Node-link mapping and psychological problems. Perceptions of a residential drug abuse treatment program for probationers

The current study examined program perceptions of 367 probationers admitted to a 4-month residential drug abuse treatment facility that focuses on group counseling. Prior research has shown that many individuals within the criminal justice system have both psychological and drug abuse problems, and that they often have limited success in drug abuse treatment programs. The current study examined whether the benefits of node-link mapping, a visual representation counseling technique that is especially beneficial in group counseling environments, would extend to individuals with psychological problems. Probationers were randomly assigned to mapping-enhanced or standard counseling. Those residents who had higher levels of psychological problems (based on a global indicator of psychological problems), and who received mapping-enhanced counseling, had more favorable perceptions of their counselors and fellow community members over time than their counterparts who received standard counseling.     

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.     

Beyond face-to-face individual counseling: A systematic review on alternative modes of motivational interviewing in substance abuse treatment and prevention

ObjectivesThis systematic review aimed to synthesize the evidence on the effectiveness of motivational interviewing (MI), delivered in modes other than face-to-face individual counseling, in preventing and treating substance abuse related behaviors.MethodsFour databases (PubMed/MEDLINE, PsycINFO, ISI Web of Science and Cochrane Library) were searched for randomised clinical trials (RCTs) that evaluated the effectiveness of alternative modes of MI (other than face-to-face individual counseling) in preventing and treating substance abuse. Eligible studies were rated on methodological quality and their findings were qualitatively synthesized.ResultsA total of 25 articles (on 22 RCTs) were eligible for this review. Beyond face-to-face counseling, telephone was the most frequently used medium for delivering MI (11 studies), followed by Internet communication (4 studies) and short message service (SMS) (2 studies). Mail was incorporated as a supplement in one of the studies for telephone MI. In contrast to one-to-one individual counseling, group MI was adopted in 5 studies. The effectiveness of telephone MI in treating substance abuse was supported by all of the published RCTs we located. Internet-based MI was effective in preventing and treating alcoholism, but its outcome appeared to be inconsistent for smoking cessation and poor for abstinence from illicit drugs. SMS-based MI appeared to be useful for controlling tobacco and drinking. Group MI was attempted for quitting alcohol and drugs, with mixed findings on its outcomes.ConclusionsCollectively, the studies reviewed indicate that telephone MI is a promising mode of intervention in treating and preventing substance abuse. The effectiveness of other alternative modes (SMS-based MI, Internet-based MI and group MI) remains inconclusive given the controversial findings and a limited number of studies. By synthesizing the currently available evidence, this systematic review suggested that telephone MI might be considered as an alternative to face-to-face MI for treating and preventing substance abuse. Further research is needed to investigate the effectiveness of SMS-based MI, Internet MI, group MI and other alternative modes. Studies with methodological rigor and incorporating MI fidelity measures have great potential to advance the understanding in this field.     

Use of vouchers to reinforce abstinence and positive behaviors among clients in a drug court treatment program

In response to the growing number of drug offenders cycling in and out of the criminal justice system without treatment for underlying drug problems, the judicial system has increasingly adopted drug courts as a strategy to divert these offenders from incarceration to supervised drug treatment. Our aim was to determine if drug court treatment effectiveness could be improved using contingency management, in the form of twice-weekly vouchers, to reinforce abstinence and positive behaviors for 163 clients over 26 weeks. We found no significant differences in outcomes among the study groups, although the Treatment Plan Group that received reinforcement for positive behaviors showed a trend toward poorer performance. We suspect that the influence of the judge within the courtroom had a stronger impact on drug court clients' attitudes, drug use behaviors, and other outcomes than the relatively low-value vouchers awarded as part of the treatment protocol.     

Informal discussions in substance abuse treatment sessions with Spanish-speaking clients

This study investigated the extent to which bilingual counselors initiated informal discussions about topics that were unrelated to the treatment of their monolingual Spanish-speaking Hispanic clients in a National Institute on Drug Abuse Clinical Trial Network protocol examining the effectiveness of motivational enhancement therapy (MET). Session audiotapes were independently rated to assess counselor treatment fidelity and the incidence of informal discussions. Eighty-three percent of the 23 counselors participating in the trial initiated informal discussions at least once in one or more of their sessions. Counselors delivering MET in the trial initiated informal discussion significantly less often than the counselors delivering standard treatment. Counselors delivering standard treatment were likely to talk informally the most when they were ethnically non-Latin. In addition, informal discussion was found to have significant inverse correlations with client motivation to reduce substance use and client retention in treatment. These results suggest that informal discussion may have adverse consequences on Hispanic clients' motivation for change and substance abuse treatment outcomes and that maintaining a more formal relationship in early treatment sessions may work best with Hispanic clients. Careful counselor training and supervision in MET may suppress the tendency of counselors to talk informally in sessions.     

Performance measures for outpatient substance abuse services: group versus individual counseling

Most substance abuse treatment programs employ various models of group therapy. Empirical evidence, however, of the benefits of group vs. individual treatment is scarce. This study examined the impact of type of treatment, defined as individual or group counseling, on treatment performance, as measured by treatment completion and goal achievement. Data on clients treated in publicly funded substance abuse outpatient treatment programs were drawn from the Massachusetts Substance Abuse Information System. A larger proportion of group to individual therapy was strongly and positively associated with increased likelihood for improved measures of treatment performance. State data systems can provide useful insights into the development and application of performance measurement.     

Improving vocational placement in drug treatment clients: A pilot study

Forty-nine methadone maintenance clients, who were seeking jobs or entrance into competitive training programs, were randomly assigned to either a 2-wk experimental vocational workshop, or to a control condition. The experimental workshop included presentation of information about vocational resources and opportunities available to drug treatment clients, and emphasized videotaped feedback of interview practice, practice and advice in completing application forms, brief relaxation training exercises, and instruction in initial attempts toward vocational placement. The control subjects received the vocational information, but did not participate in the remainder of the workshop. At a time corresponding to the end of the workshop, all subjects were assessed as to acceptability as an employee/trainee via blind ratings of interview and written applications. Experimental subjects were rated as superior on both (P < 0.04 and 0.01 respectively). Further, at 3 months posttreatment, 50% of the experimental subjects had been placed, as compared with 14% of the controls (χ² = 4.44, P < 0.05).     

A model of the effects of node-link mapping on drug abuse counseling

This paper examines the effectiveness of a promising cognitive enhancement technique called node-link mapping. Maps provide a concrete, visual, and computationally efficient means for exploring personal issues, and have received substantial empirical support. We introduce two models to provide a framework for understanding how node-link mapping improves substance abuse counseling. The TCU Process Model reviews the general process of substance abuse treatment. The second model reflects an effective treatment session. Implications of the models and node-link mapping findings are discussed, as well as future research directions.     

Perspectives on privacy in the pharmacy: The views of opioid substitution treatment clients

BackgroundMany pharmacists practise in settings in which protecting privacy can be difficult. To address this, some community pharmacies are rearranging their retail space to provide private areas for clinical consultations. Such facilities are deemed particularly important when dealing with clients who have sensitive medical conditions, such as opioid dependence.ObjectiveTo explore Opioid Substitution Treatment (OST) patients’ perceptions of privacy in a community pharmacy setting, with a particular focus on the layout of the community pharmacy.MethodsWe conducted semi-structured interviews with OST clients. Recruitment and the interviews were conducted at state government drug and alcohol clinic. The interviews were audio recorded and transcribed verbatim. The data were analysed in NVivo using the framework approach.ResultsWe interviewed fourteen OST clients. Most participants were concerned about privacy and considered that the pharmacy layout could enhance or hinder privacy. However, they disagreed about exactly which pharmacy layout was most privacy-protecting. In addition, a small group of clients interviewed who had a very positive relationship with pharmacists believed that the relationship contributed to their confidence that their privacy was protected.ConclusionsThere is little consensus amongst consumers about how to protect privacy in the community pharmacy. The range of views expressed by clients in this study may reflect the lack of consensus about the nature of privacy in health ethics. Attention to the meaning of and rationales for privacy protections may be helpful when designing pharmacy layouts to meet the needs of a broad range of consumers. An enclosed or screened private area which can be used as a consultation area for all private pharmacy discussions, including for OST dosing, could be a solution to addressing these varying views on privacy in the pharmacy. Further attention to enhancing the pharmacist and client relationship may assist in reducing sensitivity about privacy.     

Self-perceived problem with alcohol use among opioid substitution treatment clients

Background and aim

Excessive alcohol use increases mortality and morbidity among opioid substitution therapy (OST) clients. Regular attendance for OST dosing presents key opportunities for screening and treatment. However, individuals' perception of their alcohol consumption as problematic or otherwise may impact their willingness to change. This study examines patterns of alcohol consumption among OST clients, perceptions of their own use and correlates of excess consumption.

Methods

Confidential, structured interviews were conducted with 264 clients of two Sydney OST clinics. Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT); and illicit drug dependence with the Severity of Dependence Scale.

Results

Forty-one percent of the participants scored ≥ 8 on the AUDIT (‘AUDIT-positive’), indicating excessive alcohol use. The higher a participant's AUDIT score, the more likely they were to demonstrate insight into the potential problems associated with their drinking (linear trend, p < 0.01). However, only half of AUDIT-positive participants believed they drank too much and/or had a problem with alcohol. One-third had discussed their drinking with OST staff, and a similar proportion reported a history of alcohol treatment. AUDIT-positive participants were more likely than others to be classified as dependent on an illicit drug in the last six months (AOR = 1.76, 95% CI:1.00–3.09), report a history of alcohol treatment (AOR = 5.70, 95% CI:2.83–11.48) and believe it is safe to drink 4 + standard drinks in one session (AOR = 5.30, 95% CI:2.79–10.06).

Conclusions

OST clients with AUDIT scores ≥ 8 appear to underestimate the risks associated with their alcohol consumption. Regular assessments of alcohol use and targeted brief alcohol interventions may improve health outcomes among OST clients.     

Deaths of clients in methadone treatment in Texas: 1994-2002

This study analyzes causes of deaths of 766 patients who died while in methadone treatment in Texas between 1994 and 2002. Compared with deaths in the general population of Texas, deaths of clients in methadone treatment were 4.6 times more likely to be from a drug overdose, 3.4 times more likely to be from liver disease, 1.7 times more likely to be from a respiratory disease, 1.5 times more likely to be from a homicide and 1.4 times more likely to be from AIDS, but less likely to be from suicide, motor vehicle accidents, cardiovascular diseases or cancer. Of the clients, 20% died of liver disease, 18% of cardiovascular disease and 14% of drug overdose. An older cohort had been in treatment longer, had more take-homes, were on higher doses and tended to die of chronic diseases. A younger cohort tended to die from traumas, including drug overdose. Time in treatment was 43.3 months; mean daily dose was 77.3mg; number of days/month dosed in the clinic was 13.9. Given these rates, the scope of services should include on-site treatment for other medical conditions and staff should be educated about and counsel about the risk of death for new patients.     

Attack behaviors in mice: from factorial structure to quantitative trait loci mapping

The emergence or non-emergence of attack behavior results from interaction between the genotype and the conditions under which the mice are tested. Inbred mice of the same strain reared or housed under conditions do not react the same way; reactions also vary according to the place selected for testing and the different opponents. A factor analysis showed that the attack behavior in non-isolated males, tested in neutral area covaried with high testosterone and steroid sulfatase and low brain 5-hydroxytriptamine (5-HT), beta-endorphin and Adrenocorticotropic Hormone (ACTH) concentration, whereas, for isolated males tested in their own housing cage, it covaried with high testosterone activity and low brain 5-HT concentration. A wide genome scan was performed with two independent populations derived from C57BL/6J and NZB/BlNJ, each being reared, housed and tested under highly contrasting conditions, as described above, and confronted with A/J standard males. Common Quantitative Trait Loci emerged for two rearing/testing conditions. For rattling latency we detected Quantitative Trait Loci on Mus musculus chromosome 8 (MMU8) (at 44, LOD score=3.51 and 47 cM, LOD score=6.22, for the first and the second conditions) and on MMU12 (at 39 cM, LOD score=3.69 and at 41 cM, LOD score=2.99, respectively). For the number of attacks, Quantitative Trait Loci were common: on MMU11 at 39 cM LOD score=4.51 and 45 cM, LOD score=3.05, respectively, and on MMU12 (17 cM, LOD score=2.71 and 24 cM, LOD score=3.10). The steroid sulfatase gene (Sts), located on the X-Y pairing region, was linked, but only in non-isolated males, tested in neutral area for rattling latency, first attack latency, and number of attacks (LOD scores=4.9, 4.79 and 3.57, respectively). We found also that the Quantitative Trait Locus encompassing Sts region interacted with other Quantitative Trait Loci. These results indicate that attack behavior measured in different rearing and testing conditions have different biological and genetic correlates. This suggests that further explorations should be done with standardized tests and, in addition, with a wide range of tests, so as to gain an understanding of the true impact of genes or pharmacological treatments on specific categories of aggressive behavior.     

Medicaid care management: Description of high-cost addictions treatment clients

High utilizers of alcohol and other drug treatment (AODTx) services are a priority for healthcare cost control. We examine characteristics of Medicaid-funded AODTx clients, comparing three groups: individuals < 90th percentile of AODTx expenditures (n = 41,054); high-cost clients in the top decile of AODTx expenditures (HC; n = 5,718); and 1760 enrollees in a chronic care management (CM) program for HC clients implemented in 22 counties in New York State. Medicaid and state AODTx registry databases were combined to draw demographic, clinical, social needs and treatment history data. HC clients accounted for 49% of AODTx costs funded by Medicaid. As expected, HC clients had significant social welfare needs, comorbid medical and psychiatric conditions, and use of inpatient services. The CM program was successful in enrolling some high-needs, high-cost clients but faced barriers to reaching the most costly and disengaged individuals.     

A treatment crisis: cocaine use by clients in methadone maintenance programs

We surveyed 11 methadone maintenance treatment programs in the Baltimore, Maryland, area to examine cocaine use among their 2414 clients and the methods employed to cope with that use. The percent of clients with at least one urine sample positive for cocaine during the month previous to study was 15.7% (379/2414) and ranged from 5.9% to 33.0% among the 11 programs. We determined the programs' use of monitoring strategies, treatment services, and administrative controls. We discuss the policy implications of our findings for methadone maintenance programs' efforts to address cocaine use with particular regard to the epidemic of human immunodeficiency virus (HIV) among intravenous drug users, their sexual partners, and offspring.     

Treatment career snapshots: profiles of first treatment and previous treatment clients.

To examine the substance abuse recovery process from a treatment-career perspective, this study compared the profiles of clients entering treatment for the first time versus those returning to treatment. Clients (N = 7,092) presenting for publicly funded treatment were assessed as part of the St. Louis Target Cities project. Previous treatment clients were more likely to have more severe substance abuse problems, additional psychiatric problems, and greater problems in other life areas. Comorbid psychiatric problems and motivation to change were identified as areas of focus for clinical intervention. Discriminant analysis yielded a significant function that accounted for 6.5% of the variance between groups. Results suggest that change occurs via multiple processes.     

Young cannabis users in residential treatment: as distressed as other clients

Doubt remains about the need for residential substance user treatment for young cannabis users. Using a series of validated clinical tools, this study compared 1,221 primarily cannabis-, psychostimulant-, alcohol-, or opioid-dependent young people admitted to an urban/rural Australian residential treatment program between 2001 and 2007. Multinomial logistic regression revealed that the cannabis user group had poorer mental health than the opioid group, poorer social functioning than the alcohol drinking group, and comparably poor functioning otherwise but remained in treatment longer than the psychostimulant and opioid user groups. Residential treatment for primarily cannabis-dependent young people with complex and multiple needs can be supported.     

Individual versus team-based case-management for clients of opioid treatment services: an initial evaluation of what clients prefer

Introduction and Aims. Case‐management is a client‐centred intervention to improve the coordination and continuity of delivery of services for people with complex needs. This service has been incorporated into opioid treatment programs in various ways. This study was undertaken to compare two case‐management models, termed individual case‐management (ICM) and team‐based case‐management (TBCM). This study aims to describe the new TBCM and client attitudes to, and acceptance of, this model compared with ICM. Design and Methods. Clients from two opioid treatment programs, one implementing ICM and one implementing the TBCM, were recruited to undertake a self‐complete survey examining satisfaction with case‐management during dosing hours over 7 months. Surveys took approximately 10 min to complete. Results. One hundred and sixty‐three clients were surveyed (62 ICM, 101 TBCM). Clients were demographically similar, but differed in terms of treatment and drug use characteristics. Significantly higher ratings of case‐management were reported from TBCM compared with ICM clients for help with opiate use (P < 0.001), other drug use (P < 0.001), mental health (P < 0.001), accommodation (P = 0.023), relationships/parenting (P = 0.003) and physical health (P = 0.002) and clinic services in terms of fairness and consistency, safety, respect, staff quality and confidentiality (P < 0.001). Compared with ICM clients, TBCM clients were more likely to report ease of access to case‐management (P < 0.001), wait significantly less time to see a case‐manager (38% vs. 7% seen same day) and 93% and 47% of clients, respectively, reported satisfaction with treatment (P < 0.001). Discussion and Conclusions. These initial data indicate client acceptance and satisfaction with the TBCM model. Further evaluation of the model, including cost‐effectiveness, is warranted.[Day CA, Demirkol A, Tynan M, Curry K, Hines S, Lintzeris N, Haber PS. Individual versus team‐based case‐management for clients of opioid treatment services: An initial evaluation of what clients prefer. Drug Alcohol Rev 2012;31:499–506]     

Development of a brief treatment instrument for routine clinical use with methadone maintenance treatment clients: the methadone treatment index

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.