Abstinence-contingent recovery housing and reinforcement-based treatment following opioid detoxification

Aims To conduct a randomized, controlled trial of abstinence‐contingent recovery housing delivered with or without intensive day treatment among individuals exiting residential opioid detoxification. Design Random assignment to one of three conditions: recovery housing alone (RH), abstinence‐contingent recovery housing with reinforcement‐based treatment RBT (RH + RBT) or usual care (UC). RH and RH + RBT participants received 12 weeks of paid recovery housing contingent upon drug abstinence. RH + RBT participants also received 26 weeks of RBT, initiated concurrently with recovery housing. Assessments were conducted at 1, 3 and 6 months after treatment enrollment. Setting Out‐patient drug‐free substance abuse treatment program in Baltimore, Maryland. Participants Patients (n = 243) who completed medication‐assisted opioid detoxification. Measurements Primary outcome was drug abstinence (opioid‐ and cocaine‐negative urine and no self‐reported opioid or cocaine use in the previous 30 days). Secondary outcomes included abstinence at all time‐points (1, 3 and 6 months), days in recovery housing and employment. Findings Overall rates of drug abstinence were 50% for RH + RBT, 37% for RH and 13% for UC (P < 0.001). At 6 months, RH + RBT participants remained more likely to meet abstinence criteria than UC participants (37% versus 20%, P = 0.016). Length of stay in recovery housing mediated abstinence outcomes and was longer in RH + RBT (49.5 days) than in RH (32.2 days; P < 0.002). Conclusions Abstinence‐contingent recovery housing improves abstinence in opioid‐dependent adults following medication‐assisted detoxification. The addition of intensive ‘reinforcement‐based treatment’ behavioural counseling further improves treatment outcomes, in part by promoting longer recovery house stays.     

Temporal Trends,Practice Patterns,and Treatment Outcomes for Infected Upper Urinary Tract Stones in the United States

Background

The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal.

Objective

To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes.

Design, setting, and participants

A weighted estimate of 396 385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999–2009.

Outcome measurements and statistical analysis

Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches.

Results and limitations

Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3–15.6) to 27.6 (27.4–27.8)/100 000); men increased from 7.8 (7.7–7.9) to 12.1 (12.0–12.3)/100 000. Rates of associated sepsis increased from 6.9% to 8.5% (p = 0.013), and severe sepsis increased from 1.7% to 3.2% (p < 0.001); mortality rates remained stable at 0.25–0.20% (p = 0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% (p = 0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52–1.74), severe sepsis (OR: 2.28; 95% CI, 2.06–2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01–3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57–2.85), and mortality (OR: 3.14; 95%CI, 13–4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity.

Conclusions

Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study.