Treatnet

Sustainable livelihoods for reintegration and rehabilitation

References:

• Amelia M. Arria (2003) Drug treatment completion and post-discharge employment in the TOPPS-II Interstate Cooperative Study. Journal of Substance Abuse Treatment; Volume 25, Issue 1 , July 2003, Pages 9-18.

Abstract

The objective of this study was to use administrative data to examine the effect of drug treatment completion on patients' subsequent employment and wages earned in the year following discharge, and to compare the consistency of these results across three states. Drug treatment and wage data from 20,495 drug treatment patients were used in this study. Treatment data were provided by the state substance abuse management information systems for Baltimore City, Washington State, and Oklahoma. Wage data were provided by the agency in each state responsible for collecting and reporting wage information. A quasi-experimental design was used to compare treatment completers and non-completers in the year after an index treatment episode. In addition, employment history in the year prior to the index episode was used to statistically adjust for group differences. The index episode of care may have included services under more than one treatment modality. The full social security number was used to link the drug treatment and wage administrative datasets. Treatment completers were 22% to 49% more likely than non-completers to be employed and to earn higher wages in the year following treatment, holding other variables constant. Patients staying in treatment longer than 90 days were 22% to 43% more likely to be employed in the year following treatment than those who stayed a shorter time. These findings were consistent across the three project states with different client populations, treatment delivery systems, and labor markets.

 

• Brooner, Robert K; Kidorf, Michael S; King, Van L; Stoller, Kenneth B; Peirce, Jessica M; Bigelow, George E; Kolodner, Ken (2004) Behavioural contingencies improve counselling attendance in an adaptive treatment model. Journal of Substance Abuse Treatment, Volume 27, Issue 3 , October 2004, Pages 223-232

Abstract

Poor patient adherence remains a serious obstacle to improving the effectiveness of many drug abuse therapies and the overall quality of care delivered in programs. The present study evaluated the utility and efficacy of incorporating behavioural contingencies in a stepped care treatment approach to motivate patient attendance to the varying amounts of prescribed weekly counselling. Study participants were opioid-dependent patients (n = 127) newly admitted to an ambulatory treatment program that provides methadone. Participants were randomly assigned to a Motivated Stepped Care condition (MSC; n = 65) with behavioural contingencies to specifically motivate counselling attendance vs. a Standard Stepped Care condition (SSC; n = 62) without these contingencies. The MSC vs. SSC condition was associated with a higher rate of counselling attendance (83% vs. 44%, p < .001) and a lower rate of poor treatment response (46% vs. 79%, p < .001). The behavioural contingencies were well tolerated and strongly associated with excellent attendance across both lower and higher doses of weekly counselling.

 

• D'Aunno, T; Vaughn, T E (1995) An organizational analysis of service patterns in outpatient drug abuse treatment units. Journal of Substance Abuse, Volume 7, Issue 1, 1995, Pages 27-42.

Abstract

The effectiveness of drug abuse treatment depends in part on meeting clients' medical and social needs related to drug abuse. Yet, we know little about the type and amount of medical and social services that clients receive in outpatient drug abuse treatment units. This article addresses this issue, drawing from conceptual perspectives in organizational theory and using data from a national random sample of 481 outpatient treatment units that participated in a phone survey in both 1988 and 1990. We examine the extent to which clients in these units receive: physical (medical) and mental health care; special treatment for multiple drug abuse; and employment, financial, and legal counselling. Results from a multivariate analysis of variance (MANOVA) indicate that there was a significant decrease from 1988 to 1990 in all services we examined. Regression analyses were conducted to identify organizational and client characteristics related to these decreases. Results show that changes in both client characteristics and key organizational factors (e.g., resources, staffing) are significantly related to decreases in the services clients receive. Implications for meeting the medical and social service needs of drug abuse clients are discussed.

 

• Friedmann, Peter D; Lemon, Stephenie C; Anderson, Bradley J; Stein, Michael D; Drug Abuse Treatment Outcome Study (DATOS) (2003) Predictors of follow-up health status in the Drug Abuse Treatment Outcome Study (DATOS). Drug And Alcohol Dependence, Volume 69, Issue 3 , April 1; Pages 243-251.

Abstract

This study examined the predictors of self-reported health status at follow-up in the Drug Abuse Treatment Outcomes Study (DATOS), a longitudinal study of drug abuse treatment programs and patients in 1991-1993. Baseline and follow-up interviews of 2966 patients in 75 programs were performed. The follow-up assessment was targeted to occur 12 months after treatment terminated; long-term methadone patients in treatment for the entire 12-month period were interviewed 24 months after intake. A composite measure, developed through principal component analysis, assessed health status. A multivariate hierarchical linear regression model adjusted for identified independent baseline predictors of health status at follow-up. Poor physical health status (including the composite measure, co-morbid conditions and pain) and greater severity of psychiatric symptoms at baseline were the strongest predictors of poor health status at follow-up. Other predictors of worse health status included older age, public insurance coverage and unemployment. We conclude that baseline health status and psychiatric symptoms predict the subsequent health status of patients in substance abuse treatment patients as in other clinical populations. Future research should examine whether early identification and treatment of physical and mental health problems among patients in addiction treatment programs might remediate their adverse effects on long-term health status outcomes.

 

• Grella, Christine E; Hser, Yih-Ing; Hsieh, Shih-Chao (2003) Predictors of drug treatment re-entry following relapse to cocaine use in DATOS. Journal of Substance Abuse Treatment, Volume 25, Issue 3 , October; Pages 145-154.

Abstract

Many drug abusers have repeated exposure to treatment, yet little is known about the reasons some individuals re-enter treatment following relapse to drug use. This paper examines the predictors of treatment re-entry among cocaine abusers who relapsed to cocaine use (N = 347) within 5 years following their index treatment episode. In-depth assessments were conducted at treatment intake in 1991-93 and at 1 and 5 years following treatment discharge. About 44% of the sample returned to treatment, at an average of 2.6 years following discharge. A logistic regression analysis demonstrated that individuals who were African American, were previously married, used cocaine at least weekly after treatment discharge, and had more service needs at the time of index treatment were more likely to re-enter treatment. The findings suggest that a longer-term perspective on treatment utilization is needed to more fully address chronic substance abuse and the problems typically associated with it

 

• John E. Berg (2003) Mortality and Return to Work of Drug Abusers From Therapeutic Community Treatment 3 Years After Entry. Journal of Clinical Psychiatry, 5(4): 164-167.

Abstract

Background: The outcome of therapeutic community treatment for drug abuse has been disputed with regard to mortality and rehabilitation to school or work as compared with other treatment modalities. Method: All patients (N = 130) admitted to a therapeutic community during 3 consecutive years (1996-1998), who had failed to stop abusing drugs after ambulatory and primary care initiatives, were assessed 1 to 4 years (mean = 36.5 months) after end of treatment. Rates of rehabilitation to school or work, changes in drug use patterns, and mortality were observed. Results: Nine persons died during the observation period (the observation time to death seemed to be shorter in women than in men). The mortality rate per 100 observation years was 2.28. Among the surviving drug abusers, 39% were working or attending school at study endpoint. One fourth currently used drugs, and approximately 14% were enrolled in a methadone maintenance program. Another 13% were in treatment or prison. Conclusion: Drug abuse is an activity that increases the mortality rate, but among the surviving persons, a considerable number are rehabilitated, as assessed after a longer observation period. The authors suggest that this outcome could not have been attained with ambulatory general practice-driven services, even with empathic follow-up.

 

• Mullins, Sharon M; Suarez, Mariann; Ondersma, Steven J; Page, Melanie C. (2004) The impact of motivational interviewing on substance abuse treatment retention: a randomized control trial of women involved with child welfare. Journal Of Substance Abuse Treatment, Volume 27, Issue 1 , July 2004, Pages 51-58.

Abstract

Previous studies have supported the efficacy of Motivational Interviewing (MI) in increasing treatment engagement and retention among people with substance abuse disorders. However, few studies have assessed the impact of MI with coerced populations, particularly women referred to drug abuse treatment by child welfare due to prenatal drug use. Seventy-one such women who used drugs during pregnancy were randomly assigned to either receive three MI sessions or to watch two educational videos and participate in a home visit. Treatment retention group attendance and random urine analysis results were evaluated in these women during the first 8 weeks of treatment. No differences were found between the two conditions on these variables. Possible reasons for these negative findings are discussed, as are ideas for future research with coerced populations.

 

• O'Brien, Charles P (2005) Anticraving medications for relapse prevention: a possible new class of psychoactive medications. The American Journal of Psychiatry, Volume 162, Issue 8 , August 2005, Pages 1423-1431.

Abstract

Psychiatrists have gradually developed a list of medications that are effective in the treatment of addictive disorders. Although alcoholism has received the most attention, nicotine, heroin, and cocaine have all been shown to be influenced by heredity. Of course, the immediate goal is the reduction of drug craving and the prevention of relapse to compulsive drug taking. A medication that can aid in the maintenance of the opiate-free state is naltrexone, a specific opiate antagonist. Naltrexone is also a good example of an anticraving medication used in the treatment of alcoholism. Clinicians currently have two types of medication to aid in the treatment of tobacco use disorder, arguably the most important addiction. Bupropion and nicotine replacement can be given in a coordinated fashion to provide the best available results. At present, no medication is approved by the Food and Drug Administration for the indication of cocaine addiction. Recently, however, five different medications, already approved for other purposes, have been found to be effective among cocaine addicts. Despite clinical trials that show benefit, anticraving medications are not well known and are underused by clinicians. Addiction is a heterogeneous condition, with variability in reactivity to the drug of abuse and to the medications available to treat it. Recent developments in pharmacogenetics may result in improved selection of medications based on genotype.

 

• Patrick M Fletcher, Bennett W; Broome, Kirk M; Delany, Peter J; Shields, Joseph; Flynn (2003) Patient and program factors in obtaining supportive services in DATOS. Journal of Substance Abuse Treatment, Volume 25, Issue 3 , October; Pages 165-175.

Abstract

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients (N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.

 

• Wong, Conrad J; Dillon, Erin M; Sylvest, Christine E; Silverman, Kenneth (2004) Contingency management of reliable attendance of chronically unemployed substance abusers in a therapeutic workplace. Experimental And Clinical Psychopharmacology, Volume 12, Issue 1, February; Pages 39-46.

Abstract

The Therapeutic Workplace is an effective drug abuse treatment that integrates abstinence reinforcement into a work setting by using a salary that drug abusers earn for work. Drug abuse patients are trained and hired to become data entry operators in a Therapeutic Workplace business. Despite the opportunity to earn a high wage, participants frequently arrive at work late and fail to work complete shifts. In the present study, a contingency management intervention to promote consistent and reliable attendance was evaluated in 4 participants. Participants were not allowed to work on days that they arrived late, and their pay was temporarily reduced each time they arrived late at work or failed to complete a work shift. A within-subject reversal design showed that the intervention increased the frequency with which participants arrived at work on time and completed work shifts.

 

• Robert A Matano, Stanley F Wanat (2000) Addiction is a treatable disease, not a moral failing. West J Med. 2000 January; 172(1): 63.

Review Article

Despite the fact that it was long ago acknowledged that alcohol and drug dependency are diseases (the AMA accepted this a quarter of a century ago), the everyday world of medical practice often reflects the stigmatizing attitudes of medical personnel reported in Angel's story. However, Lozano's article also illustrates the power of medical staff to intervene positively in addictions, and her encounter with Angel's mother stimulates a number of observations. Individual clinicians can have a great impact on substance abuse through their role in identifying, treating, and preventing the disease. A review of 44 studies of brief interventions in healthcare settings showed that even brief interactions with medical personnel have significant effects on patients' drinking.1 The vulnerability of a patient in a medical encounter and the authority of the medical provider can be harnessed for the immediate and long-term benefit of the patient, whatever the level of severity of substance misuse. Clinicians and their patients are often bound by the same unscientific, shaming beliefs about substance misuse; these beliefs create barriers to treatment.2 Angel's story conveys her mother's sense of being stigmatized by healthcare providers because of her illness. Lozano's intervention is an example of knowledge dispelling both stigma and pain. Physicians' fear of offending patients often leads to their avoidance of making the diagnosis of substance misuse or dependence.3 Just as knowledge about the Mongolian spot allowed Angel's mother to free herself from her mistaken belief, so too providers can benefit from casting aside unscientific and damaging beliefs regarding substance misuse. Patients and providers need to know that addiction is a treatable disease not a moral failing. The scope and impact of substance misuse across society are profound. Approximately 1 in 5 outpatients seeking primary care and 1 in 4 hospital patients are dependent on alcohol; yet, only about 1 in 7 people who are dependent on alcohol are ever treated.5 A study at a number of mainly urban hospitals found that approximately 1 in 9 infants evaluated had been exposed to illegal drugs in utero.6 Unintended pregnancies are one of the consequences for female substance misuser who exchange sex for drugs. Although Angel's problem is far from unique, her mother's-"a woman focusing all her energy on trying to do things right"-experience of an escape from addiction and restoration of the mother-daughter bond is not the norm. Substance misuse is underidentified and undertreated; individual clinicians have the power to change this. Substance misuse is under-identified and undertreated; individual clinicians have the power to change this. Lozano's encounter with Angel and her mother shows that substance misuse is not only treatable but is also preventable. Children of current and former substance misusers are at high risk of themselves abusing substances.7 Will Angel follow in her mother's footsteps as genetic, psychological, social, and cultural factors often dictate? Or will some intervention occur to prevent her progression to addiction? In a 1-year study of 445 adolescents receiving routine care from 119 family practitioners, 62.5% of the adolescents did not receive any health habit counselling (that is, risky sexual behavior, exercise, tobacco, alcohol and other substances). The authors note this "... clearly represents a missed opportunity for preventive counseling. The clinicians in Angel's story have moved the process of treatment, and prevention, forward by educating her mother. Although the medical setting is an ideal context for intervening to stop the progression of substance misuse, medical personnel often fail to act. Clinicians report that they lack the knowledge, skills, attitudes, and practical experience to address substance misuse. Physicians rate doctor-patient communication on substance misuse as extremely important but rate their own related training and skills dramatically lower; cross-cultural and gender issues add to the challenge.9 Training programs for health professionals devote too little time to substance misuse, leaving clinicians ill equipped to deal with this widespread health problem. Better training will result in physicians who are better able to prevent, identify, and treat substance misuse in the future-but what about now? Angel's story illustrates that, in the arena of substance misuse, the beliefs and actions of individual clinicians matter.