issue of drug and alcohol dependence. These studies focus on the drug abuse treatment process in areas of engagement in treatment and participation in program activities, the effect of the patient's age and treatment history in predicting treatment retention and outcomes, and the impact of prior treatment experience on the level of treatment engagement and subsequent outcomes. A cost-benefit model for drug abuse treatment is developed. Significant contributions are made in the development of a comprehensive model of the treatment process, including the relationship of patient attributes, program factors, and outcomes. Findings on retention from the United Kingdom's national treatment outcome research study (NTORS), a study similar in design to DATOS, also are presented.     

Economic costs of drug abuse: financial, cost of illness, and services

This article examines costs as they relate to the financial costs of providing drug abuse treatment in private and public health plans, costs to society relating to drug abuse, and many smaller costing studies of various stakeholders in the health care system. A bibliography is developed from searches across PubMed, Web of Science, and other bibliographic sources. The review indicates that a wide collection of cost findings is available to policy makers. For example, the financial aspects of health plans have been dominated by considerations of actuarial costs of parity for drug abuse treatment. Cost-of-illness methods have been developed and extended to drug abuse costing to measure the national level of burden and are important to the economic evaluation of interventions at the program level. Costing is done in many small and focused studies, reflecting the interests of different stakeholders in the health care system. For costs in programs and health plans, as well as cost offsets of the impact of substance abuse treatment on medical expenditures, findings are surprisingly important to policy makers. Maintaining ongoing research that is highly policy relevant from the point of view of health services, more is needed on costing concepts and measurement applications.     

The impact of I(Kr) blockade on medicinal chemistry programs

Inhibition of the cardiac I(Kr) current leads to prolongation of the QT interval and to a risk of ventricular arrhythmia. This activity has been observed for a wide range of small molecules and results from their binding to the hERG ion channel. The off-target inhibition of I(Kr) presents a daunting challenge for many medicinal chemistry programs. This review article presents case studies that describe a rang of findings across several projects at Merck. The article begins with a review of findings from the original efforts to identify I(Kr) blockers as antiarrhythmic therapeutics. A discussion follows of in vitro and in vivo assays that have been utilized for the assessment of I(Kr) inhibition. General SAR rules that have been found to be useful guides for diminishing hERG activity in lead compounds are discussed and case studies are presented that illustrate specific observations. The case studies highlight how the issue of hERG antagonism was navigated on four distinct medicinal chemistry programs.     

Previous participation in outpatient methadone program and residential treatment outcome: a research note from Hong Kong

Methadone maintenance programs are good examples of harm-reduction efforts because heroin addicts stabilized on methadone have been found to be able to reduce illicit drug use and criminality and improve their life condition, even though they have not achieved abstinence. While excluding the criterion of abstinence allows the harm-reduction approach to distinguish itself from traditional treatment, little research attention has been paid to the relationship between methadone programs and abstinence-oriented treatment programs. This research note reports some of the findings of a study of 77 former male clients of SARDA, a voluntary residential treatment agency in Hong Kong, pertaining to such a relationship. Findings suggest that a client's previous participation in the Outpatient Methadone Program of the Department of Health could facilitate successful outcome in his subsequent participation in SARDA's treatment program and help him to continue his drug-free status in the post-SARDA treatment period. Conceptual and policy implications of the findings are discussed. [Translations are provided in the International Abstracts Section of this issue.]     

Narcotic Addiction in the Pain-Prone Female Patient II. Some Factors in the Doctor-Patient Relationship

The study of treatment outcome has its own history, and the experience of other service fields in this area may be of considerable interest to researchers concerned with the effectiveness of treatment for drug abusers. Methodological issues that emerged from psychotherapy's efforts at self-evaluation are reviewed and contrasted with work done on treatment outcome in drug programs. An overview is presented of current research on the improvement of drug abusers and on treatment effectiveness.     

Antidepressants in clinical practice: limitations of assessment methods and drug response

There is a recognized gap between knowledge derived from 'efficacy' data - based on usually brief randomized controlled trials and findings in natural practice 'effectiveness' studies. In considering the limitations of current antidepressants in clinical practice, we have selected three clinically important issues to examine in a natural practice data base that has been in existence for several years. These relate to: (1) Diagnostic heterogeneity and potential advances using functional brain imaging; (2) Variability of outcome measures during treatment and (3) Time to response and prediction of outcome. Copyright 2001 John Wiley & Sons, Ltd.     

Program Factors and Treatment Outcomes in Drug Dependence Treatment: An Examination Using Meta-Analysis

In comparison with studies of client characteristics and treatment processes, limited research has been conducted on how program features of drug dependence treatment programs may affect client outcomes. Of particular interest are those characteristics of programs that may have a clinically significant impact on outcomes and that are amenable to change within programs. This study examines the impact of various program factors on client outcomes using data from a meta-analysis of drug dependence effectiveness studies (n = 143). Because of heterogeneity among studies, the data are analyzed in terms of type of outcome variable (drug use and crime), type of design (single-group and treatment-comparison group), and type of treatment (methadone maintenance, therapeutic communities, outpatient drug free, and detoxification). For the more valid treatment-comparison group studies, the weighted mean effect size was 0.29 for drug use outcomes and 0.17 for crime outcomes. Program factors found to be significantly correlated with effect size in one or more modalities were decade of treatment, researcher involvement in treatment delivery, maturity of the program, counselor/client ratio, treatment implementation, treatment exposure, and methadone dosage.     

Program factors and treatment outcomes in drug dependence treatment: an examination using meta-analysis

In comparison with studies of client characteristics and treatment processes, limited research has been conducted on how program features of drug dependence treatment programs may affect client outcomes. Of particular interest are those characteristics of programs that may have a clinically significant impact on outcomes and that are amenable to change within programs. This study examines the impact of various program factors on client outcomes using data from a meta-analysis of drug dependence effectiveness studies (n = 143). Because of heterogeneity among studies, the data are analyzed in terms of type of outcome variable (drug use and crime), type of design (single-group and treatment-comparison group), and type of treatment (methadone maintenance, therapeutic communities, outpatient drug free, and detoxification). For the more valid treatment-comparison group studies, the weighted mean effect size was 0.29 for drug use outcomes and 0.17 for crime outcomes. Program factors found to be significantly correlated with effect size in one or more modalities were decade of treatment, researcher involvement in treatment delivery, maturity of the program, counselor/client ratio, treatment implementation, treatment exposure, and methadone dosage.