Drinking Goal Trajectories and Their Association with Client Characteristics and Outcomes among Clients in Outpatient Alcohol Treatment

Background: Drinking goal preferences could change over time in alcohol treatment and during follow up. Objectives: To examine the stability of drinking goals over time, types of drinking goal trajectory, and the associations between drinking goal trajectories and baseline client characteristics and treatment outcomes. Methods: We performed secondary analysis of a dataset from a multicenter longitudinal study on the effectiveness of outpatient alcohol treatment (n = 543). Drinking goals (abstinence, controlled drinking, nonrestricted drinking, undecided) and alcohol use were assessed at treatment admission, discharge, and 6- and 12-month follow up. Results: At admission, 32% of the subjects aimed for abstinence and 57% for controlled drinking, while 10% were undecided, and 1% did not want to restrict themselves. The proportions of clients aiming for abstinence and controlled drinking were relatively stable across the four assessments, and the proportion of clients who changed their drinking goal from abstinence to controlled drinking did not differ significantly from the number who changed in the opposite direction. Clients with abstinence-focused trajectories reported higher baseline alcohol use than those focused primarily on controlled drinking. Meanwhile, attaining nonhazardous drinking and reduced alcohol use at 12-month follow up were more likely among clients with abstinence-focused trajectories than those focused on controlled drinking. Conclusions: Since the majority of clients maintain their initially selected drinking goal, counsellors might inform them at treatment admission about the various probabilities of achieving nonhazardous drinking depending on their selected drinking goal.     

Association Between Drinking Goal and Alcohol Use One Year After Residential Treatment: A Multicenter Study

This study examined whether patients’ drinking goals at admission to and discharge from 12 residential alcohol use disorder treatment programs were associated with alcohol-related outcomes at 1-year follow-up. Detoxified patients (N = 289) completed assessments at admission, after treatment, and at 1-year follow-up. Drinking goals of abstinence, conditional abstinence (in principle abstinence but potential occurrence of lapses or drinking, when urges are strong), and controlled drinking changed during treatment and predicted the 1-year follow-up outcomes (abstinence, number of standard drinks, and number of days to the first alcohol use). Goals at discharge had a better predictive value. The goal of abstinence at discharge had better outcomes than conditional abstinence; the poorest had controlled drinking.     

Effects of Treatment Type on Alcohol Consumption Partially Mediated by Alcoholics Anonymous Attendance

Background: As insurance coverage, funding sources and venues for drug and alcohol treatment evolve in the United States, it is important to assess how the type of treatment received may impact long-term outcomes. The current study aims were to examine effects of treatment type on alcohol consumption in the year after treatment intake and to test mediators of effects of treatment type on later alcohol use. Methods: Longitudinal data from clients in inpatient and outpatient alcohol treatment programs in California (n = 560) were used in ordinary least squares path analysis adjusting for respondent characteristics typically associated with both treatment completion and alcohol use. The primary outcome was amount of alcohol consumed in the 12 months after treatment entry; hypothesized mediators were treatment duration and participation in Alcoholics Anonymous (AA). Results: Despite higher baseline problem severity and a shorter treatment duration, inpatient clients consumed less alcohol after treatment than outpatient clients (B [95% CI] = ?0.95 [?1.67, ?0.23]). AA involvement was a significant mediator of the relationship between treatment type and alcohol consumption, with inpatient clients being more involved in AA and also drinking less after treatment than outpatient clients; the bias-corrected bootstrap 95% confidence interval for the indirect effect (B = ?0.20) was entirely below zero (?0.43 to ?0.05). Conclusions: Outpatient clients may benefit from customized posttreatment recommendations to identify additional resources to assist in the recovery process during the first year after treatment.     

Alcohol Treatment Goal Choice Predicts Longitudinal Drinking Outcomes in Adolescent Substance Users

Social cognitive theory suggests when individuals select their own goals, they work harder to achieve them and experience increases in self-efficacy. Research in adults with alcohol use disorder supports the utility of treatment goal choice in predicting longitudinal outcomes; a total abstinence (TA) goal choice has been associated with better clinical outcomes versus a controlled use goal choice. Research on goal choice in adolescent substance users has not been reported. Data from 110 adolescents were collected upon admission to outpatient substance use disorder treatment. Hierarchical linear regressions tested baseline goal choice as a predictor of drinking outcomes at 6-, 12-, and 24-month follow-ups. Goal choice significantly predicted drinking outcomes at 12-month follow-up, but not at 6- or 24-month time points; TA was associated with better clinical outcomes. These findings suggest that goal choice may have clinical utility as a predictor of alcohol use disorder clinical course in adolescents.     

Treatment History: Relationship to Treatment Outcomes

It is important to understand whether the number of prior treatment episodes relate to treatment completion, discharge status, and 6-month outcomes. The data set contains information on 2,429 clients in treatment. A modified Addiction Severity Index was administered at the time of admission and at 6-months postdischarge. Additionally, length of stay and discharge status data were obtained. ANOVAs, MANOVAs, and χ² tests were used. Clients with the most prior treatment episodes had greater baseline substance use and psychosocial severity, and were more likely to be treated in residential settings. Nonetheless, treatment acceptance was greatest for these clients. Clients with no prior treatment reported the least acceptance. Treatment completion rates did not vary as a function of treatment experience. Clients achieved positive changes in multiple life domains regardless of treatment history. Nevertheless, at admission, discharge and follow-up, clients with ≥ 2 treatments generally had greater problems than clients with fewer treatments.     

Effects of distance to treatment on subsequent alcohol consumption

Background: Distance and travel time are barriers to attending and completing drug and alcohol treatment. Few studies have examined proximity to treatment in relation to long-term outcomes.

Objectives: Aims were to examine effects of distance to treatment on alcohol consumption in the year after treatment intake; assess moderation of distance effects by treatment type; and test mediators of effects of distance to treatment on later alcohol use.

Methods: Data from clients in inpatient and outpatient alcohol treatment programmes in California (n?=?560) were used in linear regression models.

Results: There was a significant interaction between treatment type and distance on later drinking, with a significant positive association of distance to treatment with alcohol use after treatment for inpatient clients only. Among inpatient clients, none of the mediators significantly explained the relationship between a longer distance to treatment and greater subsequent alcohol use.

Conclusion: Inpatient clients may benefit from customized post-treatment recommendations to identify recovery resources near home.     

Admissions to detoxification after treatment: Does engagement make a difference?

ABSTRACT

Background: Treatment engagement is a well-established performance measure for the treatment of substance use disorders. This study examined whether outpatient treatment engagement is associated with a reduced likelihood of subsequent detoxification admissions. Methods: This study used administrative data on treatment services received by clients in specialty treatment facilities licensed in Massachusetts. The sample consisted of 11,591 adult clients who began an outpatient treatment episode in 2006. Treatment engagement was defined as receipt of at least 1 treatment service within 14 days of beginning a new outpatient treatment episode and receipt of at least 2 additional treatment services in the next 30 days. The outcome was a subsequent detoxification admission. Multilevel survival models examined the relationship between engagement and outcomes, with time to detoxification admission as the dependent variable censored at 365 days. Results: Only 35% of clients met the outpatient engagement criteria, and 15% of clients had a detoxification admission within a year after beginning their outpatient treatment episode. Controlling for client demographics, insurance type, and substance use severity, clients who met the engagement criteria had a lower hazard of having a detoxification admission during the year following the index outpatient visit than those who did not engage (hazard ratio = 0.87, P < .01). Conclusions: Treatment engagement is a useful measure for monitoring quality of care. The findings from this study could help inform providers and policy makers on ways to target care and reduce the likelihood of more intensive services.     

Settings and Functions Related to Simultaneous Use of Alcohol with Marijuana or Cocaine Among Clients in Treatment for Substance Abuse

Objectives: The paper identifies the central theoretical components for developing a typology of alcohol use with other substances. The settings and functions related to the simultaneous use of alcohol with marijuana or cocaine are examined using a dataset from a study of treatment clients in Ontario, Canada (data collected between the years 2003 and 2005). Methods: A cross-sectional design was used where patients 18 years or older completed a self-administered questionnaire upon admission to various treatment programs. Clients who reported using marijuana (n = 499) or cocaine (n = 375) in the past year were asked how often they use these substances in combination with alcohol. Findings: Simultaneous use is very common among treatment clients, with differences in the settings and functions associated with alcohol used in combination with cocaine or marijuana, and by various sociodemographic characteristics. The study's limitations are noted.     

The Impact of Employment Counseling on Substance User Treatment Participation and Outcomes

The nationally representative Alcohol and Drug Services Study (ADSS, 1996–1999) is used to examine employment counseling's impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N = 988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.     

A day treatment program in a therapeutic community setting: six-month Outcomes : The Walden House Day Treatment Program

Although not well represented in the literature, day treatment programs targeting substance abuse problems have increased in both number and acceptability in recent years. This article reports on a day treatment program based on the Therapeutic Community (TC), and on outcomes for a sample of substance abuse clients (n = 66) entering the program. Participants were interviewed early in treatment and 6 months after admission using the Addiction Severity Index (ASI) and other measures. Clients entering day treatment were demographically diverse, with serious substance-abuse problems and psychiatric morbidity. Median retention in day treatment was about 5 weeks, but many clients received a contiguous episode of residential treatment, so that the median for total time in treatment was 18 weeks. Clients located and interviewed at 6-month follow-up (n = 38) showed significant improvement in alcohol and drug use, legal and social problems, and psychiatric symptoms. Findings suggest that day treatment can be used effectively as a precursor to residential treatment and that some clients applying for residential treatment can be treated effectively in day treatment alone.     

Notes from practice: Methadone prescribing in north central London—doses,compliance, goals and treatment setting

Aims: To examine methadone prescribing in public drug treatment services in inner London; compare levels of methadone prescribing with national guidelines and surveys; investigate whether methadone reduces illicit opiate use; and compare clients treated in specialist clinics with those in shared-care in general practice.

Methods: A cross-sectional survey of four drug treatment services in north central London.

Findings: Data were collected on 715 clients. Mean methadone dose was 57.2?mg but for clients on methadone maintenance, the mean dose was 63.4?mg. Reported heroin use fell from 24.8 days in the last 30 at initial assessment to 11 days (p?<?0.001). Clients on methadone doses greater than 60?mg were more likely than those on lower doses to test negative for morphine on urinalysis (49% vs. 39.4%, p?<?0.01). Clients in GP shared-care were more likely to have been in treatment for less time, be on lower doses of methadone and have stabilization or detoxification as their treatment goal.

Conclusions: Methadone treatment is associated with a reduction in illicit opiate use but not abstinence. Inadequate doses and lack of supervised consumption may in part explain the relatively poor response to treatment. Clients in GP shared-care received substantially different treatment from those in the specialist clinics.     

Secondary outcomes: Group and individual change and relationships to drinking outcomes

This article describes pre to posttreatment changes in secondary outcome domains, and examines the relationships between drinking outcomes and secondary outcomes, in a Swedish treatment sample. Structured interviews, including the Addiction Severity Index (ASI) Composite Scores, were performed on admission (n = 244), and after 12 months (n = 188, 77%). Significant problem reductions were observed for all domains except for the employment and medical domains. Posttreatment abstainers did not show greater improvement in secondary domains than did those who were in remission, and correlations between primary and secondary ASI domains, were generally low at baseline and follow-up. At the same time, those who met criteria for alcohol dependence during the follow-up year, reported significantly poorer secondary outcomes than did those with favorable drinking outcomes. Findings suggest that in the study sample, continuous abstinence did not automatically lead to better psychosocial adjustment, but that continued alcohol dependent drinking was associated with deterioration in secondary outcome domains.     

Point Prevalence and Patterns of Mental Health Comorbidity Among People Accessing Australia's First Older Adult–Specific Alcohol and Other Drug Treatment Service

Objective: There are good data regarding the prevalence and patterns of dual diagnosis among the general population; however, data regarding the older adult cohort are limited. We aimed to extend the knowledge of the point prevalence and patterns of dual diagnosis among older adults and the impact of dual diagnosis on the utilization of alcohol and other drug treatment services.

Method: A 12-month medical chart audit of clients discharged from an Australian older adult–specific alcohol and other drug treatment service was performed. Measures included the Alcohol Use Disorders Identification Test–Consumption, the Drug Use Disorders Identification Test–Consumption, the Kessler 10, and the Modified MINI Screen. Additional data collected included mental health diagnoses, number of session types, and treatment outcomes.

Results: There were 79 (n = 45, 57% male) medical charts audited, with a mean age of 65.9 years (SD = 5.8). There were 68 (89%) clients having at least one comorbid mental illness. Clients with a dual diagnosis were younger (p = .011) than those without. Some comorbid mental health conditions were associated with additional service utilization (p < .05). Clients with personality disorders required more telephone calls and outreach services (p < .05). The number of mental health diagnoses was associated with additional treatment sessions (p < .05).

Conclusions: Further research with a larger sample size of older adults seeking age-specific alcohol and other drug treatment services is required. Older adult–specific alcohol and other drug treatment services need to allow for longer episodes of care for clients with certain dual diagnoses and a focus on reducing anxiety to increase treatment retention.     

Client's perceived need for treatment and its impact on outcome

Objectives. Based on the concept of “stage of change,”; this study examines the relationship between patients’ motivation for substance abuse treatment and their posttreatment improvements in the areas measured by the Addiction Severity Index (ASI; alcohol, drug, medical, psychiatric). We attempt to answer the following questions: Do clients’ perceptions of “need for drug, alcohol, psychiatric, and medical treatment”; at admission predict their improvements on these problems at 6‐month follow‐up? How do clients’ perceived needs contribute to their use of treatment and their reported change? Methods. Clinical interview data (N = 696) collected using the ASI from the Target Cities Project in the city of Philadelphia in 1993 and 1995. Results. Clients’ motivation made a substantial difference in their improvement following treatment in all problem areas. Clients who said treatment was even slightly important on the ASI at admission made more changes than clients who reported that treatment was “not at all”; important. Even when the motivation groups were approximately equated for lifetime problem severity there was still a significant effect of recent motivation as expressed on the ASI. Conclusions. These data are consistent with other findings from the “stage of change”; literature suggesting that treatment is only important for patients who are ready or at least somewhat motivated to receive it. These findings underscore the importance of efforts to increase patients’ readiness for treatment in order to achieve better treatment effects.     

Matching Clients’ Needs With Drug Treatment Services

This paper reports results of a study that investigated whether matching drug treatment services with client needs improved outcomes for a sample of 171 clients who participated in community-based drug treatment programs. Clients were initially assessed on multiple problem areas (alcohol use, drug use, medical, psychological, family/social, legal, employment, housing) and on areas of special needs or stated preferences for services (e.g., transportation, child care, language). A 6-month follow-up interview reassessed clients’ problems/needs in all areas and collected information on the services received. The results showed that some services significantly improved client outcome for those who had expressed needs for such services. Notably, services meeting the need for vocational training, child care, transportation, and housing showed beneficial effects. A higher level of needs and services matching (defined either by the ratio of services received to services desired, or by the total level of met versus unmet needs in the eight problem areas) significantly predicted longer treatment retention.     

Personal Network Characteristics of Youth in Substance Use Treatment: Motivation for and Perceived Difficulty of Positive Network Change

Background: Among youth in substance use treatment, peer substance use consistently predicts worse treatment outcomes. This study characterized personal (egocentric) networks of treated youth and examined predictors of adolescents’ motivation and perceived difficulty in making changes in the peer network to support recovery. Methods: Adolescents (aged 14–18; N = 155) recruited from substance use treatment reported on substance use severity, motivation to abstain from substance use, abstinence goals such as “temporary abstinence,” motivation and perceived difficulty in reducing contact with substance-using peers, and personal network characteristics. Personal network variables included composition (proportion of abstinent peers) and structure (number of network members, extent of ties among members) for household and nonhousehold (peer) members. Results: Although a majority of peer network members were perceived as using alcohol or marijuana, youth in treatment had relatively high motivation to abstain from substance use. However, treated youths’ motivation to reduce contact with substance-using peers was relatively low. In particular, a goal of temporary abstinence was associated with lower motivation to change the peer network. For marijuana, specifically, network composition features (proportion of abstinent peers) were associated with motivation and perceived difficulty to change the peer network. For marijuana, in particular, network structural variables (extent of ties among members) were associated only with perceived difficulty of changing the peer network. Conclusions: Despite high motivation to abstain from substance use during treatment, adolescents reported low motivation to reduce contact with substance-using peers. Personal motivation to abstain and abstinence goal predicted motivation to reduce contact with substance-using peers. In contrast, particularly for marijuana, network structure predicted perceived difficulty of network change. Results highlight the potential utility of addressing motivation and perceived difficulty to change the peer network as part of youth network-based interventions.     

Family Planning in Substance Use Disorder Treatment Centers: Opportunities and Challenges

Background: Alcohol, tobacco, and drug use during pregnancy can cause a range of adverse birth outcomes. Promoting family planning among women with substance use disorders (SUD) can help reduce substance exposed pregnancies. Objectives: We conducted qualitative research to determine the acceptability and feasibility of offering family planning education and services SUD treatment centers. Methods: Focus groups and in-depth interviews were conducted with clients, staff and medical providers at three treatment centers. Interviews were transcribed and data was analyzed using a flexible coding scheme. Results: Clients reported being interested in family planning services while they were in treatment. Most preferred to receive these services onsite. Providers also felt that services should be received onsite, though cited several barriers to implementation, including time constraints and staff levels of comfort with the subject. Conclusions/Importance: Women in SUD treatment are open to the integration of family planning services into treatment. Treatment centers have the opportunity to serve as models of client-centered health homes that offer a variety of educational, preventive, and medical services for women in both treatment and recovery.     

Client‐reported reasons for non‐engagement in drug and alcohol treatment

Introduction and Aims. To examine client‐reported reasons for missed early appointments at a drug and alcohol treatment service and to compare characteristics of those who missed appointments with those who attended. Design and Methods. Clients who missed a first or second appointment between 1 May and 31 August 2007 at a public community‐based outpatient treatment facility were invited to participate in a semistructured telephone interview. This consisted of an open‐ended question asking the reason(s) for nonattendance, followed by a questionnaire of items for therapeutic alliance and service satisfaction, perceived impact of substance use and previous treatment experience, mostly rated on Likert scales. Database information on demographic and clinical variables was gathered for all clients who were accepted for treatment within the study time frame. Characteristics of those who missed a first or second appointment (n = 66) were compared with those who attended at least their first two appointments (n = 97). Results. Of clients who missed their appointments, 80.6% provided reasons for nonattendance, which included extraneous factors (50.0%), service shortcomings (29.7%), no further need for service (16.2%) and motivational ambivalence (4.1%). They generally had high ratings of therapeutic alliance and service satisfaction and identified their substance use as having a negative impact on their lives. Clients who missed appointments were more likely to be male, unmarried and have a history of polysubstance use. Discussion and Conclusions. Extraneous issues relating to the client may be a dominant obstacle in early treatment engagement. Efforts to overcome these issues may therefore improve early engagement.[Coulson C, Ng F, Geertsema M, Dodd S, Berk M. Client‐reported reasons for non‐engagement in drug and alcohol treatment. Drug Alcohol Rev 2009;28:372–378]     

Combined treatment for at-risk drinking and smoking cessation among Puerto Ricans: A randomized clinical trial

Tobacco and alcohol use are linked behaviors that individually and synergistically increase the risk for negative health consequences. This study was a two-group, randomized clinical trial evaluating the efficacy of a behavioral intervention, “Motivation And Problem Solving Plus” (MAPS +), designed to concurrently address smoking cessation and the reduction of at-risk drinking. Targeted interventions may promote coaction, the likelihood that changing one behavior (smoking) increases the probability of changing another behavior (alcohol use). Puerto Ricans (N = 202) who were smokers and at-risk drinkers were randomized to standard MAPS treatment focused exclusively on smoking cessation (S-MAPS), or MAPS +, focused on cessation and at-risk drinking reduction. Drinking outcomes included: number of at-risk drinking behaviors, heavy drinking, binge drinking, and drinking and driving. MAPS + did not have a significant main effect on reducing at-risk drinking relative to S-MAPS. Among individuals who quit smoking, MAPS + reduced the number of drinking behaviors, the likelihood of meeting criteria for heavy drinking relative to S-MAPS, and appeared promising for reducing binge drinking. MAPS + did not improve drinking outcomes among individuals who were unsuccessful at quitting smoking. MAPS + showed promise in reducing at-risk drinking among Puerto Rican smokers who successfully quit smoking, consistent with treatment enhanced coaction. Integrating an alcohol intervention into cessation treatment did not reduce engagement in treatment, or hinder cessation outcomes, and positively impacted at-risk drinking among individuals who quit smoking. Findings of coaction between smoking and drinking speak to the promise of multiple health behavior change interventions for substance use treatment and chronic disease prevention.