The Relationship Between the Quality of Drug User Treatment and Program Completion: Understanding the Perceptions of Women in a Prison-Based Program

To determine why some women offenders complete prison-based drug user treatment and others leave early, clients' (N = 101) perceptions of various aspects of the quality of the treatment experience were compared. Analyses of both quantitative and qualitative data indicate that clients who completed the program had a more favorable perception of staff and felt empowered by the experience in treatment. Most of the clients who left early did so because of conflicts or disagreements with the program's rules. We discuss how a supportive approach to personal development may enhance client perceptions of program quality and increase retention rates.     

Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach

Introduction and Aims. Staff interactions with their clients are an important factor in the quality of care that is provided to people in drug treatment. Yet there is very little research that addresses staff attitudes or clients' perceptions of discrimination and prejudice by staff with regard to treatment outcomes. This research aimed to assess whether perceptions of discrimination by staff predict drug treatment completion. Design and Methods. The study used a mixed methods approach. Ninety‐two clients in residential rehabilitation facilities in Sydney were administered a series of quantitative measures assessing drug history, severity of drug use, treatment history, perceptions of staff discrimination and treatment motivation. Clients were followed up regularly until an outcome (dropout or completion) was obtained for the full sample. Results. Perceptions of discrimination were a significant predictor of treatment completion, with greater perceived discrimination associated with increased dropout. Qualitative interviews with 13 clients and eight health‐care workers from these treatment services were then conducted to gain insight into how perceived discrimination may impact on treatment experiences. Clients and staff discussed how they would address the issue of perceived discrimination during the current treatment experience. Discussion and Conclusions. Adopting a mixed methods approach facilitated exploration of the impact of perceived discrimination on treatment from both clients' and health‐care workers' perspectives. This methodology may also enhance interpretation and utilisation of these findings in drug treatment.[Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: Utility of a mixed methods approach. Drug Alcohol Rev 2010;29;491–497]     

Injection drug users' experience with and attitudes toward methadone clinics in Denver, CO

Clients' perceptions and attitudes toward methadone treatment programs are frequently overlooked in substance abuse research. Given the importance of methadone maintenance as a harm-reduction strategy and clients' concerns about treatment, it is essential to understand perceptions and attitudes toward existing programs. Using data from the 2009 National HIV Behavioral Surveillance system with injection drug users in Denver, CO, we evaluated participants' experiences with methadone clinics and examined predictive factors associated with ever being a client of a methadone clinic. Costs of services, perceptions of staff not caring about the client, and attitudes toward the counseling services seemed to be the major barriers to program retention. Besides heroin use, previous attempt at self-detoxification and being infected with hepatitis C were the strongest predictors of ever being on methadone treatment. Addressing the barriers to program retention and encouraging treatment engagement are essential to embracing methadone maintenance as a harm-reduction strategy for injection drug users.     

Reducing corticosteroid phobia in pharmacy staff and parents of children with atopic dermatitis

Background Besides physicians, pharmacy staff has an important role to inform patients on appropriate medication use. However, they might also experience corticophobia themselves, affecting patient counseling and subsequently patient’s disease management. Objective Implementation of an intervention for pharmacy staff to improve knowledge and stimulate positive perceptions towards TCS use, in order to reduce corticophobia in pharmacy staff and parents of young AD patients. Setting Nine community pharmacies in the Netherlands. Method We developed an intervention consisting of education of pharmacy staff followed by counseling of parents. The intervention was implemented in pharmacies and intervention effectiveness was studied using a pre-post design with an intervention period of 3 months. At baseline and follow-up (3 months), pharmacy staff and parents completed a questionnaire. Main outcome measure Corticophobia, both beliefs and worries, measured with the TOPICOP questionnaire. Higher scores indicate a more negative attitude. Result Baseline and follow-up data were available for 19 pharmacy staff members and 48 parents who attended a counseling session in the pharmacy. In both groups there was as decrease in negative beliefs and worries towards TCS (p?<?0.05). Mean total TOPICOP scores decreased from 42 to 35% and from 33 to 25% for parents and pharmacy staff respectively. Conclusion Our results show the prevalence of corticophobia among parents. Education of pharmacy staff and targeted patient counseling seems to be effective in reducing corticophobia.

     

Substance abuse treatment entry,retention and effectiveness: out-of-treatment opiate injection drug users

This study was designed to assess the effect of client characteristics and community interventions on treatment entry and retention, and to evaluate the relative effectiveness of treatment, compared to other interventions, in reducing drug use and crime among out-of-treatment opiate injectors. Subjects (N = 2973) from 15 cities were randomly assigned to: standard intervention (SI)-HIV testing and counseling; or enhanced intervention (EI)-SI plus additional educational sessions stressing responsible drug use. EI in some cities included staff assistance with treatment admission (i.e. ‘active’ referral). All locations provided intervention by community outreach workers. Factors positively associated with treatment entry included: prior treatment, intervention by community workers, assignment to the EI, not injecting cocaine, injecting opiates, and fewer program interventions received. Sites where the EI included active referral achieved significantly higher treatment entry rates than sites where the EI did not. Findings supported the efficacy of treatment over other interventions in reducing drug use and arrests, the addition of staff assistance to facilitate clients' entry into treatment, and the involvement of community outreach workers in achieving treatment entry.     

ABSTRACTS FROM 2003 AMERSA CONFERENCE

Abstract

Objectives: This study examined organizational trends from 1990 to 2000 and unit characteristics associated with the duration of nonmethadone outpatient addiction treatment.

Methods: Program directors and clinical supervisors from a nationally representative panel of nonmethadone outpatient units in the United States were surveyed in 1990, 1995, and 2000. Treatment duration was measured from clinical supervisors' reports of the average length of stay. Negative binominal regression models controlled for multivariate effects.

Results: Treatment duration modestly declined between 1990 and 2000 while addiction severity increased. Affiliation with a mental health center, older program age, JCAHO accreditation-ostensibly a marker for structural quality-and serving more clients with prior authorization requirements-a measure of managed care stringency-were associated with shorter treatment durations.

Conclusions: These findings suggest that treatment duration did not increase between 1990 and 2000 despite clients' worsening addiction severity and growing evidence that longer duration of formal treatment improves treatment outcome. In addition, programs with JCAHO accreditation and stronger managed care oversight appeared to seek efficiencies through reductions in treatment duration.     

A Group Therapy Program for Opioid-Dependent Adolescents and Their Parents

ABSTRACT. Background: Opioid dependence is a significant problem for adolescents in the United States. Psychosocial treatment for adolescents with opioid use disorders may be effective, although it has not been well studied. Methods: This paper describes a 13-week psychoeducational group therapy program with parallel tracks for adolescents with opioid use disorders and their parents attending an outpatient substance use program in a children's hospital. In addition to group therapy, participating adolescents received medical care, including medication-assisted treatment for opioid dependence, drug testing, medical follow-up, psychopharmacology, individual counseling, and parent guidance. Data were collected as part of a quality improvement project for the program. Forty-two adolescents and 72 parents attended the group program between 2006 and 2009. Frequencies were computed and a weighted kappa was used to assess agreement between adolescent and parent reports of use and driving risk. Results: Of the 42 adolescents participating in the 13-week group program, 36 (86%) completed 3 or more group sessions, and 24 (57%) completed 10 or more sessions. Twenty-two (52%) adolescent participants reported abstinence from all substances on each of their weekly evaluations. Adolescent-parent agreement for substance use was good to very good: weighted kappa (95% confidence interval) .76 (.60, .87), but poor for driving risk, weighted kappa .11 (?.20, .40). Conclusions: Completion rates and self-report of outcomes from this group program indicate promise and warrant further testing.     

Relating Therapist Characteristics to Client Engagement and the Therapeutic Alliance in an Adolescent Custodial Group Substance Misuse Treatment Program

Background: Client engagement in substance misuse treatment programs is directly associated with positive treatment outcomes. The nature of these programs means there are often difficulties engaging and retaining clients, but authors have consistently found a strong therapeutic alliance is associated with client engagement. While research has focused on the association between the alliance and engagement, the factors that influence the therapeutic alliance have received less attention. Objective: To examine therapists' characteristics, namely therapists' stress and empathy levels, as potential predictors of client engagement and the therapeutic alliance, within an adolescent substance misuse group treatment program. Method: The sample included 84 adolescent clients and 14 therapists from a Secure Training Centre in England. Client engagement in the treatment program was observed, while self-reporting measures assessed the therapeutic alliance (client and therapist-rated), and therapists' stress and empathy levels. Results: Multiple regression analysis revealed that therapists' stress levels negatively influenced the therapeutic alliance and had a curvilinear relationship with client engagement, indicating that stress is not exclusively negatively related to engagement. Although stress was found to negatively impact both cognitive and affective empathy, neither cognitive nor affective empathy were significantly related to client engagement or the therapeutic alliance. Conclusions: This study demonstrates the importance of therapist characteristics on client engagement and the therapeutic alliance. Within practice stress can have a positive impact on clients' engagement. Nevertheless, therapists may need additional support to deal with stress effectively. Therapists' empathy may too be fundamental to client engagement, but only it if is perceived by clients.     

Views of Australian mental health stakeholders on clients' problematic drug and alcohol use

Introduction and Aims. Substance misuse by people with a serious mental illness may exacerbate psychiatric symptoms and contribute to relapse. The aim of the study was to ascertain the views of a wide range of Australian mental health service providers on staff education and training, client contact and management, assessment, and treatment effectiveness and service delivery. Design and Methods. A survey was sent to a sample of 171 mental health stakeholders in Australia identified through internet searches, state and territory mental health departments and professional organisations. Results. Of the 66 respondents (39% response rate), the substances identified to be most problematic were alcohol and cannabis. Integrated service models of treatment were identified as the most preferable and effective. Barriers to treatment included client motivation to reduce substance use, poor communication and coordination between treatment services, and lack of specific services for dual diagnosis clients. Almost all indicated a need for further training in the area of dual diagnosis. Discussion and Conclusions. Dual diagnosis is common and the reality is that this vulnerable clientele will continue to challenge service providers and treatment approaches into the foreseeable future. Issues include the organization and delivery of treatment services, education and training, resource allocation, collaboration between treatment agencies and clinically relevant research evaluating the effectiveness of practice. It is thus surprising that with so much investment in this area the majority of stakeholders are still dissatisfied with access to and the level of care for dual diagnosis clients.[Cleary M, Hunt GE, Matheson S, Walter G. Views of Australian mental health stakeholders on clients' problematic drug and alcohol use. Drug Alcohol Rev 2009;28:122–128]     

Supervised Methadone Consumption: Client Issues and Stigma

Supervised methadone consumption is an important part of methadone maintenance treatment (MMT) but may contribute to stigma for clients. Data from qualitative interviews with MMT clients (n = 64) conducted in 2002–2003 in Canada were analyzed using thematic analytic methods. Three themes dominated clients' accounts of supervised consumption (convenient access to services, relationships with pharmacists and dispensing staff, and attributes of the dispensing space) and were interwoven with experiences of stigmatization. While some dispensing contexts may help clients manage a stigmatized identity, others confer or make visible this identity. Reducing stigmatizing experiences within dispensing environments may improve MMT outcomes and decrease barriers to treatment. The study's limitations are noted.     

Antinarcotic Testing in California: Of Substantive Due Process

Abstract

It is generally recognized that the evaluation of treatment progress requires multiple methods of assessment. To provide a basis for supplementing existing measures, the current study investigated the use of a peer rating methodology for evaluating the treatment progress of 381 probationers admitted to a four-month residential drug abuse facility. Self ratings of “working the program” (i.e., conscientiously participating in treatment) were compared with ratings by peers in the program and with ratings by counselors. Peer and counselor ratings were more highly correlated with each other than with client self ratings. Peer as well as self ratings detected differences between enhanced and standard counseling, and were related to individual difference measures known to be associated with treatment progress. In addition, peer midterm ratings of “working the program” were related to both self and counselor ratings of clients' end term participation, and counselor ratings of the likelihood of remaining clean and sober. These findings support the use of peer ratings as additional indicators of treatment progress.     

Patient,Program, and System Barriers and Facilitators to Detoxification Services in the U.S. Veterans Health Administration: A Qualitative Study of Provider Perspectives

Background: Because substance use disorder (SUD) treatment is expanding, and detoxification (detox) is often the entry point to SUD treatment, it is critical to provide ready access to detox services. Objectives: The purpose of the current study was to examine patient, program, and system barriers or facilitators to detox access within an integrated health care system with variable rates of detox utilization across facilities. Methods: Inpatient and outpatient providers from 31 different U.S. Veterans Health Administration detox programs were interviewed. Results: Qualitative analyses identified six facilitators and 11 barriers to detox access. Facilitators included program staff and program characteristics such as encouragement and immediate access, as well as systemic cooperation and patient circumstances. Barriers to detox included programmatic and systemic problems, including lack of available detox services, program rules or admission requirements, funding shortages, stigma related to a SUD diagnosis or receiving detox services, and a deficiency of education and training. Other major barriers pertained to patients' lack of motivation and competing responsibilities. Conclusions/Importance: To improve detox access, health care settings should consider enhancing supportive relationships by emphasizing outreach, engagement, and rapport-building with patients, improving systemic communication and teamwork, educating patients on available detox services and the detox process, and addressing patient centered barriers such as resistance to detox or competing responsibilities. In addition, programs should consider open-door and immediate-admission policies. These approaches may improve detox access, which is important for increasing the likelihood of transitioning patients to SUD treatment, thus improving outcomes and reducing utilization of high-cost services.     

Outpatient continuing care after residential substance use disorder treatment in the US Veterans Health Administration: Facilitators and challenges

Background: In the U.S. Veterans Health Administration (VHA), residential treatment programs are an important part of the continuum of care for patients with substance use disorders (SUDs). Outpatient continuing care after residential treatment helps maintain early recovery and treatment gains. Knowing more about the drivers of variation in continuing care practices and performance across residential programs might inform quality improvement efforts. Methods: Metrics of continuing care were operationalized and calculated for each of VHA's 63 SUD Residential Rehabilitation Treatment Programs (SUD RRTPs) and 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track in fiscal year 2012. Management and frontline staff of these programs were then interviewed to learn what factors might contribute to high or low program performance on the metrics compared with national averages. Results: Among SUD RRTPs, the mean rate of outpatient SUD/MH continuing care was 59% within 7 days and 80% within 30 days, and the mean rate of SUD continuing care was 63% within 30 days. Among MH RRTPs with a SUD track, these rates were 56%, 75%, and 36%, respectively. There was substantial variability in continuing care rates across the 97 programs: 21%–93% for SUD/MH care within 7 days, 36%–100% for SUD/MH care within 30 days, and 4%–91% for SUD care within 30 days. Interviews with representatives of 44 programs revealed key facilitators of continuing care: accountability of program staff, predischarge scheduling, predischarge introductions to continuing care providers, strong patient relationships, accessibility, and persistent emphasis. Key challenges included inadequate program staffing, lack of program staff accountability, and poor accessibility. Conclusions: Wide variation in continuing care rates across programs and identification of common facilitators at high-performing programs suggest substantial opportunity for improvement for programs with lower performance.     

Parental Criminal Justice Involvement and Children's Involvement With Child Protective Services: Do Adult Drug Treatment Courts Prevent Child Maltreatment?

Background: In light of evidence showing reduced criminal recidivism and cost savings, adult drug treatment courts have grown in popularity. However, the potential spillover benefits to family members are understudied.

Objectives: To examine: (1) the overlap between parents who were convicted of a substance-related offense and their children's involvement with child protective services (CPS); and (2) whether parental participation in an adult drug treatment court program reduces children's risk for CPS involvement.

Methods: Administrative data from North Carolina courts, birth records, and social services were linked at the child level. First, children of parents convicted of a substance-related offense were matched to (a) children of parents convicted of a nonsubstance-related offense and (b) those not convicted of any offense. Second, we compared children of parents who completed a DTC program with children of parents who were referred but did not enroll, who enrolled for <90 days but did not complete, and who enrolled for 90+ days but did not complete. Multivariate logistic regression was used to model group differences in the odds of being reported to CPS in the 1 to 3 years following parental criminal conviction or, alternatively, being referred to a DTC program.

Results: Children of parents convicted of a substance-related offense were at greater risk of CPS involvement than children whose parents were not convicted of any charge, but DTC participation did not mitigate this risk.

Conclusion/Importance: The role of specialty courts as a strategy for reducing children's risk of maltreatment should be further explored.     

Effective Outpatient Drug Treatment Organizations: Program Features and Selection Effects

This research identifies program features that predict outpatient drug treatment outcomes. Treatment effectiveness is measured at the organizational level of analysis in a nationally representative sample of non-methadone outpatient drug misuse treatment organizations (N = 394). Multivariate analyses are conducted to identify program features at various stages of the client career that are related to client outcomes after controlling for client characteristics, organizational characteristics, and social area characteristics. Results indicate that effective non-methadone outpatient drug misuse treatment is related to a number of program features including adequate staff levels, quality assurance efforts, and client follow-up, as well as selection factors that reflect client problem severity.     

Lessons Learned From the Deadly Sisters: Drug and Alcohol Treatment Disruption,and Consequences from Hurricanes Katrina and Rita

This paper reports on the effects of Hurricanes Katrina and Rita on drug and alcohol treatment in Texas in 2005–2006. Findings are based on a secondary analysis of administrative data on 567 hurricane-related admissions and on interview data from a sample of 20 staff in 11 treatment programs. Katrina evacuees differed from Rita clients in terms of demographics and primary problem substances and treatment needs, while the experiences of program staff and needed changes to improve disaster readiness were more similar. Additional systematic research is needed to document the intermediate and long-term impacts of the storms in these and other affected areas.     

Promising performance of a juvenile justice diversion programme in remote Aboriginal communities, Northern Territory, Australia

Introduction and Aims . Diversion from court and prison has been recommended for Indigenous Australian youth who commit offences. As no evaluations of such programmes have been published, we describe processes and early outcomes of a diversion programme in the Northern Territory. Design and Methods . From 2003 to 2006, among 1700 remote Indigenous community residents, 35 young people (aged 11–18 years, median 15 years) committed offences. They were diverted from criminal justice and referred to a community‐based diversion initiative. Client assessment records and staff interviews furnished data to examine clients' diversion pathways and early programme results. Results . Eighteen clients were reportedly using a substance at the time of their offence; cannabis (n = 9), petrol (n = 5), alcohol (n = 4). The remaining 17 had histories of using one or more of these. Two clients could not complete local diversion programs because they moved to other regions; one case was not pursued for legal reasons, leaving 32 clients exposed to the local programme. By July 2006, four clients were continuing in their programmes, three had breached them, but 25 had completed them in periods ranging from 2 to 60 weeks (median = 26 weeks), a completion rate of 89% (25/28). Just one client re‐offended after completing diversion. Discussion and Conclusions . A high completion rate was achieved despite: a dearth of locally available drug and alcohol treatment services and diversion options; shifts in police approaches; heavy administrative burdens to meet legal requirements; and difficulties communicating across cultural barriers.