Director's Report to the National Advisory Council on Drug Abuse
February, 2002
Research Findings
Services Research
Correlates and 6-month Outcomes for Co-occurring Cannabis Use in Rural and Urban At-risk Drinkers
Little is known about the functional correlates of recent cannabis use when such use is additional to an "alcohol disorder" in non-treatment populations. Researchers report on data from a prospective study of a large probability community survey of 733 at-risk drinkers in six Southern U.S. states (Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee) conducted from 1995 to 1996. Twenty-one percent reported cannabis use during the past six months at the baseline interview. These cannabis users were significantly less likely to be married, employed, or a high school graduate (p <. 05). They were also more likely to have a diagnosis of "antisocial personality disorder" or "panic disorder. Recent cannabis users also reported more negative consequences of their alcohol use, including more frequent recent diagnoses of an "alcohol disorder," legal difficulties associated with their drinking, and more social consequences attributed to drinking. At the six-month follow-up interview, negative alcohol outcomes were associated with concurrent cannabis use, including higher frequency and quantity of alcohol consumption, greater frequency of recent "alcohol abuse" and "dependence," and greater social consequences of drinking. These results all point to substantially poorer functioning and experiences of individuals with concurrent at-risk alcohol and cannabis use. Authors suggest that cannabis use may be a marker for greater impairment associated with at-risk drinking. Booth, B.M., Kirchner, J.A.E. Substance Use & Misuse, 36(6-7), pp. 717-733, 2001.
Engagement Models for Adolescents in DATOS-A
Considerable research conducted with adults in drug treatment has demonstrated that engaging patients is essential for maximizing treatment retention, completion, and posttreatment outcome. This study applies a model of treatment engagement previously developed and tested with adults. Based on the importance of during-treatment activities for improving outcomes, relationships between patient background, treatment readiness, and therapeutic engagement were examined in a national sample of adolescents admitted to 20 treatment programs representing three modalities. Adolescent patients with higher readiness for treatment at intake subsequently became more therapeutically involved, replicating previous findings on relationships between motivation and engagement in adult samples. One of the most influential background factors associated with higher treatment readiness was patient relationships with family and friends. Interventions that focus on treatment readiness appear to be appropriate strategies for improving treatment engagement. Broome, K.M., Joe, G.W., Simpson, D.D. Journal of Adolescent Research, 16(6), pp. 608-623, 2001.
Treatment Service Patterns and Organizational Structures: An Analysis of Programs in DATOS-A
Findings from earlier studies have suggested that like adults, adolescent patient profiles differ by modality. As a first step in examining drug abuse treatment typologies for adolescents, the researchers investigated the relationship between patient needs and program characteristics. They hypothesized that there may be systematic differences in the types of services provided that are a function of program characteristics as well as the needs of patients entering treatment. The availability of a variety of treatment services was examined within a national sample of programs treating adolescent drug abuse patients. Treatment service delivery profiles were created and examined in the context of organizational variables such as program modality program directors' academic credentials, program capacity staff composition, accreditation, and patient problems. Results suggested that distinct profiles of services existed within residential and outpatient modalities and that these service profiles were related both to organizational factors and to patient problem profiles. Delany, P.J., Broome, K.M., Flynn, P.M., and Fletcher, B.W. Journal of Adolescent Research, 16(6), pp. 590-607, 2001.
Attrition Prevention with Individuals Awaiting Publicly Funded Drug Treatment
The aim of this study was to evaluate the effectiveness of a motivational intervention to reduce attrition from a waiting list for substance abusers seeking publicly funded treatment. Randomized clinical trial compared an “attrition prevention" condition to standard care while awaiting treatment admission. The study was conducted at a centralized substance abuse assessment and referral center in Seattle, Washington. Study participants comprised substance abusers (n = 654) eligible for publicly funded drug abuse treatment. Measurements collected were: alcohol and drug use, substance-related negative consequences, areas in need of help, perceived need for help, emotional status, readiness to change, reasons for seeking and perceived barriers to entering treatment. Overall, approximately 70% of clients entered treatment, and of these approximately 70% completed their assigned treatment. Those who entered treatment showed significant reductions in substance use and improved psychosocial function at a short-term 3-month follow-up. However, the attrition prevention intervention had no differential effect on treatment entry, completion, or outcome compared to the standard waiting list. Further, there were no differences across therapists on these outcome measures. Authors concluded that a motivational attrition prevention intervention did not enhance treatment entry, completion, or outcome among treatment-seeking substance abusers and suggested that alternative strategies, such as contingency management and case management, may help facilitate treatment entry for individuals seeking publicly funded treatment. Donovan, D.M., Rosengren, D.B., Downey, L., Cox, G.B., and Sloan, K.L. Addiction, 96(8), pp. 1149-1160, 2001.
Drug Abuse Treatment and Comprehensive Services for Adolescents
Data from two national studies of treatment spanning two decades-Treatment Outcome Prospective Study (TOPS), 1979 to 1981, and Drug Abuse Treatment Outcome Studies for Adolescents (DATOS-A), 1993 to 1995-provided a comparison of treatment and services provided to 261 TOPS and 1.519 DATOS-A in treatment adolescent patients in a cross-modality sample of 24 TOPS and 31 DATOS-A programs. The authors used patient self-reports of treatment needs and services received to compare unmet needs for six services. Findings showed a general decline over treatment eras in services received that was only partially offset by significant decreases in some self-reported service needs in DATOS-A. Unmet needs increased significantly over treatment eras for specific services, including psychological, family, employment, and financial services. The highest need in both studies was for family services. The DATOS-A appeared to be addressing family needs better than the TOPS program much of which was more adult focused. Across all DATOS modalities, from 40% to 50% patients reported unmet need for psychological services, considerably higher than the 7% to 10% of TOPS patients. Potential explanations for the increases in unmet needs include changes in treatment access and decreases in program resources for services. Etheridge, R.M., Smith, J.C., Rounds-Bryant, J.L., and Hubbard, R.L. Journal of Adolescent Research, 16(6), pp. 563-589, 2001.
The Effect of Drug Treatment on Criminal Behavior among Adolescents in DATOS-A
This study examined the effects on criminal behavior among 1,167 adolescents who participated in a community-based substance abuse treatment study (Drug Abuse Treatment Outcome Studies for Adolescents) (DATOS-A). The primary goals of this study were to assess the effect of substance abuse treatment on adolescent crime and to identify the patient characteristics that were most closely associated with reductions in crime during the posttreatment period. Results confirmed that among adolescents who had engaged in criminal activity during the 12 months prior to entering DATOS-A treatment, reductions in alcohol or marijuana use were independently associated with significant reductions in the likelihood of committing crimes during the 12-month follow-up period. The present study also provides further support for emphasizing dynamic rather than static patient characteristics to predict the likelihood of continued drug-related offending among substance-abusing adolescents. Farabee, D., Shen, H.K., Hser, Y.I., Grella, C.E., and Anglin, M.D. Journal of Adolescent Research, 16(6), pp. 679-696, 2001.
Using the Drug Abuse Screening Test (DAST-10) to Analyze Health Services Utilization and Cost for Substance Users in a Community-based Setting.
The dual purpose of this study was to: (1) determine whether problematic drug users, defined through the Drug Abuse Screening Test (DAST-10), exhibited differences in health services utilization and cost relative to a combined group of non-problematic drug users and non-drug users; and (2) assess whether the findings were similar to those for chronic drug users (CDUs) and injecting drug users (IDUs). Results showed that health services utilization and total cost were very similar for problematic drug users defined through quantity-frequency (i.e., CDU, IDU) and diagnostic (i.e., DAST-10) criteria. Findings suggest that quantity/frequency criteria, for problematic drug use were reasonable approximations for diagnostic-based measures. French, M.T., Roebuck, M.C., McGeary, K.A., Chitwood, D.D., and McCoy, C.B. Substance Use & Misuse, 36(6-7), pp. 927-946, 2001.
Transportation and Retention in Outpatient Drug Abuse Treatment Programs
To determine whether certain types of transportation assistance improve outpatient treatment retention beyond thresholds shown to have therapeutic benefits, we analyzed data from 1,144 clients in 22 outpatient methadone maintenance (OMM) programs and 2,031 clients in 22 outpatient drug-free (ODF) programs in the Drug Abuse Treatment Outcomes Study (DATOS), a national, 12-month, longitudinal study of drug abuse treatment programs. Directors' surveys provided information about provision of car, van, or contracted transportation services or individual vouchers/payment for public transportation. Chart-abstracted treatment retention was dichotomized at 365 days for OMM and 90 days for ODF. Separate multivariate hierarchical linear models revealed that provision of car, van, or contracted transportation services improved treatment retention beyond these thresholds for both OMM and ODF, but individual vouchers or payment for public transportation did not. Future research should validate whether car, van, or contracted transportation services improve retention and other treatment outcomes in outpatient drug abuse treatment. Friedmann, P.D., Lemon, S.C., and Stein, M.D. Journal of Substance Abuse Treatment, 21(2), pp. 97-103, 2001.
Prospective Risk Factors and Treatment Outcomes Among Adolescents in DATOS-A
The researchers applied a problem behavior approach to examining the relationship between pretreatment risk factors and posttreatment outcomes among 292 admissions to nine outpatient drug-free (ODF) and 418 admissions to eight residential (RES) adolescent programs. Assessments were administered at intake into treatment and 12 months following discharge. Using a structural modeling approach, the researchers found stability over time for alcohol use, criminal involvement, and psychological maladjustment. For adolescents treated in outpatient programs, (a) severity of drug use predicted lower rates of treatment retention, and (b) family drug involvement was related to higher posttreatment rates of alcohol use. Among those treated in residential programs, (a) family drug involvement and criminal involvement predicted lower rates of treatment retention, and (b) conduct disorders were related to more marijuana use at follow-up. The findings underscore the need for intervention strategies that address the intrapsychic and interpersonal functioning of drug-abusing adolescents to improve their behavioral outcomes. Galaif, E.R., Hser, Y.I., Grella, C.E., and Joshi, V. Journal of Adolescent Research, 16(6), pp. 661-678, 2001.
Risk Transfer and Accountability in Managed Care Organizations' Carve-Out Contracts
This study examined characteristics of contracts between managed care organizations (MCOs) and managed behavioral health organizations (MBHOs) in terms of delegation of functions, financial arrangements between the MCO and the MBHO, and the use of performance standards. Nationally representative administrative and clinical information about the three largest types of commercial products offered by 434 MCOs in 60 market areas was gathered by telephone survey. These products comprised services provided by health maintenance organizations, preferred provider organizations, and point-of-service plans. Chi square tests were performed between pairings of all three types of products to ascertain differences in the degree to which claims processing, maintenance of provider networks, utilization management, case management, and quality improvement were delegated to MBHOs through specialty contracts among the various types of products. Contractual specifications about capitation arrangements, risk sharing, the use of performance standards, and final utilization review decisions were also compared. For all types of products, almost all the major functions were contracted by the MCO to the MBHO. Although most contracts assigned some risk for the costs of services to the MBHO, the degree of this risk varied by product type. Except in the case of preferred-provider organizations, a large number of performance standards were identified in MCOs' contracts with MBHOs, although financial incentives were rarely tied to such standards. Findings led the authors to conclude that MCOs that contract with MBHOs place major responsibility, both financial and administrative, on the vendors. Garnick, D.W., Horgan, C.M., Hodgkin, D. Merrick, E.L., Goldin, D., Ritter, G. and Skwara, K.C. Psychiatr Serv, 52, pp. 1502-1509, 2001.
12-step Program Participation and Effectiveness: Do Gender and Ethnic Differences Exist?
Although 12-Step is increasingly utilized as a recovery resource and is viewed by many addiction specialists as an integral component of treatment and long-term recovery, questions regarding participation and effectiveness of 12-Step programs for women and ethnic minorities have been raised. Utilizing data from the Los Angeles Target Cites Evaluation Project (n = 356), participants in adult outpatient alcohol and drug treatment were followed for 24 months and rates of 12-Step participation and effectiveness were assessed for all gender and ethnic groups. Contrary to reports that 12-Step is more appropriate for European-American males, statistical analyses reveals that women and ethnic minorities are equally likely to attend 12-Step programs, and to recover in conjunction with such participation as European-American males. Although 12-Step may not appeal to all seeking to cease alcohol and drug use, the clinical implications for treatment providers and other addiction specialists points to the benefits of integrating 12-Step components into traditional treatment programs and recommending 12-Step participation for clients of all gender and ethnic groups. Hillhouse, M.P., and Fiorentine, R. J Drug Issues, 31(3), pp. 767-780, 2001.
Effects of Program and Patient Characteristics on Retention of Drug Treatment Patients
The objective of this study was to examine effects of program and patient characteristics on patient retention in residential drug treatment programs, outpatient drug-free programs (ODF), and methadone maintenance (NIM) programs. Patient data were based on admission and discharge records for individuals entering treatment programs in Los Angeles County during 1992 and 1993. Program data were collected from program directors via a mail survey. The study sample included 26,047 patients in 87 programs. The dependent variable was patient completion of a critical threshold of treatment (360 days for MM and 180 days for the other two modalities). Authors applied logistic regression hierarchical linear modeling analysis for each modality. Principal findings showed that threshold retention rates were generally low in all three modalities (18.1% for residential programs, 22.9% for ODF, and 13.6% for MM). An articulated programmatic focus and low caseload increased patient retention in residential programs. A lower level of group therapy focus increased patient retention in ODF programs. A low programmatic focus and a low percentage of recovering staff were associated with high retention rates among MM patients. For ODF programs, none of the slopes showed random effects, while for residential and MM programs, some program factors contributed to the explanation of the random effects in several slopes (e.g., drug use severity). Authors concluded that program practice and service provision played important roles in determining patient retention in treatment. Service providers and planners should consider these key factors to improve retention of patients, which is likely to increase overall treatment effectiveness and efficiency. Hser, Y.I., Joshi, V., Maglione, M., Chou, C.P., and Anglin, M.D. Evaluation and Program Planning, 24(4), pp. 331-341, 2001.
Relationships Between Counseling Rapport and Drug Abuse Treatment Outcomes
This study examined the association between counseling rapport and drug abuse treatment outcomes. Two cohorts of outpatients who were being treated with methadone in four cities were studied. Cohort 1 comprised 354 patients in community-based nonprofit programs, and cohort 2 comprised 223 patients from a private for-profit program. Logistic regression analyses were used to assess the importance of counseling rapport as a predictor of drug use and criminality relative to treatment retention in the index treatment, satisfaction with treatment, and whether additional treatment was received after the index treatment. In both cohorts, ratings made by counselors, during treatment, of therapeutic involvement and relationships with patients provided a useful measure of counseling rapport. A lower level of rapport during treatment predicted worse post-index treatment outcomes, including more cocaine use and criminality, both by itself and after adjustment for treatment retention, satisfaction with treatment, and post-index treatment status. Counseling strategies were associated with the development of counseling rapport. Findings led authors to conclude that counseling rapport is a vital part of the therapeutic process and helps explain why and when treatment is effective. It contributes explicitly to the prediction of outcomes, apart from treatment retention, and accounts in part for the usual association between treatment retention and outcomes. Joe, G.W., Simpson, D.D., Dansereau, D.F., Rowan-Szal, G.A. Psychiatr Serv, 52(9), pp. 1223-1229, 2001.
A Self-administered Instrument for Assessing Therapeutic Approaches of Drug-user Treatment Counselors
In this article authors describe the development and psychometric properties of a self-administered instrument for assessing drug-user treatment counselors' therapeutic approaches such as psychodynamic or interpersonal, cognitive-behavioral, family systems or dynamics, 12-step, and case management. Authors generated an initial pool of items corresponding to these five approaches and modified them based on expert ratings. Three sets of items were developed. The first concerned the beliefs underlying each therapeutic approach. The second and third concerned the practices of each applicable approach within individual and group counseling, respectively. With the exception of case management, an approach that originated within social work and which is only applicable to individual counseling, the other four approaches are applicable, at least theoretically, to both individual and group counseling. Additionally, authors included items that describe techniques used exclusively with groups (i.e.. group techniques). Finally, they included some items that are not associated with any of the traditional approaches but which reflect the practical approach that drug-user treatment programs often take to both individual and group counseling (i.e., practical counseling). The initial instrument consisted of 17 subscales with a total of 76 items. This instrument was administered to 226 counselors from 45 drug-user treatment programs in Los Angeles County. Based on this data, the researchers further refined these scales using confirmatory factor analysis to ensure both construct validity and discriminant validity. The final instrument consisted of 14 subscales with a total of 48 items. Kasarabada, N.D., Hser, Y.I., Parker, L., Hall, E., Anglin, M.D., and Chang, E. Substance Use & Misuse, 36(3), pp. 273-299, 2001.
Organizational and Financial Issues in the Delivery of Substance Abuse Treatment Services
Examination of organizational and financial characteristics of the specialty substance abuse treatment system allows an understanding of how to meet the needs of clients in the system. Further, this assessment may afford insights into how the specialty sector may adapt in the changing environment of managed care. Data from Phase I of the Alcohol and Drug Services Study (ADSS) describe the specialty substance abuse treatment system in terms of type of care, setting, level of affiliation, licensure/accreditation, ownership, revenue sources, client referral sources, client's primary substance of abuse, and managed care. Although the system is largely outpatient and remains substantially two tiered in terms of public/private funding mix, it varies along a number of organizational and financial dimensions which have implications for system structure and facility viability in the changing environment of substance abuse treatment service delivery. Horgan, C.M., Reif, S., Ritter, G.A., and Lee, M.T., Recent Dev Alcohol, 15, pp. 9-26, 2001.
Financing of Substance Abuse Treatment Services
The financing of treatment for substance abuse problems has differed from the rest of financing of health care in part because of the dominant role of the public sector as the payer of services. Nonetheless, the rise of managed care has affected substance abuse treatment services as well as the rest of the health care system. Alternative payment mechanisms are one important component of some managed care approaches. Behavioral health carve-outs are another managed care development that has affected substance abuse services. In this chapter, salient features of financing for substance abuse treatment are reviewed within the conceptual framework of payers (purchasers and intermediaries), providers, and consumers. Existing literature on substance abuse treatment financing is summarized, while recognizing that much remains to be researched. Horgan, C.M., and Merrick, E.L. Recent Dev Alcohol,15, pp. 229-252, 2001.
A Client-Treatment Matching Protocol For Therapeutic Communities: First Report
The present study is the first report on a client-treatment matching protocol (CMP) to guide admissions to residential and outpatient substance abuse treatment settings. Two cohorts, a field test sample (n = 318) and cross-validation (n = 407) sample were drawn from consecutive admissions to nine geographically distributed multisetting therapeutic communities (TCs). A passive matching design was employed. Clients received the CMP on admission, but agencies were "blind" to the CMP treatment recommendation (i.e., match) and assigned clients to treatment by the usual intake procedures. Bivariate and logistical regression analyses show that positive treatment dispositions (treatment completion or longer retention in treatment)) were significantly higher among the CMP-matched clients. The present findings provide the empirical basis for studies assessing the validity and utility of the CMP with controlled designs. Though limited to TC-oriented agencies, the present research supports the use of objective matching criteria to improve treatment. Melnick, G., De Leon, G., Thomas, G. and Kressel, D., Journal of Substance Abuse Treatment, 21(3), pp. 119-128, 2001.
Differences among Out-of-treatment Drug Injectors who Use Stimulants Only, Opiates Only or Both: Implications for Treatment Entry
The goal of this study was to compare drug and alcohol use, psychological symptoms and substance abuse treatment entry among 583 street-recruited, out-of-treatment injection drug users (IDUs) who used stimulants only, opiates only or both stimulant and opiate. Data analyzed from structured interviews indicated that stimulant-only users had the most severe alcohol problems and the highest psychological symptom scores for hostility, paranoia and psychoticism. In the 2 months following their interview only 3% of the stimulant-only users entered substance abuse treatment, as compared to nearly half of the participants in the other two groups. Even after controlling for variables that differed among the groups by logistic regression analysis, stimulant only users were still 24-25 times less likely than opiate only or both stimulant and opiate users to enter treatment. Researchers and clinicians are challenged to better understand and address the unique needs of stimulant users, including potential psychological problems and alcohol abuse, in order to attract them to treatment and serve them through a comprehensive treatment approach. John, D., Kwiatkowski, C.F., and Booth, R.E. Drug Alcohol Depend, 64(2), pp 165-172, 2001.
Selective Contracting in Managed Care: The Case of Substance Abuse Treatment
The authors address two critical questions concerning managed care and outpatient substance abuse treatment organizations. Specifically, they consider (1) to what extent selective contracting occurs between managed care firms and treatment providers and (2) what attributes of treatment providers and their operating environments are associated with selective contracting. Using data from a nationally representative sample of outpatient treatment organizations, the authors find evidence of systematic selection. Several indicators of providers' quality and costs, including accreditation status, private ownership, size, and prior experience with managed care, are positively associated with managed care contracting. By contrast, units providing methadone treatment are less likely to be involved in managed care. To a lesser extent, characteristics of treatment providers' operating environment, including extent of competition based on costs and attributes of the Medicaid managed care program, are also positively associated with managed care contracting. Lemak, C.H., Alexander, J.A., and D'Aunno, T.A. Medical Care Research and Review, 58(4), pp. 455-481, 2001.
A Comparison of Psychosocial Barriers Among Welfare Recipients: Implications For Drug Treatment
Implementation of Temporary Assistance for Needy Families (TANF) presents welfare recipients with time-limited benefits and work requirements. However, it is estimated that over 140,000 welfare recipients meet the DSM-IV criteria for "drug dependence." In this study, samples of chronic drug using and non-drug using female TANF recipients were compared with regard to: current employment, psychological functioning, self-perceived employment skills, barriers to employment, and need for help in seeking employment. It was found that non-drug using study participants were significantly more likely to be employed and reported significantly higher self-perceived work skills than users. Chronic users reported significantly greater barriers to seeking employment. Montoya, I.D., Atkinson, J.S., and Struse, H.M. Substance Use & Misuse, 36(6-7), pp. 771-788, 2001.
Examining the Substance Use Patterns and Treatment Needs of Incarcerated Sex Offenders Using data from a Bureau of Justice Statistics' national prison inmate survey, this paper analyzes alcohol and drug use and abuse patterns among men incarcerated in state prison for sex crimes. Of the 13,986 inmates in the sample, 11.5% were incarcerated for a sex offense. Two thirds were substance-involved, meaning that they were under the influence of alcohol or drugs at the time of their crime, had committed a crime to get money for drugs, had histories of regular illegal drug use, had received treatment for alcoholism, or shared some combination of these characteristics. The level and type of substance-involvement was related to age and race, to history of victimization, and to victim characteristics. We discuss the implications of these findings for correctional program interventions, including assessing drug and alcohol problems, availability of substance abuse treatment for sex offenders, and the conjunction of such treatment with other programs. Peugh, J., and Belenko, S. Sex Abuse. 13(3), pp. 179-195, 2001.
Patient Characteristics and Treatment Outcomes for African American, Hispanic, and White Adolescents in DATOS-A
This study attempts to extend what is known about adolescent substance abusers in adolescent-oriented substance abuse treatment by describing and comparing background and pretreatment characteristics and posttreatment outcomes of African American (n = 213), Hispanic (n = 108), and White adolescent (n = 773) substance abusers who participated in the Drug Abuse Treatment Outcome Studies for Adolescents (DATOS-A). The pretreatment data indicated that patients in each group were similar only with respect to basic demographics (gender, age and primary drug use) but differed in terms of referral source, involvement with the criminal justice system and prevalence of mental disorders. Posttreatment comparisons revealed significant racial/ethnic differences in serious posttreatment criminal behavior, only. Logistic regression results indicated that African American adolescents had a lower likelihood of engaging in serious illegal activity as compared to White adolescents during the posttreatment period. The results of this study provide at mechanism for more comprehensive understanding of adolescent substance abusers, their treatment needs, and their treatment outcomes. Rounds-Bryant, J.L., and Staab, J. Journal of Adolescent Research, 16(6), pp. 624-641, 2001.
Using Cost and Financing Instruments for Economic Evaluation of Substance Abuse Treatment Services
Standardized economic evaluation instruments are an important tool in the analysis of change and performance of addiction treatment. Nevertheless, compared to other health care sectors, economic evaluation of addiction treatment is still rare. The present paper proposes two comprehensive economic evaluation instruments that are methodologically sound and that meet the objectives of comprehensiveness, standardization, and comparability. The Drug Abuse Treatment Cost Analysis Program (DATCAP) can be used to estimate the economic cost of treatment services; the Drug Abuse Treatment Financing Analysis Program (DATFAP) is a companion instrument and analyzes the complexity and change of treatment financing. This paper outlines the contents of each instrument and, for illustrative purposes, presents results from several case studies. Suggestions for updates and enhancements for each instrument are also discussed. Salome, H.J., and French, M.T. Recent Dev Alcohol.,15, pp. 253-269, 2001.
The Organization of Substance Abuse Managed Care
Managed care came to dominate the delivery of substance abuse services during the 1990s. This paper uses literature and new data to describe and analyze the set of arrangements it implies. The description suggests that substance abuse managed care typically is "carved out" of the general health care plan and treatment is coordinated by a behavioral health managed care company that manages treatment access, length, type, and intensity. This administrative agent is provided financial incentives to keep costs low and otherwise faces such mandates as to ensure timely access to treatment and to deliver reports. A typical agent has some interest in improving the quality of decision-making, but has few incentives for controlling the treatment technology. In contrast, agents tend to control treatment providers through relatively rigid rules that substitute outpatient for inpatient care, regulate the length and intensity of services, provide limited social services, mandate accreditation, allow limited clinician discretion, administer an entire "network" of providers as an only slightly differentiated mass, and rarely shape the details of the treatment process. These patterns are analyzed in terms of transaction cost economics and institutional and resource dependency theories. In general, it is argued that managed care reflects an interest in controlling costs but also in ensuring access within an environment where there is uncertainty accompanying competing demands, varying conceptions of the client, and controversies over the efficacy of specific treatment technologies. Sosin, M.R., and D'Aunno, T. Recent Dev Alcohol, 15, pp. 27-49, 2001.
Effects of Managed Care on Programs and Practices for the Treatment of Alcohol and Drug Dependence
Managed care is affecting the organization and financing of treatment services for alcohol and drug dependence. This paper examines the effects of managed care on program operations including the use of clinical protocols, the administrative burden, information systems, staffing, and program consolidation. It also reviews the effects of managed care on system performance related to employer-sponsored health plans, state employee health plans, and Medicaid and other public plans. This review of managed care's influences on the alcohol and drug abuse treatment system finds evidence of systemic reductions in access to inpatient care and increased reliance on outpatient services. Moreover, although analyses of behavioral health carve-outs often suggest increases in the use of outpatient care, evaluations of substance abuse claims report reductions in ambulatory utilization for the treatment of alcohol and drug dependence. Recent Dev. Alcohol, 15, pp. 51-71, 2001.
Social Support Systems of Women Offenders who Use Drugs: A Focus on the Mother-daughter Relationship
Conceptually, social support among very heavily drug-involved women is complex and multidimensional. This article examines the structure and function of the social support systems of women offenders (N = 100) who used drugs during the last 6 months before entering court-mandated drug-free treatment programs. These systems typically contain about nine supporters, almost equally divided between men and women, and about half of the women's supporters are family members. The women identify parents and partners as their major providers of practical help and advice. They look most to their partners for a sympathetic ear, and to their parents for affirmation of their self-worth. Overall, two-thirds of the women identify their mothers as among their supporters. These mothers are often anxious to do whatever they can to help their daughters stop using drugs. Paradoxically, the assistance many mothers give their daughters in providing money or basic life necessities often enables the daughter's drug use. Although many daughters appreciate their mother's help, there is an element of distrust and control in many of the mother-daughter relationships, and some daughters receive unwanted help from their mothers. Drug treatment providers can benefit from understanding their clients' social support systems, especially the dynamics of important relationships with main pretreatment supporters, such as parents. By gaining this understanding and helping their clients to effectively accept and use social support, Strauss, S.M., and Falkin, G.P. American Journal of Drug and Alcohol Abuse, 27(1), pp. 65-89, 2001.
Crack Cocaine, Alcohol, and Other Drug Use Patterns among Homeless Persons with Other Mental Disorders
This study examined the co-occurrence of cocaine, alcohol, marijuana, and other drug use among treatment seeking homeless persons to determine whether alcohol use predicted cocaine use differently than marijuana and other drugs predicted cocaine use. Participants were 141 homeless persons with substance use and other nonpsychotic mental disorders seeking drug treatment at a metropolitan health care agency for homeless persons. They were 72.3% male, 27.7% female, 82.7% African American, 17.3% Caucasian, with an average age of 37.7 (SD 7.1) years and had 13.1 (SD 2.4) average years of education. Results supported the assertion that cocaine use was strongly associated with extent of alcohol use and that the association between cocaine and alcohol was stronger than the association between cocaine and other drug use, including marijuana. Participants with cocaine plus alcohol disorders were retained longer in treatment than disorders of cocaine only with no differences in abstinence outcome. The findings should drive further research into the use of alcohol as a trigger or predictor of cocaine use, the deleterious effects of the combined use of cocaine and alcohol, and specialized treatments for polysubstance users. Usdan, S.L., Schumacher, J.E., Milby, J.B, Wallace, D., McNamara, C., and Michael, M. Am J Drug Alcohol Abuse, 27(1), pp. 107-120, 2001.
Rural-Urban Differences In Substance Use And Treatment Utilization Among Prisoners
Surveys of incarcerated offenders and arrestees consistently report high rates of both alcohol and drug use in this population. This drug-crime connection has highlighted the need to learn more not only about drug treatment effectiveness, but also about drug treatment utilization. While studies have begun to examine drug treatment utilization, most of these studies have been based on urban substance abusers. Little is known about the extent to which urban and rural substance abusers may be different in terms of treatment utilization. This study, therefore, examines differences between urban and rural drug use patterns and treatment utilization among chronic drug abusers to determine whether, and in what ways, rurality may affect substance abuse and treatment seeking. The study examines these issues in a group of chronic drug users who were incarcerated at the time of the study. Findings show significant differences in drug use and treatment utilization of urban and rural offenders. Chronic drug abusers from rural and very rural areas have significantly higher rates of lifetime drug use, as well as higher rates of drug use in the 30 days prior to their current incarceration than chronic drug abusers from urban areas. Nonetheless, being from a very rural area decreased the likelihood of having ever been in treatment after controlling for the number of years using and race. While problem recognition appears to explain much of the effect of very rural residence on treatment utilization for alcohol abuse, the effects of being from a very rural area on seeking treatment for drug abuse remain statistically significant even after controlling for several other variables. The findings point to the importance of providing culturally appropriate education to very rural communities on the benefits of substance abuse treatment and of providing substance abuse treatment within the criminal justice system. Warner, B.D., and Leukefeld, C.G. The American Journal of Drug and Alcohol Abuse, 27(2), pp. 265-280, 2001.
Social Support and Abstinence from Opiates and Cocaine during Opioid Maintenance Treatment
Social support may play an important role in helping drug users achieve abstinence; however these benefits may depend on the type of support experienced. In this prospective observational study, we examined the extent to which general and abstinence-specific support, both structural and functional, predicted opiate and cocaine abstinence in 128 opioid maintenance patients receiving either methadone or LAAM. A new multidimensional self-report instrument assessing abstinence-specific functional support was developed for the study. Previously validated measures were used to assess the remaining types of support. With baseline abstinence and other statistically important covariates adjusted, hierarchical logistic regression analyses demonstrated that the associations between social support at study baseline and biochemically confirmed abstinence 3 months later varied by type of support and by drug. Greater abstinence-specific structural support (operationalized as fewer drug users in the social network) and decreases in three types of negative abstinence-specific functional support (Complaints about Drug Use, Drug Exposure, and Demoralization) predicted cocaine, but not opiate abstinence. There were no effects for general support, whether structural or functional, on abstinence from either drug. Interventions that focus on modifying patients' abstinence-specific support may be helpful in reducing the high rates of cocaine use disorders in this population. Wasserman, D.A., Stewart, A.L., and Delucchi, K.L. Drug and Alcohol Dependence, 65(1), pp. 75-85, 2001.
Integrating Primary Medical Care With Addiction Treatment: A Randomized Controlled Trial
The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment. The objective of this study was to examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse-related medical conditions (SAMCs). A randomized controlled trial was conducted between April 1997 and December 1998. Subjects comprised adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, CA. Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. Main outcome measures included: abstinence outcomes, treatment utilization, and costs 6 months after randomization. Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs. 63%, P = .18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs. independent care, 73%; P = .23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs. $324.09, P = .19). However, patients with SAMCs (n = 341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs. 55%, P =.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1.04-4.25) SAMCs. Patients with SAMCs had a slight but nonsignificant trend of higher costs in the integrated care group ($470.81 vs. $427.95, P =.14). The incremental cost-effectiveness ratio per additional abstinent patient with an SAMC in the integrated care group was $1581. Authors concluded that individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective. These findings are relevant given the high prevalence and cost of medical conditions among substance abuse patients, new developments in medications for addiction, and recent legislation on parity of substance abuse with other medical benefits. Weisner, C., Mertens, J., Parthasarathy, S., Moore, C., and Lu, Y. JAMA. 286(14), pp. 1715-1723, 2001.
Drug Courts - A Bridge Between Criminal Justice and Health Services
There is striking overlap between the public health threats of drug abuse and crime. Crimes are often drug related, and drug abusers frequently encounter the criminal justice system. However, with few exceptions (e.g., Treatment Alternatives to Street Crime, TASC), the intersection of drug abusers with the courts has rarely addressed the defendants' drug problems. Drug courts represent an innovative approach to addressing both crime and drug abuse. Especially promising, and of great importance given that drug abuse is associated with a host of other health and social service needs, is the link that drug courts represent between the criminal justice and health services systems. Connections to health services are considered vital to drug courts but are poorly understood. The need for a bridge between criminal justice and health services is discussed, and a conceptual framework for its investigation is presented. Using data collected from site visits of 14 drug courts across the United States and Puerto Rico, the services available to drug court clients are described and linkages between drug courts and health services (including drug treatment providers) are explained. Wenzel, S.L., Longshore, D., Turner, S., and Ridgely, M.S. Journal of Criminal Justice, 29(3), pp. 241-253, 2001.
Risk Adjustment Alternatives in Paying for Behavioral Health Care under Medicaid
The aim of this study was to compare the performance of various risk adjustment models in behavioral health applications such as setting mental health and substance abuse (MH/SA) capitation payments or overall capitation payments for populations including MH/SA users. The 1991-93 administrative data from the Michigan Medicaid program were used. Authors compared mean absolute prediction error for several risk adjustment models and simulated the profits and losses that behavioral health care carve outs and integrated health plans would experience under risk adjustment if they enrolled beneficiaries with a history of MH/SA problems. Models included basic demographic adjustment, Adjusted Diagnostic Groups, Hierarchical Condition Categories, and specifications designed for behavioral health. Differences in predictive ability among risk adjustment models were small and generally insignificant. Specifications based on relatively few MH/SA diagnostic categories did as well as or better than models controlling for additional variables such as medical diagnoses at predicting MH/SA expenditures among adults. Simulation analyses revealed that among both adults and minors considerable scope remained for behavioral health care carve outs to make profits or losses after risk adjustment based on differential enrollment of severely ill patients. Similarly, integrated health plans have strong financial incentives to avoid MH/SA users even after adjustment. Authors concluded that current risk adjustment methodologies do not eliminate the financial incentives for integrated health plans and behavioral health care carve-out plans to avoid high-utilizing patients with psychiatric disorders. Ettner, S.L., Frank, R.G., McGuire, T.G., and Hermann, R.C. Health Serv Res, 36(4), pp. 793-811, 2001.
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