Interaction Effects of Client and Treatment Program Characteristics on Retention: An Exploratory Analysis Using Hierarchical Linear Models

This paper applied a hierarchical linear modeling approach to explore the interaction effects of treatment program and client characteristics on client retention in treatment for drug users. Program characteristics included services provision, funding sources, and staff-client gender congruence, and client characteristics included gender, age at admission, and drug use level prior to admission. The same model was applied separately to three modalities: residential, methadone maintenance, and outpatient drug-free programs. Data were obtained from 59 treatment programs and 3,764 of their clients who had discharge records. The most noteworthy significant interaction effect detected was program's funding source and client's gender on treatment retention in the outpatient drug-free modality. for example, female clients remained less time in the programs that accepted only public funding than in the programs that accepted both public and private funding. Male clients remained in the treatment an average of 25.3 fewer days than female clients in drug-free programs that only accepted public fund, but stayed about the same time as females if the programs received mixed funding.     

Workforce professionalism in drug treatment services: impact of California's Proposition 36

This article investigates whether California's Proposition 36 has promoted the workforce professionalism of drug treatment services during its first 5 years of implementation. Program surveys inquiring about organizational information, Proposition 36 implementation, and staffing were conducted in 2003 and 2005 among all treatment providers serving Proposition 36 clients in five selected California counties (San Diego, Riverside, Kern, Sacramento, and San Francisco). A 1-hour self-administered questionnaire was completed by 118 treatment providers representing 102 programs. This article examines five topics that are relevant to drug treatment workforce professionalism: resources and capability, standardized intake assessment and outcome evaluation, staff qualification, program accreditation, and information technology. Results suggest that Proposition 36 had a positive influence on the drug treatment workforce's professionalism. Improvements have been observed in program resources, client intake assessment and outcome evaluation databases, staff professionalization, program accreditation, and information technology system. However, some areas remain problematic, including, for example, the consistent lack of adequate resources serving women with children.     

Women opiate users' perceptions of treatment services in New York City

This paper focuses on the treatment experiences of women opiate users in New York City. Historically, drug research has used male samples, and drug treatment programs have been based upon the concerns of men. Treatment counselors and administrators are typically male, and female clients are frequently outnumbered by male clients. In addition, unique needs of women are not addressed. Primary among these needs is child care, a provision that is not a standard feature of most programs. Additionally, many women opiate users may be in dysfunctional families and/or have histories of sexual victimization that may require special counselling. Using data from 208 women drug users who had been in an opiate treatment program, this paper examines their perceptions of the extent to which these programs incorporate women's distinctive concerns and the degree to which such provisions are affected by the perceived numbers of women clients in these programs.     

Alcoholics anonymous affiliation at treatment intake among white and black Americans

OBJECTIVE: Black Americans are overrepresented in the public alcohol treatment system, but may be less likely to use informal services such as Alcoholics Anonymous (AA). Some commentators perceive AA as a white, middle-class organization that is unlikely to appeal to blacks. This epidemiological study considers prior attendance and engagement in AA among 791 black and white men and women entering treatment in public, private and HMO substance abuse programs. METHOD: Clients were interviewed in-person within the first 3 days of inpatient treatment or the first 3 weeks of outpatient treatment. RESULTS: Black clients dominate public detoxification programs and report more drug and employment problems than whites (who report more family problems). Those with prior treatment experiences and those reporting they had gone to AA as part of treatment reported overall higher rates of AA affiliation, with blacks more likely to say they felt like a member of AA (64% vs 54% of whites), had a spiritual awakening as a result of AA (38% vs 27%) and had done service at AA meetings in the last year (48% vs 37%); whites were more likely to have had a sponsor (23% vs 14%) and to have read program literature (77% vs 67%). CONCLUSIONS: Controlling for other effects such as prior inpatient or outpatient treatment, blacks are about twice as likely as whites to report having attended AA as part of treatment (OR = 1.70). More research is needed to understand referral pathways to AA among blacks, and the differential effect this may have on sustained participation in AA and on long-term sobriety.     

Stability in a large drug treatment system: Examining the role of program size and performance on service discontinuation

BackgroundLittle is known about the stability of public drug treatment in the United States to deliver services in an era of expansion of public insurance. Guided by organizational theories, we examined the role of program size, and performance (i.e., rates of treatment initiation and engagement) on discontinuing services in one of the largest treatment systems in the United States.MethodsThis study relied on multi-year (2006–2014) administrative data of 249,029 treatment admission episodes from 482 treatment programs in Los Angeles County, CA. We relied on survival regression analysis to identify associations between program size, treatment initiation (wait time) and engagement (retention and completion rates) and discontinuing services in any given year. We examined program differences between discontinued versus sustained services in pre- and post-expansion periods.ResultsSixty-two percent of programs discontinued services at some point between 2006 and 2014. Program size and rates of treatment retention were negatively associated with risk of discontinuing services. Proportion of female clients was also negatively associated with risk of discontinuing services. Compared to residential programs, methadone programs were associated with reduced likelihood of discontinuing services. Two interactions were significant; program size and retention rates, as well as program size and completion rates were negatively associated with risk of discontinuing services.ConclusionsProgram size (large), type (methadone), performance (retention) and client population (women) were associated with stability in this drug treatment system. Because more than 70% of programs in this system are small, it is critical to support their capacity to sustain services to reduce existing disparities in access to care. We discuss the implications of these findings for system evaluation and for responding to public health crises.     

Drug assertiveness and sexual risk-taking behavior in a sample of HIV-positive, methamphetamine-using men who have sex with men

Drug assertiveness skills have been demonstrated to be effective in reducing substance use behaviors among patients with alcohol or heroin use disorders. This study examined the association between drug assertiveness and methamphetamine use, psychological factors, and sexual risk behaviors in a sample of 250 HIV-positive men who have sex with men enrolled in a safer sex intervention in San Diego, CA. Less assertiveness in turning down drugs was associated with greater frequency and larger amounts of methamphetamine use, lower self-esteem, higher scores on a measure of sexual sensation seeking, and greater attendance at risky sexual venues. These data suggest that drug assertiveness training should be incorporated into drug abuse treatment programs and other risk reduction interventions for methamphetamine users.     

Loitering by patients on methadone maintenance: a perception or a problem

Loitering has become an increasing matter of concern to both communities and staff involved in drug treatment programs. In order to determine the prevalence of this problem a retrospective two-year study was performed among clients enrolled in a community methadone maintenance treatment program (MM). Of 1064 persons enrolled in MM during this time, 190 (17.8%) were identified as loiterers with 121 (63.7%) loiterers actively enrolled in MM. No significant differences between loiterers and a matched group of MM clients were seen with respect to time in treatment, presence of drug abuse or excessive alcohol intake. Differences between loiterers and non-loiterers were observed with respect to criminal activity (29% vs. 11%, respectively, P less than 0.001), non-opioid drug abuse (78% vs. 67%, respectively, P less than 0.01) and productive activity (44% vs. 61%, respectively, P less than 0.01). Excessive alcohol intake was seen in 15.4% of the study group. No relationship existed between excessive consumption of alcohol and loitering, arrests, and use of mood altering drugs as determined by urinalysis. No relationship could be demonstrated between loitering and residence in the community surrounding the program. Only 11 (6%) of all loiterers lived within two blocks of the program boundaries, and only 59 (31%) resided within East Harlem. These findings suggest that loitering is a real cause for concern being engaged in mainly by individuals who are neither socially productive nor residents of the immediate community surrounding the program. It is therefore important to develop strategies for dealing with this problem not only to reassure the community but to facilitate rehabilitation.     

A qualitative study of barriers to formal treatment among women who self-managed change in addictive behaviours

Alcohol and drug abuse and dependence are common disorders in our society, and the vast majority of those who recover do so without formal treatment. Although this phenomenon appears to be more common among women than men there has been no gender-sensitive research. This qualitative study explored the barriers to formal treatment seeking among women who self-managed change in their alcohol and other drug dependence. The principal barriers identified included social stigma and labelling, lack of awareness of the range of treatment options, concerns about childcare, the perceived economic and time costs of residential treatment, concerns about the confrontational models used by some treatment services, and stereotypical views of clients of treatment services. A number of recommendations were made regarding program reach and content.     

Preliminary analysis of the Northern Territory's illicit drug court diversion program highlights the need to examine lower program completion rates for indigenous clients

Introduction and Aims. Court drug diversion programs are now available in all jurisdictions in Australia, but there is increasing evidence that such programs have differing success rates for certain client populations, including indigenous clients. This study investigates client characteristics, program completion rates and factors associated with retention, for all 484 clients admitted to the Northern Territory's Court Referral and Evaluation for Drug Intervention and Treatment 12 week illicit drug pre‐sentence court diversion program between July 2003 and December 2008. Design and Method. Client data were collected by court clinicians as part of the face‐to‐face assessment interview and treatment outcomes were recorded. Results. Multivariate logistic regression analysis showed that indigenous clients were significantly less likely to complete their treatment than non‐indigenous clients, as were clients who were younger, male, had an educational level of Year 10 or less, were unemployed, had a previous custodial order and used drugs other than cannabis. Discussion and Conclusions. The lower program completion rates for indigenous clients are consistent with findings from other Australian studies and highlight the need to further explore and address factors contributing to this result.[Rysavy P, Cunningham T, O'Reilly‐Martinez R. Preliminary analysis of the Northern Territory's illicit drug court diversion program highlights the need to examine lower program completion rates for indigenous clients. Drug Alcohol Rev 2011;30:671–676]     

Comparing the impact of standard and abbreviated treatment in a therapeutic community. Findings from the district of Columbia treatment initiative experiment

This study examines the efficacy of providing Enhanced Abbreviated or Standard Inpatient treatment and Outpatient treatment to drug-abusing clients. The experiment randomly assigned 412 clients to two therapeutic community programs, which differed primarily in planned duration. This study addressed limitations of prior research, as it used random assignment of clients to treatment programs, achieved high follow-up rates and used objective measures of drug use and criminal history. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. Completing the entire 12-month program (inpatient and outpatient) was more important than duration of inpatient program attended. Regardless of program, completers had substantial reductions in posttreatment drug abuse and arrests. A 12-month course of treatment including at least 6 months in a therapeutic community followed by outpatient treatment can produce marked reductions in drug abuse and crime among persons who complete both phases.     

Relationship between Housing Status and Retention Rates among HIV-Positive African Americans Enrolled in a Comprehensive Care Program

Service provision using “one-stop shopping” of medical, psychiatric, and case management services at the same location has been associated with superior client retention. The Yadumu project tested this premise, with attention to HIV-infected African Americans. Each client was assigned a case manager, who arranged meetings with mental health, substance abuse, and medical care professionals. The Center for Mental Health Services, National Outcome Measures (CMHS NOMs) questionnaire was used to evaluate client progress. Data were collected longitudinally and the program evaluation was performed by an outside center. Among 129 clients, 47% were male, 30% were female, and 22% were transgender. The majority (72%) were African American. Clients who lived in detox/drug treatment programs had higher completion rates (48%) than those who were homeless or otherwise housed (28%) (p = 0.04). Logistic regression was used to assess associations between independent factors and retention. Clients satisfied with their housing situation were less likely to retain in the program than those who were not satisfied with their housing situation (OR = 0.15, 95% CI: 0.03–0.78). High discharge rates among HIV-infected people were observed and may reflect the unstable circumstances of the population studied, but structured residential programs could be advantageous for improving retention.     

Delivery of HIV risk-reduction services in drug treatment programs

This study examined services received for HIV risk reduction among individuals in drug treatment. Analyses were conducted using data from 4,412 participants in the national Drug Abuse Treatment Outcome Study (DATOS), a prospective multisite study of drug treatment effectiveness. A higher percentage of individuals in long-term residential programs received HIV-related services, compared with clients in short-term inpatient, methadone maintenance, and outpatient drug-free programs. More men than women, and individuals at higher sex-risk as compared with those at lower sex-risk, received HIV services. Logistic regression analyses indicated that individuals who engaged in sex work had a higher likelihood than those who did not, of receiving HIV-related services, although individuals with high-risk or multiple sexual partners were no more likely than others to receive HIV services. More comprehensive service delivery is needed in order to reduce the risk for HIV among clients in drug treatment.     

Effects of women-sensitive,long-term residential treatment on psychological functioning of diverse populations of women

A number of studies have found that women who abuse substances enter treatment with greater psychological problems and more vulnerabilities than men. This article reports on a 5-year study of clients in a comprehensive, residential drug treatment program for women and their children. Psychological assessments on 362 women included the Basic Personality Inventory (BPI), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Luria-Nebraska Neuropsychological Battery, Screening Test (LNNB-ST). Early in the course of treatment, the typical client tends to experience a great deal of distress, as evidenced by scores on the CES-D. Other assessments indicate she is relatively alienated, mistrustful of others, and resentful of rules imposed on her by others. Repeated assessments show that these psychological indicators improve significantly as the client progresses through the treatment program. Additional studies are needed to focus on long-term treatment outcomes of women in programs designed specifically for them.     

Risk Factors for Recent Intimate Partner Violence among Methamphetamine-Using Men and Women

The Substance Abuse, Violence, and HIV/AIDS (SAVA) syndemic model describes how the confluence of the three epidemics of substance abuse, violence, and HIV risk work synergistically to create excess burden among populations. We sought to identify risk factors associated with recent intimate partner violence (IPV) victimization among heterosexual methamphetamine (meth)-using men (n = 108) and women (n = 122) enrolled in FASTLANE-II, an HIV behavioral intervention in San Diego, CA. Women and men reported high rates of physical-only (women: 20%; men: 18%) and sexual (women: 25%; men: 23%) IPV. Multinomial regression analysis revealed that individuals who reported lower social support and individuals who reported a greater likelihood of engaging in risky sexual behaviors while high on meth were more likely to report IPV versus no IPV. Women who reported a greater likelihood of engaging in risky sexual behaviors while high on meth were 1.58 times more likely to report physical-only IPV versus no IPV, while men who reported similar behaviors were 1.15 times more likely to report physical-only IPV versus no IPV. Our findings highlight the influence of interpersonal factors on IPV. This research supports further study on gender-specific risk/protective factors and the development of gender-specific interventions targeting the SAVA syndemic among meth users.     

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.     

General and Specific Psychotherapy Role Induction with Substance-Abusing Clients

The present study examined the effects of general and specific psychotherapy role induction on return rates and attendance in psychotherapy for substance-abusing clients. The subjects were 111 of 129 consecutive applicants to a community outpatient drug treatment center. Following a standard intake interview, clients received either a general psychotherapy role induction or a drug treatment specific role induction, or were placed in one of two control conditions. Results indicated that clients who received role induction procedures were more likely than controls to return after the intake interview. Furthermore, clients who received the drug treatment specific role induction returned at a significantly higher rate than all other clients. Analysis of attendance rates after 3 months showed that role induction had no effect on continuation in treatment.     

Allocative and implementation efficiency in HIV prevention and treatment for people who inject drugs

BackgroundEstimated global new HIV infections among people who inject drugs (PWID) remained stable over the 2010–2015 period and the target of a 50% reduction over this period was missed. To achieve the 2020 UNAIDS target of reducing adult HIV infections by 75% compared to 2010, accelerated action in scaling up HIV programs for PWID is required. In a context of diminishing external support to HIV programs in countries where most HIV-affected PWID live, it is essential that available resources are allocated and used as efficiently as possible.MethodsAllocative and implementation efficiency analysis methods were applied. Optima, a dynamic, population-based HIV model with an integrated program and economic analysis framework was applied in eight countries in Eastern Europe and Central Asia (EECA). Mathematical analyses established optimized allocations of resources. An implementation efficiency analysis focused on examining technical efficiency, unit costs, and heterogeneity of service delivery models and practices.ResultsFindings from the latest reported data revealed that countries allocated between 4% (Bulgaria) and 40% (Georgia) of total HIV resources to programs targeting PWID — with a median of 13% for the eight countries. When distributing the same amount of HIV funding optimally, between 9% and 25% of available HIV resources would be allocated to PWID programs with a median allocation of 16% and, in addition, antiretroviral therapy would be scaled up including for PWID. As a result of optimized allocations, new HIV infections are projected to decline by 3–28% and AIDS-related deaths by 7–53% in the eight countries. Implementation efficiencies identified involve potential reductions in drug procurement costs, service delivery models, and practices and scale of service delivery influencing cost and outcome. A high level of implementation efficiency was associated with high volumes of PWID clients accessing a drug harm reduction facility.ConclusionA combination of optimized allocation of resources, improved implementation efficiency and increased investment of non-HIV resources is required to enhance coverage and improve outcomes of programs for PWID. Increasing efficiency of HIV programs for PWID is a key step towards avoiding implicit rationing and ensuring transparent allocation of resources where and how they would have the largest impact on the health of PWID, and thereby ensuring that funding spent on PWID becomes a global best buy in public health.     

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.     

Are Specialized LGBT Program Components Helpful for Gay and Bisexual Men in Substance Abuse Treatment?

In the New York metropolitan area, a convenience sample of 187 men previously treated in substance abuse programs between 2000 and 2006 completed questionnaires regarding their reported outcomes, completion rates, and perceptions of treatment. The sample included 81 gay and bisexual (“gay/bisexual”) men in “traditional” programs (with no specialized groups for gay/bisexual clients), 51 gay/bisexual men in “LGBT specialized treatment” (programs with specialized groups for gay/bisexual clients), and 55 heterosexual men. In bivariate and multivariate analyses, heterosexual men and gay/bisexual men in LGBT specialized treatment had more favorable results than did gay/bisexual men in traditional programs, suggesting the effectiveness of LGBT program components.     

Exploring stakeholder perceptions of acceptability and feasibility of needle exchange programmes, syringe vending machines and safer injection facilities in Tijuana, Mexico

BackgroundInjection drug use is a growing public health crisis along the U.S.–Mexican border and rising rates of blood-borne infections highlight the pressing need for harm reduction interventions. We explored the acceptability and feasibility of such interventions in Tijuana, a city adjacent to San Diego, California.MethodsUsing in-depth qualitative interviews conducted from August 2006–March 2007 with 40 key stakeholders – pharmacists, legal professionals, health officials, religious officials, drug treatment providers, and law enforcement personnel – we explored the acceptability and feasibility of interventions to reduce drug-related harm in Tijuana, Mexico. Interviews were taped with consent, transcribed verbatim, and translated. Content analysis was conducted to identify themes which included barriers, structural limitations, and suggestions for implementation.ResultsTopics included acceptance and feasibility of needle exchange programmes (NEPs), syringe vending machines, and safer injection facilities (SIFs), structural barriers and suggestions for implementation. Of these interventions, NEPs were deemed the most acceptable (75%); however, only half believed these could be feasibly implemented, citing barriers involving religion, police, and lack of political will, public awareness, and funding.ConclusionsIncreasing HIV infection rates among injection drug users in Tijuana have prompted interest in public health responses. Our results may assist policy strategists in implementing social-structural interventions that will help create enabling environments that facilitate the scale-up and implementation of harm reduction in Tijuana.