Treatnet

Community based treatment

 

References:

• A. D. Peters & M. M. Reid (1998) Methadone treatment in the Scottish context:  outcomes of a community-based service for drug users in Lothian.  Drug and Alcohol Dependence, Volume (Issue):  50(1) pp. 47-55.

Abstract

Few studies investigating the effectiveness of methadone treatment for opiate dependence have emanated from the UK. The core feature of treatment offered by Lothian Health's Community Drug Problems Service involves the prescribing of methadone by the client's general practitioner. Of a cohort of 494 daily users of opiates attending the service, 39 percent remained in treatment for at least 12 months. Up to two years in-treatment follow-up revealed significant improvement in injecting and criminal behaviour. There were no HIV seroconversions reported during the treatment period. There was no improvement in injection equipment sharing condom use, illicit drug user or employment status. "Satisfactory' discharge was achieved for 40 percent of those in treatment for at least six months. These results are largely consistent with the outcomes of methadone programmes elsewhere.

 

• Andrew R. Morral, Daniel F. McCaffreyb and Greg Ridgewayc (2004). Effectiveness of Community-Based Treatm ent for Substance-Abusing Adolescents: 12-Month Outcomes of Youths Entering Phoenix Academy or Alternative Probation Dispositions. Psychology of Addictive Behaviours, Volume 18, Issue 3 , September: 257-268.

Abstract

Whereas strong efficacy research has been conducted on novel treatment approaches for adolescent substance abusers, little is known about the effectiveness of the substance abuse treatment approaches most commonly available to youths, their families, and referring agencies. This report compares the 12-month outcomes of adolescent probationers (N = 449) who received either Phoenix Academy, a therapeutic community for adolescents that uses a treatment model that is widely implemented across the U.S., or an alternative probation disposition. Across many pre-treatment risk factors for relapse and recidivism, groups were well matched after case-mix adjustment. Repeated measures analyses of substance use, psychological functioning, and crime outcomes collected 3, 6, and 12 months after the baseline interview demonstrated that Phoenix Academy treatment is associated with superior substance use and psychological functioning outcomes over the period of observation. As one of the most rigorous evaluations of the effectiveness of a traditional community-based adolescent drug treatment program, this study provides evidence that one such program is effective. Implications of this finding for the dissemination of efficacious novel treatment approaches are discussed.

 

• A. P. Shakeshaft, J. A. Bowman, S. Burrows, C. M. Doran & R. W. Sanson-Fisher (2002) Community-based alcohol counselling: a randomized clinical trial.  Addiction, Volume (Issue):  97(11) pp. 1449-1463.

Abstract

The aim of the report was to examine the effectiveness of a brief intervention (BI) and cognitive behaviour therapy (CBT) for alcohol abuse. A randomised trial with clients randomised within counsellors was designed in a community-based drug and alcohol counselling in Australia. Of all new clients attending counselling, 869 (82%) completed a computerised assessment at their first consultation. Four hundred and twenty-one (48%) were defined as eligible, of whom 295 (70%) consented and were allocated randomly to an intervention. Of these, 133 (45%) wer followed-up at six months post-test. BI comprised the elements identified by the acronym FRAMES: feedback, responsibility, advice, menu, empathy, self-efficiency. Face-to-face counselling time was not to exceed 90 minutes. CBT comprised six consecutive weekly sessions: introduction; cravings and urges; managing crises; saying 'no' and solving problems; emergencies and lapses; and maintenance. Total face-to-face counselling time was 270 minutes (six 45-minute sessions). Treatment outcomes are measured in terms of counsellor compliance, client satisfaction, weekly and binge consumption, alcohol-related problems, the AUDIT questionnaire and cost-effectiveness. When analysed on an intention-to-treat basis and for those followed-up, treatment outcomes between BI and CBT were not statistically significantly difference between them ini clients' reported levels of satisfaction. For low-dependence alcohol abuse in community settings, BI may be the treatment of choice. 

 

• Brown, Barry S; O'Grady, Kevin E; Battjes, Robert J; Katz, Elizabeth C (2004) The Community Assessment Inventory--client views of supports to drug abuse treatment. Journal Of Substance Abuse Treatment, Volume 27, Issue 3 , October, Pages 241-251

Abstract

A measure assessing client views of the community supports available to them was developed and tested with entrants to outpatient drug free treatment. Items for a Community Assessment Inventory (CAI) fell into four areas of potential social support for treatment entry and engagement: (1) partner and/or family with whom living; (2) family living outside the home; (3) friends; and (4) the community itself. Based on 241 study participants, it was found that internal consistency alphas for the four scales ranged between .79 and .88. Both total CAI score and individual scales assessing support from friends and from partner/spouse were found capable of predicting treatment readiness as assessed using the TCU Motivation Scale. Evidence of construct validity was suggested by differences in CAI total score between participants reporting and not reporting involvement in discussions with others regarding crime and regarding drugs. Findings are also provided regarding leisure time activities and social relations of treatment entrants.

 

• Campbell, Cynthia I; Alexander, Jeffrey (2005) A Health services for women in outpatient substance abuse treatment. Health Services Research, Volume 40, Issue 3 , June 2005, Pages 781-810

Abstract

OBJECTIVE: To evaluate how a sample of outpatient substance abuse treatment units respond to organizational and environmental influences by adopting and implementing treatment services for women. DATA SOURCES: The National Drug Abuse Treatment System Survey from 1995 and 2000, a national survey of outpatient substance abuse treatment units. STUDY DESIGN: Health services for women are the dependent variables. The predictors include organizational and environmental factors that represent resource dependence and institutional pressures for the treatment unit. Logistic regression and Heckman selection models were used to test hypotheses. DATA COLLECTION: Program directors and clinical supervisors at each treatment unit were interviewed by telephone in 1995 and 2000. PRINCIPAL FINDINGS: Units that depended on specific funding for women's programs and that depended on government funds were more likely to adopt, but not necessarily implement, women's services. Methadone units and units that train more staff to work with women were more likely to adopt as well as implement women's services. Private not-for-profit units were more likely to adopt some services, while for-profit units were less so. However, in general, neither for-profit nor not-for-profit units significantly implemented services. There was evidence that the odds of adopting services were greater in 2000 than 1995 for two services, but were otherwise stable. CONCLUSIONS: There is considerable variation in the adoption and implementation of women's services. In addition, not all adopted services were significantly implemented, which could reflect limited organizational resources and/or conflicting expectations. This also suggests that referral mechanisms to these services, and therefore access, may not be adequate. Government funds and specific funds for women's programs are important resources for the provision of these services. Women's services appear more available in methadone units, suggesting that regulation has been influential and that the recent methadone accreditation system should be evaluated. Staff training may be one strategy to encourage implementation of these services. For the most part, the adoption of services for women did not change between 1995 and 2000.

 

• C. Godfrey, D. Stewart & M. Gossop (2004) Economic analysis of costs and consequences of the treatment of drug misuse: 2-year outcome data from the National Treatment Outcome Research Study (NTORS).   Addiction,  Volume (Issue):  99(6) pp. 697-707.

Abstract

Some economic costs and consequences of drug misuse and treatment were investigated among clients recruited to the National Treatment Outcome Research Study (NTORS). This was a longitudinal prospective cohort design comprising 549 clients recruited from 54 residential and community treatment programmes: data were collected from interviews conducted at treatment intake, at 1 year and at 2-year follow-ups. Treatment costs included index and other drug treatments. Costs were estimated for use of health and social care services, criminal activity and the use of criminal justice resources. Costs were based upon self-reported data collected by structured face-to-face interviews combined with unit cost estimates taken from a variety of sources. Addiction treatment was costed at £2.9 million in the 2 years prior to index treatment, and a further £4.4 million in the subsequent 2 years. Economic benefits were largely accounted for by reduced crime and victim costs of crime. Crime costs fell by £16.1 million during the first year and by £11.3 million during the second year. Health-care costs were relatively small but approximately doubled during the course of the study. The ratio of consequences to net treatment investment varied from 18:1 to 9.5:1, depending on assumptions. This is likely to be a conservative estimate of the benefit-cost ratio because many potential benefits were not estimated. The data showed clear economic benefits to treating drug misusers in England. 

 

• Dermatis Helen; Guschwan Marianne T, Galanter Marc et al. (2004) Orientation toward spirituality and self-help approaches in the therapeutic community. Journal Of Addictive Diseases: The Official Journal Of The ASAM, American Society Of Addiction Medicine, Volume 23, Issue 1 , 2004, Pages 39-54

Abstract

Although Alcoholics Anonymous and other Twelve-Step interventions are among the most widely utilized self-help options by persons with chemical dependency, little is known concerning whether this approach should be integrated with non-spirituality based self-help approaches. The purpose of this study was to assess the extent to which clients receiving inpatient treatment in a residential therapeutic community (TC) felt that spirituality based interventions should be featured in TC treatment. Three hundred twenty-two members of the Daytop TC completed a survey assessing personal orientation to spirituality and attitudes towards spirituality based treatments. The majority of clients believed that the TC program should feature spirituality more in treatment. Nearly half agreed that the Twelve-Step (AA) approach should be more a part of TC treatment. Preference for Twelve-Step meeting interventions was positively correlated with past attendance at Twelve-Step meetings. Personal spiritual orientation to life was positively correlated with endorsement of spirituality based interventions in TC treatment. These findings highlight the importance of integrating treatment approaches which address the spiritual needs of TC residents.

 

• E. Lawental (2000) Ultra rapid opiate detoxification as compared to 30-day inpatient detoxification program-a retrospective follow-up study. Journal of Substance Abuse, Volume (Issue):  11(2) pp. 173-181.

Abstract

Ultra rapid detoxification (URD) has recently gained significant media attention as a promising treatment for opiate addiction. URD combined with follow-up naltrexone was portrayed as a quick and painless initial detoxification, as well as a long-term cure for the addiction. Following the therapeutic initiation of URD, articles began to emerge in the scientific literature. URD was sceptically viewed by the substance addiction treatment community, scepticism initially based on the theoretical understanding of addiction as a bio-psycho-social problem and the belief that detoxification and medication alone cannot provide long-term abstinence. This initial response was later supported by some scientific studies. URD continues to stir controversy, leading to this study. The authors used available data to conduct a pilot study of URD, comparing it to traditional 30-day inpatient detoxification programmes (IDP) used in Israel in achieving long-term abstinence. A sample of 226 men and women, 18 years or older, who entered detoxification in the IDP (N = 87) or in the URD (N = 139) were all clients who received treatment in either of these programmes between March and September 1996. Eighty-one (92%) of the IDP subjects and 82 (60%) of the URD subjects were successfully interviewed by telephone 12 to 18 months after their participation in these programmes. The results provide preliminary evidence that URD may be much less effective and more expensive than traditional treatment. No specific subgroup of clients benefitted more from URD, although a prospective study employing random assignment might be more successful in identifying such a group. This study appears to offer justification for the current longer-term bio-psycho-social treatment alternatives for opiate addiction. 

 

- Galanter, Marc; Dermatis, Helen; Glickman, et al. (2004) Network therapy: decreased secondary opioid use during buprenorphine maintenance.  Journal Of Substance Abuse Treatment, Volume 26, Issue 4 , June 2004, Pages 313-318.

Abstract

Network therapy (NT) employs family members and/or friends to support compliance with an addiction treatment carried out in office practice. This study was designed to ascertain whether NT is a useful psychosocial adjunct, relative to a control treatment, for achieving diminished illicit heroin use for patients on buprenorphine maintenance. Patients agreeing to randomization to either NT (N = 33) or medication management (MM, N = 33) were inducted onto short-term buprenorphine maintenance and then tapered to zero dose. NT resulted in significantly more urine toxicologies negative for opioids than MM (65% vs. 45%) and more NT than MM patients (50% vs. 23%) experienced a positive outcome relative to secondary heroin use by the end of treatment. The use of NT in office practice may therefore improve the effectiveness of eliminating secondary heroin use during buprenorphine maintenance. It may also be useful in enhancing compliance with an addiction treatment regimen in other contexts.

 

• Gruber, Kenneth J; Fleetwood, Thomas W. (2004) In-home continuing care services for substance use affected families. Substance Use & Misuse, Volume 39, Issue 9 , July 2004, Pages 1379-1403.

Abstract

The role of in-home work with substance use affected family members has great potential for addressing family and personal issues that are often not well addressed by continuing care interventions that involve limited contact with the family and the impact alcohol and other drug "abuse" has on the family environment. This article reviews the importance of involving the family in the recovery process and offers comparative advantages of an in-home visitation approach for assisting the substance user with maintaining substance use avoidance, reintegrating with the family, and addressing unresolved family issues affecting children and spousal relationships.

 

• J. D. Griffith, M. L. Hiller, K. Knight & D. D. Simpson (1999 ) Cost-effectiveness analysis of in-prison therapeutic community treatment and risk classification . Prison Journal,  Volume (Issue):  79(3) pp. 352-368.

Abstract

Policy makers need scientifically based information to help them to determine which correctional treatment alternatives are effective and economically viable. Three-year outcome data from 394 parolees (291 treated, 103 untreated comparison) were examined to determine the relative cost-effectiveness of prison-based treatment and after-care, controlling risk of recidivism. Findings showed that intensive services were cost-effective only when the entire treatment continuum was completed, and that the largest economic impact was evident among high-risk cases. Therefore, assignments to correctional treatments should consider an offender's problem severity level, and every effort should be made to engage them in aftercare upon release from prison. 

 

• J. Johnson (2000) Cost-effectiveness of mental health services for persons with a dual diagnosis. A literature review and the CCMHCP.  Journal of Substance Abuse Treatment, Volume (Issue):  18(2) pp. 119-127.

Abstract

People suffering from co morbid mental illness and substance abuse disorders (the dually diagnosed) are thought to constitute large portions of clients treated as outpatients by public-sector community-based mental health providers. These providers dispense units of ambulatory mental health services and treatments incrementally to maintain clients in the community and out of psychiatric hospitals. Community maintenance is one step, albeit critical, toward quitting drugs and eventual abstinence. Thus, there is a need for information that compares the effectiveness and cost of such services on dually diagnosed clients to identify appropriate low-cost high-yield treatment and service options and packages. This article provides a review of the literature on the effectiveness of ambulatory mental health services and recent emergent reports of cost-effectiveness of programmes for the dually diagnosed, paying special attention to the gray areas and gaps. This article also describes a new project; an inexpensive add-on to an existing community mental health centre. The project will be examining over five years of data to compare influence and cost of different ambulatory mental helath services and treatments delivered to a matched pair group of clients with dual disorders and those with only mental illness. The intention of this project is not only to address gray areas and gaps in the literature, but also to inform a more rational deployment of mental health services.

 

• J. McCusker, C. Bigelow, M. Vickers-Lahti, D. Spotts, F. Garfield & R. Frost  (1997) Planned duration of residential drug abuse treatment: efficacy versus effectiveness. Addiction, Volume (Issue):  92(11) pp. 1467-1478.

Abstract

Two randomised controlled trials of residential drug abuse treatment programmes found the programmes to be equally effective, based on outcomes among those assigned to the treatments. This study aimed to compare the relative efficacy of the programmes, based on outcomes among those who received the specific treatment programme as planned. At one facility, clients were randomised to three-month or six-month versions of a traditional therapeutic community programme. At the second facility, clients were randomised to three-month or six-month versions of a modified therapeutic community programme that emphasised relapse prevention and health education. Five hundred and thirty-nine clients (86 percent) completed a follow-up interview at least 16.5 months after admission. In the relapse prevention trial, benefits of the six-month programme were generally limited to those who stayed at least 40 days. In the therapeutic community trial, among those who stayed at least 171 days, the 12-month programme had a beneficial effect on employment. Otherwise, there were inconsistent differences between the 6- and 12-month programmes. On average, clients who stayed in treatment at least 80 days benefited from continuing in treatment for up to six months, but not beyond. Conversely, those admitted to programmes of longer planned duration who dropped out of treatment early had worse outcomes than those who dropped out of shorter programmes. Thus, although longer planned duration of treatment may be efficacious, it is not effective.

 

• John Strang (2003) Effect of national guidelines on prescription of methadone: analysis of NHS prescription data, England 1990-2001. BMJ. March 2; 324(7336): 501

References

Though there is strong evidence to support the use of methadone maintenance for opiate addiction1 it is often delivered poorly. Evidence based guidelines were developed in 1996 and 1999 (see www.doh.gov.uk/drugdep.htm and further details on bmj.com) and widely publicised in the United Kingdom.23 In 1998 we found scant evidence of any impact4 and concluded that "if planners are awaiting major change in methadone prescribing as a result of central exhortation, they should not hold their breath." However, perhaps guidelines may have a slower cumulative effect.

Method and results

We examined data on all NHS methadone prescriptions dispensed by community pharmacists in England. These account for 98% of methadone prescriptions in England.5 Unpublished commercial data indicate that 95% of methadone prescriptions from general practitioners are for addiction treatment (IMS Health).

To investigate the impact of the guidelines we used two specific recommendations from the Department of Health (the 1996 taskforce report and the Orange Guidelines 1999): firstly, that prescribing of methadone in tablet form should cease (based on concerns about intravenous misuse), and, secondly, that injectable methadone (methadone ampoules) should not be prescribed as mainstream treatment. We examined the proportion of methadone prescriptions per year issued as oral syrup, tablets, or injectable ampoules to identify any change of professional practice.

We examined the six years preceding 1996 (1990-5) to establish prevailing trends in methadone prescribing and then the six years during which the new guidelines were introduced (1996-2001) to study any change. Between 1990 and 2001, NHS prescriptions for methadone dispensed in England tripled-from 425 400 to 1 318 100 annually-increasing every year. However, the proportionate annual increase fell from 15.3%, 23.8%, and 21.1% (first three years) down to increases of 2.7%, 3.6%, and 3.8% (last three years) (table).

Over the six year baseline period (1990-5), the proportion of methadone prescriptions prescribed as tablets was steady at between 7.8% and 9.8% annually. Thereafter, the proportion steadily reduced (1% per annum) to 4.0% by 2001, and the absolute number also fell every year. Similarly, prescriptions for injectable methadone were stable for 1990-5 (range 8.0% to 9.7%, peaking at 9.7% in 1994) but steadily reduced thereafter, from 8.7% in 1995 to 3.9% in 2001. From 1997 the absolute number of prescriptions as ampoules fell annually.

Comment

Over the past decade, the extent of methadone prescribing in England has tripled, deriving from a substantial year on year increase that was greatest during the first half of the 1990s. Every year community pharmacies across England dispense over 1.25 million NHS prescriptions for methadone, suggesting that about 50 000 opiate addicts are receiving methadone at any one time.

Since 1996 there has been a profound change in national practice regarding methadone prescribing in the directions proposed by the new national recommendations.23 Over six years (1996 compared with 2001) the proportions prescribed as tablets (from 9.8% to 4.0%) and as injectable ampoules (from 8.7% to 3.9%) have halved, contrasting with the predominantly steady state of the preceding six year period.

Our data constitute objective evidence that the widespread publishing of national guidelines was followed by major change in national patterns of prescribing, with change occurring gradually and, at least in this instance, still accumulating after six years. We conclude that the eventual impact of national guidance will be substantial; change is not immediate and may take several years; and researchers and planners should not make premature judgment.

 

• Keawkingkeo, Suwanee (2005) Community drug abuse prevention in a Hmong village in Thailand. Journal Of Psychosocial Nursing And Mental Health Services, Volume 43, Issue 2 , February 2005, Pages 22-29.

Abstract

The goal of this project was to implement a model of drug abuse prevention, drawing on health care, psychosocial and legal principles, in a selected village community in Thailand. Primary, secondary, and tertiary prevention strategies were used within a nursing conceptual framework that included the interactions among the person, drugs, and environment. An initial community survey revealed 112 addicted individuals and identified many at risk groups, such as children of addicted parents, adolescents, and women. Primary health care and dental health services were provided in the community, as well as drug abuse education and activities for school children and at-risk groups. Treatment camps were also established in the community on two occasions to provide detoxification and rehabilitation services for addicted individuals. At the end of the 3-year program, there were no new addicted individuals, and the number of addicted individuals decreased from 112 to 50 (after first treatment) and 26 (after second treatment). In addition, the villagers were more aware of problems related to using opium and heroin and of modern, approved drugs to treat illnesses. The prevention strategies were beneficial for the community members, as well as the addicted individuals and their families.

 

• K. Wolff, A. W. M. Hay, A. Vail, K. Harrison & D. Raistrick (1996) Non-prescribed drug use during methadone treatment by clinic- and community-based patients. Volume (Issue),  91(11) pp. 1699-1704.

Abstract

The authors investigated the efficacy of methadone treatment in clinic-based (n = 10) and community-based (n = 10) patients by studying the relationships between dose, plasma concentrations of methadone and non-prescribed drug use using logistic regression. They found that clinic-based patients had significantly reduced odds of having a urine sample test positive for illicit drugs when compared to community-based patients (OR = 0.20; 95 percent confidence interval 0.10-0.38: p < 0.001). There was no relationship between either methadone dose or plasma methadone concentration and testing positive for non-prescribed drugs (including cocaine, cannabis, amphetamine, ecstasy, benzodiazepines). The authors looked specifically at the misuse of opiate drugs. Location was again important and clinic-based patients had significantly reduced odds of having a urine sample test positive for opiate drugs (OR = 0.36, 95 percent confidence interval 0.18-0.71: p approximately 0.004). Opiate drug use in the patients was also significantly related to plasma methadone concentration, increasing noticeably when the drug concentration < .048 nmol/L (p approximately 0.04). They found no relationship between methadone dose and odds of having a positive urine drug test in either clinic- or community-based patients. 

 

• L. Amass, W. Ling, T. E. Freese, C. Reiber, et al. (2004) Bringing buprenorphine-naloxone detoxification to community treatment providers: the NIDA Clinical Trials Network field experience. American Journal on Addictions, Volume (Issue):  13(Supplement 1) pp. 42-66.

Abstract

In October 2002, the US Food and Drug Administration approved buprenorphine-naloxone (Suboxone) sublingual tablets as an opioid dependence treatment available for use outside traditionally licensed opioid treatment programmes. The NIDA Center for Clinical Trials Network (CTN) sponsored two clinical trials assessing buprenorphine-naloxone for short-term opioid detoxification. These trials provided an unprecedented field test of its use in 12 diverse community-based treatment programmes. Opioid-dependent men and women were randomised to a 13-day buprenorphine-naloxone taper regimen for short-term opioid detoxification. The 234 buprenorphine-naloxone patients averaged 37-years-old and used mostly intravenous heroin. Direct and rapid induction onto buprenorphine-naloxone was safe and well tolerated. Most patients (83%) received 8 mg buprenorphine-2 mg naloxone on the first day and 90% successfully completed induction and reached a target dose of 16 mg buprenorphine-4 mg naloxone in three days. Medication compliance and treatment engagement was high. An average of 81% of available doses was ingested, and 68% of patients completed the detoxification. Most (80.3%) patients received some ancillary medications with an average of 2.3 withdrawal symptoms treated. The safety profile of buprenorphine-naloxone was excellent. Of 18 serious adverse events reported, only one was possibly related to buprenorphine-naloxone. All providers successfully integrated buprenorphine-naloxone into their existing treatment milieus. Overall, data from the CTN field experience suggest that buprenorphine-naloxone is practical and safe for use in diverse community treatment settings, including those with minimal experience providing opioid-based pharmacotherapy and/or medical detoxification for opioid dependence. 

 

• L. K. Dasinger, P. A. Shane & Z. Martinovich (2004) Assessing the effectiveness of community-based substance abuse treatment for adolescents. Journal of Psychoactive Drugs, Volume (Issue):  36(1) pp. 27-33.  

Abstract

The Adolescent Treatment Models initiative, a 10-site, multimodality, prospective study, was designed to evaluate adolescent substance abuse treatment outcomes and to assess the relative efficacy of different treatment models. Based upon longitudinal data gathered at multiple assessment points using a standardised instrument, treatment outcome trajectories were determined for a cohort of 1,057 adolescents from entry into substance abuse treatment until 12 months post-intake. Client outcomes on substance use and programme effectiveness were explored across individual treatment programmes and levels of care. Strong treatment effects, defined as a significant reduction in alcohol and other drug use at three months post-intake, were found. The reductions of greatest magnitude in relation to pre-treatment use occurred among adolescents in residential treatment. Within level of care, few significant differences in treatment effects were found between programmes. Relapse effects, defined as an increase in substance use at 12 months relative to 3 months, were observed across nearly all programmes, but varied in relation to treatment modality. This is most evident among those entering residential treatment, with the highest rate of relapse occurring among adolescents in long-term residential treatment care. Despite strong evidence of treatment effectiveness, continuing care is vital to maintenance of treatment benefit. 

 

• Mojtabai, R (2005) Use of specialty substance abuse and mental health services in adults with substance use disorders in the community. Health Services Research, Volume 40, Issue 3 , June 2005, Pages 781-810

Abstract

AIMS: To examine the patterns and correlates of use of specialty substance abuse and mental health services among adults with alcohol or non-alcohol drug abuse or dependence in the community. METHODS: Analyses focused on 5,568 participants with alcohol or non-alcohol drug abuse or dependence drawn from a large representative cross-sectional survey of the US general population-the 2002 US National Survey on Drug Use and Health (NSDUH). RESULTS: Only 9.7% of adults with substance use disorders used specialty substance abuse services in the past year; 22.4% used mental health services. Severity of substance use disorder and less education were associated with using substance abuse services. Whereas psychological distress and impairment in role functioning due to psychological problems were associated with mental health service use. Male gender, black race/ethnicity, and lack of health insurance acted as barriers to using mental health services but not specialty substance abuse services. Past year use of substance abuse services, but not mental health services, was associated with lower likelihood of continued use of substances in the past month. CONCLUSIONS: Individuals with substance use disorders are more likely to use mental health services than specialty substance abuse services. However, only people who use specialty substance abuse services have a lower risk of continued use of substances. Findings highlight the need for integration of substance abuse treatments in the mental health care system and attention to different barriers to the two types of services.

 

• P. M. Flynn, S. G. Craddock, R. L. Hubbard, J. Anderson & R. M. Etheridge  (1997)  Methodological overview and research design for the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, Volume (Issue):  11(4) pp. 230-243.

Abstract

The Drug Abuse Treatment Outcome Study (DATOS) is the third in a series of national multisite studies of community-based treatment sponsored by the National Institute on Drug Abuse. The major goal of this prospective cohort study of adult clients entering treatment from 1991 to 1993 is to evaluate treatment effectiveness. The study included 10,010 admissions from 96 programmes in 11 cities. Interviews were conducted at admission and during treatment and 2,966 selected participants completed a 12-month follow-up interview. This article describes the methodological aspects of the study and provides an overview of programme and client samples. Data collection procedures and instrumentation are described and the analytical approach used to attain the research objectives is presented. Future plans for a longer term follow-up are also described, along with the potential contributions of DATOS findings to treatment policy. 

 

• P. M. Flynn, P. L. Kristiansen, J. V. Porto & R. L. Hubbard  (1999) Costs and benefits of treatment for cocaine addiction in DATOS. Drug and Alcohol Dependence, Volume (Issue):  57(2) pp. 167-174.

Abstract

The objective was to examine the cost of long-term residential (LTR) and outpatient drug-free (ODF) treatments for cocaine-dependent patients participating in the Drug Abuse Treatment Outcome Studies (DATOS), calculate the tangible cost of crime to society, and determine treatment benefits. Subjects were 502 cocaine-dependent patients selected from a national and naturalistic nonexperimental evaluation of community-based treatment. Financial data were available for programs from ten US cities where the subjects received treatment between 1991 and 1993. Treatment costs were estimated from the 1992 National Drug Abuse Treatment Unit Survey (NDATUS), and tangible costs of crime were estimated from reports of illegal acts committed before, during, and after treatment. Sensitivity analyses examined results for three methods of estimating costs of crime and cost-benefit ratios. Results showed that cocaine-dependent patients treated in both LTR and ODF programs had reductions in costs of crime from before to after treatment. LTR patients had the highest levels and costs of crime before treatment, and the greatest amount of crime cost reductions in the year after treatment, and yielded the greatest net benefits. Cost-benefit ratios for both treatment modalities provided evidence of significant returns on treatment investments for cocaine addictions. 

 

• R. M. Etheridge & R. L. Hubbard  (2000) Conceptualizing and assessing treatment structure and process in community-based drug dependency treatment programs. Substance Use and Misuse, Volume (Issue):  35(12-14) pp. 1757-1795.

Abstract

Having established the effectiveness of drug dependency treatment, the next generation of research will necessitate a focus on treatment structure and process and the systems within which programmes operate. As a foundation for a process conceptualisation, the authors constructed a grounded theory definition of treatment consisting of core elements and related comprehensive services. They then presented the multilevel conceptual framework that guided the Drug Abuse Treatment Outcome Study (DATOS) treatment structure and process study design and instrumentation, anchored by supporting empirical literature. The framework emphasises seven critical levels of process measurement that future research should consider in order to avoid potential spurious findings. 

 

• T. C. Helmus, K. K. Saules, E. P. Schoener & J. M. Roll (2003) Reinforcement of counselling attendance and alcohol abstinence in a community-based dual diagnosis treatment program: a feasibility study. Psychology of Addictive Behaviors, Volume (Issue):  17(3) pp. 249-251.

Abstract

This study evaluated the effectiveness of a community-based contingency management (CM) protocol reinforcing punctual dual-diagnosis group counselling attendance and negative breath alcohol levels. Participants were 20 dual-diagnosis patients. The A-B-A within-subjects reversal design included a 4-week baseline phase (BL), a 12-week CM intervention and a 4-week return-to-baseline phase (R-BL). Group counselling was provided twice weekly, with breath tests before each session. CM attendance rates were significantly higher (65% ± 28%) than BL (45% ± 32%, p < .05) and remained elevated in the R-BL phase (68% ± 29%). Despite clinical reports of frequent intoxication, during the study all breath test results were negative, regardless of study phase. Thus, no contingency effect on alcohol use could be determined. Results suggest that CM interventions can be effective in increasing attendance in a community treatment programme for the dually diagnosed. 

 

• Zosia Kmietowicz (2005) GPs asked to do more for drug misusers. Drug And Alcohol Dependence. Volume 78, Issue 3 , June 1, 2005, Pages 345-354.

More GPs need to get involved in providing care for drug misusers if the government's plans to overhaul and expand current drug rehabilitation services are going to succeed, the Audit Commission has said.

Although some drug treatment services are excellent, these are thin on the ground, the report says. Most services are poorly organised, offer only limited treatments, and are understaffed. Many have such long waiting lists that more than half the clients booked in never show up, and because after-treatment support is poor in many areas, clients "fall through the net" and are never heard of again.

The government has allocated an extra £167m ($240m; €273m) over the next two years and has set up the National Treatment Agency in England to improve the quality of care and access to it. But for this additional funding to make a difference, services need to be urgently reviewed and better coordinated and staffed, says the report.

Despite often being the people to whom drug misusers turn first, many GPs are reluctant to take on the care of these patients, a survey by the commission of more than 1500 GPs found.

Over 70% of GPs said that opiate misusers could not be managed in routine surgery and three quarters said it was inappropriate to perform dose assessment for drug substitutes in primary care. Sara Kulay, project manager of the commission's report, said it was particularly worrying that a third of GPs currently prescribing methadone were not confident about what they were doing.

"We would like to see more GPs involved in caring for people who misuse drugs," said Ms Kulay. "The nature of drug misuse problems is that clients need rapid access to treatment," she added. "But long waiting lists mean clients are turned away when they ask for help."

According to the commission's survey of drug services in 11 areas of England and Wales, the average waiting time was 35 days in 2000, although in three areas clients were asked to wait 100 days to be treated.

Changing Habits: The Commissioning and Management of Community Drug Treatment Services for Adults is available at www.audit-commission.gov.uk