Use of mental health and substance abuse treatment services by female injection drug users

This article examines whether female injection drug users (IDUs) who have a history of using mental health services (i.e., one or more psychiatric hospitalizations or counseling) enter types of drug treatment different from those of female IDUs who do not have a history of using mental health services. Data used for this exploration originate from a statewide drug-treatment database covering all women who entered drug treatment in the state of Massachusetts from 1996 to 2001. A total of 7776 women were included in the study. Through the use of logistic regression analysis, the study determined that those female IDUs who had a mental health service history, compared with female IDUs who had no such history, were about two-thirds more likely to enter substance abuse treatment other than detoxification only. Specifically, women with a mental health service history were about 66% more likely to enter substance abuse treatment modalities such as drug-free outpatient counseling, methadone maintenance, and/or long-term residential services rather than detoxification alone. This is a positive result, indicating that female IDUs who have mental health problems and therefore have high needs for effective substance abuse treatment are entering the more intensive and/or longer term modalities likely to lead to better outcomes. Possible factors accounting for this, including the referral process within detoxification centers, the role of community referral agents, and the experience women gain as a consequence of receiving services in more than one service system, are discussed.     

Increasing access and providing social services to improve drug abuse treatment for women with children

Aims. To assess the impact of a substance abuse treatment program for women with children designed to increase access to treatment through transportation, outreach and child-care services. Also, to assess the impact of using access services on the use of other services and on treatment effectiveness. Design. A quasi-experimental non-equivalent control group design was used with path analysis to examine the impact of participation in an enhanced services program that provided transportation, outreach and child-care services on the use of other social services and on the use of alcohol and illicit drugs. Setting. Treatment clients were interviewed in- person at enhanced treatment programs and regular substance abuse programs. Participants. Study participants included a randomly selected sample of women with children who were clients of the Illinois Department of Children and Family Services. Participants were enrolled in enhanced or regular substance abuse treatment programs. Measurements. Study participants completed in-person interviews about their characteristics, services use and past and current substance use. Findings. Participation in the enhanced program was negatively related to substance use. Further, use of access services was related to use of social services which in turn, was negatively related to substance use. Conclusion. The study indicates that services that enhance access to treatment and respond to the range of social service needs of women are important for effective substance abuse treatment for women with children.     

Can Encouraging Substance Abuse Patients to Participate in Self‐Help Groups Reduce Demand for Health Care? A Quasi‐Experimental Study

BACKGROUND: Twelve-step-oriented inpatient treatment programs emphasize 12-step treatment approaches and the importance of ongoing attendance at 12-step self-help groups more than do cognitive-behavioral (CB) inpatient treatment programs. This study evaluated whether this difference in therapeutic approach leads patients who are treated in 12-step programs to rely less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term health care costs. METHODS: A prospective, quasi-experimental comparison of 12-step-based (N = 5) and cognitive-behavioral (n = 5) inpatient treatment programs was conducted. These treatments were compared on the degree to which their patients participated in self-help groups, used outpatient and inpatient mental health services, and experienced positive outcomes (e.g., abstinence) in the year following discharge. Using a larger sample from an ongoing research project, 887 male substance-dependent patients from each type of treatment program were matched on pre-intake health care costs (N = 1774). At baseline and 1-year follow-up, patients' involvement in self-help groups (e.g., Alcoholics Anonymous), utilization and costs of mental health services, and clinical outcomes were assessed. RESULTS: Compared with patients treated in CB programs, patients treated in 12-step programs had significantly greater involvement in self-help groups at follow-up. In contrast, patients treated in CB programs averaged almost twice as many outpatient continuing care visits after discharge (22.5 visits) as patients treated in 12-step treatment programs (13.1 visits), and also received significantly more days of inpatient care (17.0 days in CB versus 10.5 in 12-step), resulting in 64% higher annual costs in CB programs ($4729/patient, p < 0.001). Psychiatric and substance abuse outcomes were comparable across treatments, except that 12-step patients had higher rates of abstinence at follow-up (45.7% versus 36.2% for patients from CB programs, p < 0.001). CONCLUSIONS: Professional treatment programs that emphasize self-help approaches increase their patients' reliance on cost-free self-help groups and thereby lower subsequent health care costs. Such programs therefore represent a cost-effective approach to promoting recovery from substance abuse.     

Welfare reform and the changing landscape of substance abuse services for low-income women

Recent welfare reform policies could fundamentally change the nature of public-sector substance abuse services available to women. This review summarizes what is presently known about substance abuse services and women on welfare, and identifies limitations in our current knowledge about the potential effects of welfare reform. Five crucial areas are examined in which research on services has fallen short: (1) assessing the need for substance abuse services across a broad spectrum of welfare populations, (2) exploring the role that alcohol and drug problems play in welfare dependency, (3) examining how welfare programs can serve as pathways to alcohol and drug treatment, (4) evaluating the effectiveness and costs of innovative welfare-treatment programs, and (5) understanding systems-level adaptations in substance abuse services for women that result from changing welfare policies. We conclude that researchers who study services should take a broad view of these issues-one that considers the unique situation of poor women and single mothers, that views substance abuse within a work impairment or disabilities framework, and one that is attuned to future changes in the effects of welfare reform as the economy and labor markets undergo change.     

Patterns of substance use among a large urban cohort of HIV-infected men who have sex with men in primary care

The present study sought to identify characteristics of HIV-infected MSM that are associated with the use of specific substances and substance abuse in general. Participants were 503 HIV-infected MSM who were receiving primary care. A self-assessment and medical records were used to obtain information about past 3-month alcohol and drug use and abuse, and demographics, HIV-disease stage and treatment, sexual risk, and mental health. Associations of these four domains with substance use and abuse outcomes were examined using hierarchical block-stepwise multivariable logistic regression. Substance use and abuse in the sample was high. Transmission risk behavior was significantly associated with over half of the outcomes. The associations of demographic and HIV-disease stage and treatment variables varied by substance, and mental health problems contributed differentially to almost every outcome. These findings should be considered for designing, implementing, and evaluating substance use programming for HIV-infected MSM.     

A comparative evaluation of substance abuse treatment: I. Treatment orientation, amount of care, and 1-year outcomes

This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups. The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment. Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up. Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up. These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes. Subsequent papers in this section focus on the proximal outcomes of treatment, patients with psychiatric as well as substance use disorders, patient-treatment matching effects, and the link between program treatment orientation and patients' involvement in and the influence of 12-Step self-help groups.     

Which substance abuse treatment facilities offer dual diagnosis programs?

This report examines the distribution of specialized programs or groups for dual diagnosis clients in substance abuse treatment facilities across the United States and the availability of services often needed by this client population at these facilities. Data from the National Survey of Substance Abuse Treatment Services (N-SSATS) were used to assess the geographic distribution and the characteristics of facilities that offer dual diagnosis treatment programs/groups and to examine the other clinical, social, and health services available in these facilities. Overall, 49.9% of all U.S. substance abuse treatment facilities offered dual diagnosis programs/groups. There were no clear regional variations on availability of these services. There were, however, clear variations based on facility ownership and treatment modality. Facilities owned by the federal, state, and local governments, and those offering inpatient treatment were more likely than were other facilities to offer dual diagnosis programs/groups. A large proportion of facilities with specialized dual diagnosis programs/ groups did not offer mental, social, or health services often needed by dual diagnosis clients. It is concluded that specialized programs for dual diagnosis clients are offered in many different substance abuse treatment facilities, attesting to the growing recognition of the special needs of this group of clients. However, dissemination of comprehensive services often needed to meet the special needs of these clients has not kept pace with the spread of specialized programs, highlighting the need for establishing and implementing standard evidence-based guidelines for dual diagnosis treatment programs in these settings.     

Factors associated with emergency room use among injection drug users of African-American, Hispanic and White-European background

This study examined the relationship between substance abuse treatment use, health services use, HIV status, and emergency room/hospital use for 507 injection drug users (IDUs). Logistic regression models showed that mental health status, severity of drug use and private health insurance were significantly associated with having used emergency room/hospital services in the past six months. History of substance abuse treatment use, positive HIV/AIDS diagnosis, mental health service use, ethnic/racial background, gender, age, education and homelessness were not significant at either the bivariate or the multivariate level. These results point to the need to improve mental health screening and referrals through emergency room medical systems.     

Integrating intervention for substance use disorder in a healthcare setting: practice and outcomes in New York City STD clinics

ABSTRACT

Objective: This article reports the integration and outcomes of implementing intervention services for substance use disorder (SUD) in three New York City public sexually transmitted disease (STD) clinics. Methods: The screening, brief intervention, and referral to treatment (SBIRT) service model was implemented in the STD clinics in 2008. A relational database was developed, which included screening results, service dispositions, face-to-face interviews with 6-month follow-ups, and treatment information. Results: From February 2008 to the end of September 2012, 146 657 STD clinic patients 18 years or older were screened for current or past substance use disorders; 15 687 received a brief intervention; 954 received referrals to formal substance abuse treatment; 2082 were referred to substance abuse support services such as Alcoholics Anonymous (AA), and 690 were referred to mental health, social or HIV awareness services. Intervention services delivered through SBIRT resulted in improvements in multiple outcomes at 6 month follow-up. Patients who received interventions had reduced SUD risks, fewer mental health problems, and fewer unprotected sexual contacts. Conclusion: Delivery of SUD services in a public health setting represents a significant policy and practice change and benefits many individuals whose SUDs might otherwise be overlooked. Intervention services for substance use disorder were integrated and highly utilized in the STD setting. Further research needs to focus on the long-term impact of SUD interventions in the STD setting, their cost effectiveness, and the extent they are financially sustainable under the new healthcare law.     

Sheltered versus nonsheltered homeless women

OBJECTIVE: To contrast sociodemographic characteristics, physical and mental health status, substance use, sexual behaviors, victimization, and utilization of health services between homeless women residing in sheltered and nonsheltered environments. DESIGN: Cross-sectional survey. A structured scale was used to measure mental health status. Physical health status, substance use, sexual behavior, history of adult victimization, and health services utilization were measured by content-specific items. SETTING: Shelters (N=47) and outdoor locations in Los Angeles. PARTICIPANTS: One thousand fifty-one homeless women. RESULTS: Homeless women living on the streets were more likely than sheltered women to be white and longer-term homeless. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed that unsheltered women had over 3 times greater odds of fair or poor physical health, and over 12 times greater odds of poor mental health than sheltered homeless women. They were also more likely than sheltered women to report using alcohol or noninjection drugs, to have multiple sexual partners, and to have a history of physical assault. About half of the overall sample reported utilization of a variety of health services; however, unsheltered homeless women were less likely to utilize all of the health services that were assessed, including drug treatment. CONCLUSIONS: There is a critical need for aggressive outreach programs that provide mental health services and substance abuse treatment for homeless women on the streets. Comprehensive services that also include medical care, family planning, violence prevention, and behavioral risk reduction may be particularly valuable for homeless women, especially those living in unsheltered environments. This research was supported by the National Institute on Drug Abuse, grants DA06719 and DA01070. Dr. Gelberg is a Robert Wood Johnson Generalist and Physician Faculty Scholar.     

Improving Health and Social Outcomes with Targeted Services in Comprehensive Substance Abuse Treatment

Background: Improved life functioning along with substance use reduction is increasingly recognized as the definition of effective addiction treatment. Objectives: To assess whether targeted health and social services contribute to improved physical/mental health and employment. Methods: This study used data from the National Treatment Improvement Evaluation Study (N = 3027) and modeled the improvement in physical/mental health and employment at discharge or 12 months after discharge compared with intake measures as a function of receipts of matched services. Results: Receiving matched medical service improves physical health only at treatment discharge; receiving matched mental health services improves mental health at discharge and 12 months after discharge; receiving matched vocational services improves employment only 12 months after discharge. Conclusions: Need–service matching contributes to improved health and social outcomes when longitudinal assessments of treatment outcomes are used to evaluate treatment effectiveness. Scientific Significance: Study findings document the value of targeted services for achieving success in health and social functioning in comprehensive substance abuse treatment.     

The impact of 9/11 on patients in New York City's substance abuse treatment programs

OBJECTIVES: This article assesses the impact of the attacks on 9/11 in New York City on drug use, relapse, and mental health from the perspective of drug users and patients in substance abuse treatment programs. METHODS: Structured interviews were conducted with 16 administrators and 75 randomly selected patients at 15 substance abuse treatment programs in New York City from December 2002 to April 2003. RESULTS: Drug use and relapse was a significant issue on and after 9/11. While Post Traumatic Stress Disorder was related to drug use, other preexisting mental health problems were not. Men were more likely to relapse than women; however, women were more emotionally affected by events following 9/11. CONCLUSIONS: The attacks on 9/11 may have contributed to relapse among drug users and exacerbated existing mental health problems among patients with a history of concurrent drug use and mental illness.     

Improving health outcomes among individuals with HIV, mental illness, and substance use disorders in the Southeast

Providing behavioral treatment for mental health and substance use disorders among HIV-infected individuals is critical because these disorders have been associated with negative outcomes such as poorer medication adherence. This study examines the effectiveness of an integrated treatment model for HIV-infected individuals who have both substance use and mental disorders. Study participants (n = 141) were recruited through routine mental health and substance abuse screening at tertiary Infectious Disease clinics in North Carolina. The study participants received integrated mental health and substance abuse treatment for one year and were interviewed at three-month intervals. Using linear regression analyses, we detected statistically significant decreases in participants' psychiatric symptomatology, illicit substance use, alcohol use, and inpatient hospital days. Participants also reported fewer emergency room visits and were more likely to be receiving antiretroviral medications and adequate psychotropic medication regimens at follow-up. No changes in sexual risk, physical health, or medical adherence were detected after treatment participation. This integrated treatment model offers an option for treating HIV-infected individuals with mental health and substance use disorders that can be adapted for use in a variety of psychiatric and medical treatment settings.     

Does distance affect utilization of substance abuse and mental health services in the presence of transportation services?

Long travel times have been identified as a significant barrier to accessing mental health and other critical services. This study examines whether distance to treatment was a barrier to receiving outpatient mental health and substance abuse care for HIV-positive persons when transportation was provided. Data from a cohort of HIV-positive persons who participated in a year-long substance abuse and mental health treatment programme were examined longitudinally. Transportation, which included buses, taxis, and mileage reimbursement for private transportation, was provided free of charge for participants who needed this assistance. Nearly three-quarters (74%) of participants utilized the transportation services. No statistically significant differences in retention in, or utilization of, the mental health and substance abuse treatment programme were identified by distance to the treatment site. This analysis demonstrated that increased distance to care did not decrease utilization of the treatment programme when transportation was provided to the client when necessary. These results provide preliminary evidence that distance to substance abuse and mental health services need not be a barrier to care for HIV-positive individuals when transportation is provided. Such options may need to be considered when trying to treat geographically dispersed individuals so that efficiencies in treatment can be attained.     

Prisoners with substance abuse and mental health problems: use of health and health services

Individuals with substance abuse and mental health problems are common in prisons and jails, but relatively little is known about the health or health services utilization of inmates with these types of problems. This study, therefore, focuses on prisoners who self-reported receiving a prior diagnosis from a physician or a psychologist who indicated they had 1) substance abuse problems only, 2) mental health problems only, and 3) substance abuse and mental health problems. A fourth group of prisoners who reported no diagnoses were included as the "no problems" group. Comparisons were made on reports of lifetime health problems, use of preventive health services, and use of medical services. Findings showed the substance abuse and mental health problems group had the most serious health problems profiles. Use of preventive health services was similar across all four groups, but the substance abuse and mental health problems group reported significantly greater use of the emergency room and more hospital stays both for their lifetime and in the year prior to their current incarceration. The policy and practical relevance of the findings are discussed.     

A Study of Substance Use in Women in the West Texas U.S. Probation and Pretrial Services System

Previous studies have shown an association between substance use in the corrections population and, though the overall probation population has been declining, the percentage of women on probation has significantly increased. This study collected data on the factors associated with substance use and criminality among West Texas women who were sentenced to the U.S. Probation and Pretrial Services System (USPPSS). Intake records for USPPSS adult women spanning 3 years were reviewed. Among all age distributions and demographics, alcohol use was found to be prevalent. A significant positive correlation was found between immediate and extended family use of alcohol or drugs. Approximately one third of women reported a lifetime history of psychiatric treatment and three fourths reported a lifetime history of emotional/verbal, physical, and/or sexual abuse. The significant association with alcohol and substance use among these women should be addressed when determining probation planning and social services. Furthermore, the high incidence of emotional/verbal, physical and/or sexual abuse, and suicidality in this population would recommend an approach that includes provision of adequate mental health services.     

The HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study: conceptual foundations and overview

A growing population of people living with HIV/AIDS have co-morbid psychiatric and substance abuse diagnoses, increasing the need for integrated services for persons with multiple diagnoses. This article reviews models of integrated services for multiply diagnosed persons living with HIV/AIDS. We focus on the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study to highlight the elements of multifaceted and integrated service delivery systems for people with HIV, substance abuse, and mental health disorders. Study organizational features and models of integrated services are discussed, including details of models for assessing mental health and substance abuse, outcomes, and the cost-effectiveness of integrated services.     

Assessing the service linkages of substance abuse agencies with mental health and primary care organizations

Fragmentation of substance abuse treatment represents a major barrier to effective treatment for individuals with cooccurring substance abuse and mental and physical health disorders. Linkages of substance abuse treatment organizations with primary care and mental health agencies are widely considered to be a feasible way to integrate services. In this study, we analyzed information collected from a national sample of 62 outpatient substance abuse treatment units (OSATs) to understand the extent of services linkages in these organizations and to identify facilitators and barriers to service linkages. Results showed that OSATs had limited service linkages with primary care and mental health providers. The cited barriers to linkages included clients' financial problems, managed care restrictions, and limited organizational capacity. Onsite service provision was implemented in some OSATs. The pattern of service linkages in OSATs appeared to reflect the health needs of substance abuse clients.     

Assessing the Service Linkages of Substance Abuse Agencies with Mental Health and Primary Care Organizations

Fragmentation of substance abuse treatment represents a major barrier to effective treatment for individuals with cooccurring substance abuse and mental and physical health disorders. Linkages of substance abuse treatment organizations with primary care and mental health agencies are widely considered to be a feasible way to integrate services. In this study, we analyzed information collected from a national sample of 62 outpatient substance abuse treatment units (OSATs) to understand the extent of services linkages in these organizations and to identify facilitators and barriers to service linkages. Results showed that OSATs had limited service linkages with primary care and mental health providers. The cited barriers to linkages included clients' financial problems, managed care restrictions, and limited organizational capacity. Onsite service provision was implemented in some OSATs. The pattern of service linkages in OSATs appeared to reflect the health needs of substance abuse clients.     

The Impact of 9/11 on Patients in New York City's Substance Abuse Treatment Programs

Objectives: This article assesses the impact of the attacks on 9/11 in New York City on drug use, relapse, and mental health from the perspective of drug users and patients in substance abuse treatment programs. Methods: Structured interviews were conducted with 16 administrators and 75 randomly selected patients at 15 substance abuse treatment programs in New York City from December 2002 to April 2003. Results: Drug use and relapse was a significant issue on and after 9/11. While Post Traumatic Stress Disorder was related to drug use, other preexisting mental health problems were not. Men were more likely to relapse than women; however, women were more emotionally affected by events following 9/11. Conclusions: The attacks on 9/11 may have contributed to relapse among drug users and exacerbated existing mental health problems among patients with a history of concurrent drug use and mental illness.