Director's Report to the National Advisory Council on Drug Abuse
May, 2001
Research Findings
Services Research
Persistence of Impaired Functioning and Psychological Distress after Medical Hospitalization for Men with Co-occurring Psychiatric and Substance Use Disorders
The objective of this study was to measure the persistence of impaired health-related quality of life (HRQL) and psychological distress associated with co-occurring psychiatric and substance use disorders in a longitudinal sample of medically hospitalized male veterans. A random sample was followed observationally for 1 year after study enrollment. The study setting included inpatient medical and surgical wards at three university-affiliated Department of Veterans Affairs Medical Centers. Patients/participants comprised a random sample of 1,007 admissions to medical and surgical inpatient services, excluding women and admissions for psychiatric reasons. A subset of participants (n = 736) was designated for longitudinal follow-up assessments at 3 and 12 months after study enrollment. This subset was selected to include all possible participants with study-administered psychiatric diagnoses (52%) frequency-matched by date of study enrollment to approximately equivalent numbers of participants without psychiatric diagnoses (48%). All participants were administered a computerized, structured psychiatric diagnostic interview for 13 psychiatric disorders (including substance use) and received longitudinal assessments at 3 and 12 months on a multidimensional measure of HRQL, the SF-36, and a measure of psychological distress, the Symptom Checklist, 90-item version. On average, HRQL declined and psychological distress increased over time (P < .05). Psychiatric disorders were associated with significantly greater impairments in functioning and increased distress on all measures (P < .001) except physical functioning (p < .05). These results were replicated in the patients (n = 130) who received inpatient or outpatient mental health or substance abuse services. The authors concluded that general medical physicians need to evaluate the mental health status of their hospitalized and seriously ill patients. Effective mental health interventions can be initiated post-hospitalization, either immediately in primary care or through referral to appropriate specialty care, and should improve health functioning over time. Booth, B.M., Blow, F.C., and Cook, C.A.L. Journal of General Internal Medicine 16(1), pp. 57-65, January 2001.
Screening and Intervention for Illicit Drug Abuse - A National Survey of Primary Care Physicians and Psychiatrists
Illicit drug abuse causes much morbidity and mortality, yet little is known about physicians' screening and intervention practices regarding illicit drug abuse. The authors mailed a survey to a national sample of 2,000 practicing general internists, family physicians, obstetricians and gynecologists, and psychiatrists to assess their screening and intervention practices for illicit drug abuse. Of 1,082 respondents (adjusted response rate, 57%), 68% reported that they regularly ask new outpatients about drug use. For diagnosed illicit drug abuse, 55% reported that they routinely offer formal treatment referral, but 15% reported that they do not intervene. In multivariate logistic regression models, more optimal screening and intervention practices were associated with psychiatry specialty, confidence in obtaining the history of drug use, optimism about the effectiveness of therapy, less concern that
patients will object, and fewer perceived time constraints. Most physicians reported that they ask patients about illicit drug use, but a substantial minority inadequately intervene in diagnosed drug abuse. Initiatives to promote physician involvement in illicit drug abuse should include strategies to increase physicians' confidence in managing drug problems, engender optimism about the benefits of treatment, dispel concerns about patients' sensitivity regarding substance use, and address perceived time limitations. Friedmann, P.D., McCullough, D., and Saitz, R. Archives of Internal Medicine, 161(2), pp. 248-251, January 22, 2001.
Linkage to Medical Services in the Drug Abuse Treatment Outcome Study
An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population. The goal of this study was to examine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs. This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview. Program directors' surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment. Exclusive on-site delivery increased medical utilization during the first month of drug abuse treatment (beta estimate, 0.22; standard error [SE], 0.06; P <0.001). Transportation services also increased 1-month medical utilization (beta estimate, 0.13; SE, 0.03; P <0.001). Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment. Friedmann, P.D., Lemon, S.C., Stein, M.D., Etheridge, R.M., and D'Aunno, T.A. Med Care. 39(3), pp. 284-295, 2001.
Telephone Management in Substance Abuse Treatment
The purpose of this article is to describe the results of a clinical trial in which telephonic case management was evaluated as a supplement to substance abuse treatment. An interactive voice response system (IVR) was developed by the research team for use in the case management of randomly assigned participants in a clinical trial research project. The features of the software program facilitated a double caseload for the case manager as well as real-time data capture. At intake, no significant differences were found between participants in the telecommunication condition and the general project. Thus, the effectiveness of random assignment was supported. An IVR was useful for case management services, was less costly, and showed acceptability to clients. A reduction in time expenditure by using telecommunication occurred within three activity areas. Telecommunication facilitated client interaction and the use of case management, and it reduced provider time expenditure. As an alternative strategy, telecommunication ease management can enhance cost effectiveness improvements. Hall, J.A. and Huber, D.L. Telemedicine Journal And E-Health, 6(4), pp. 401-407, 2000.
The Effectiveness of Two Intensities of Psychosocial Treatment for Cocaine Dependence
Structured treatments for cocaine dependence have been shown to be effective despite high attrition rates. What is unclear is what level of treatment intensity is needed to improve and sustain patient outcomes, especially among low SES urban residents. This study evaluated whether there were differences between two levels of treatment intensities for cocaine dependence in reducing substance use and improving health and social indicators. Ninety-four cocaine dependent predominantly African-American male veterans were randomly assigned to either a 12 h/week day hospital program (DH12) or a 6 h/week outpatient program (OP6) and were evaluated at baseline, during treatment and at 4 and 7 months post-treatment. Both treatments stressed abstinence, behavior change and pro-social adjustment and only differed in level of treatment intensity. During-treatment measures included urine toxicologies, program attendance, treatment completion and aftercare attendance. Participants reported a 52% reduction in days of cocaine use and experienced significant improvements in employment and psychiatric functioning at seven months post-treatment. However, there was no significant difference between the DH12 and OP6 programs in terms of abstinence during treatment, treatment completion, treatment or aftercare attendance or any Addiction Severity Index (ASI)-related variable assessing level of functioning at 4 and 7 months. While future research with a larger community-based sample that includes female clients is necessary, the current findings demonstrate that a 6 h/week program is just as effective and thus has a significant cost savings compared to a 12 h/week treatment modality for cocaine dependence. Coviello, D.M., Alterman, A.I., Rutherford, M.J., Cacciola, J.S., McKay, J.R. and Zanis, DA. Drug and Alcohol Dependence, 61(2), pp. 145-154, 2001.
Relapse Outcomes in a Randomized Trial of Residential and Day Drug Abuse Treatment
Relapse outcomes at 6-, 12-, and 18-month intervals were compared between clients randomly assigned to day (n=114) versus residential (n=147) drug abuse treatment. Day clients were more likely than residential clients to relapse 6 months post-admission (OR=3.06, p<0.001); however, no setting differences at 12 or 18 months were found. Few baseline predictors were prospectively related to relapse at 12 and 18 months. These predictors were usual employment status (part-time OR=17.47, p<0.001; full-time OR=2.54, p<0.001), history of drug injecting (OR=5.39, p<0.01), multiple sex partners (OR=1.16, p<0.01), and not having a gay sexual partner (OR=0.05, p<0.03) during 6 months prior to admission. Still, these baseline predictors, together with the existing literature, could be used by drug treatment professionals to identify individuals who may be at high risk for relapse over time, and to offer specialized treatment and aftercare resources as intervention and prevention measures. Greenwood, G.L., Woods, W.J., Guydish, J. and Bein, E. Journal of Substance Abuse Treatment, 20(1), pp. 15-23, 2001.
Therapeutic Communities - Enhancing Retention in Treatment Using "Senior Professor" Staff
Evaluation research documents a firm relationship between retention and treatment outcomes among substance abusers in therapeutic communities (TCs). However, most admissions leave treatment prematurely, particularly in the first months after admission. This paper reports findings from a controlled study that assessed the efficacy of an intervention to reduce early dropout in a residential TC. In the "Senior Professor" (SP) intervention, the most experienced clinical and managerial staff in a TC program were utilized to conduct program induction seminars during the first weeks of admissions, traditionally the period of the highest rate of dropout. Rates of short-term retention (30 days of treatment) were compared for the experimental cohort (N = 362), who received the intervention, and a cohort of admissions (N = 243), who received standard or non-enhanced treatment. The authors showed that the SP intervention significantly reduced the likelihood of early dropout compared with controls. The enhanced effects are most evident for the new inductees with the lowest levels of motivation. Some theoretical and clinical implications are discussed as to the utilization of experienced staff to increase retention among new inductees with relatively lower motivational levels, who are at greatest risk for early dropout. De Leon, G., Hawke, J., Jainchill, N., and Melnick, G. Journal of Substance Abuse Treatment, 19(4), pp. 375-382, 2000.
Twenty-Five Strategies for Improving the Design, Implementation and Analysis of Health Services Research Related to Alcohol and Other Drug Abuse Treatment
While some aspects of addiction can be studied in laboratory or controlled settings, the study of long-term recovery management and the health services that support it requires going out into the community and dealing with populations and systems that are much more diverse and less under our control. This in turn raises many methodological challenges for the health service researchers studying alcohol and other drug abuse treatment. The authors identify some of these challenges related to the design, measurement, implementation and effectiveness of health services research. They then recommend 25 strategies (and key primers) for addressing them: (1) identifying in advance all stakeholders and issues; (2) developing conceptual models of intervention and context; (3) identifying the population to whom the conclusions will be generalized; (4) matching the research design to the question; (5) conducting randomized experiments only when appropriate and necessary; (6) balancing methodological and treatment concerns; (7) prioritizing analysis plans and increasing design sensitivity, (8) combining qualitative and quantitative methods; (9) identifying the four basic types of measures needed; (10) identifying and using standardized measures; (11) carefully balancing measurement selection and modification; (12) developing and evaluating modified and new measures when necessary; (13) identifying and tracking major clinical subgroups; (14) measuring and analyzing the actual pattern of services received; (15) incorporating implementation checks into the design; (16) incorporating baseline measures into the intervention; (17) monitoring implementation and dosage as a form of quality assurance; (18) developing procedures early to facilitate tracking and follow-up of study participants; (19) using more appropriate representations of the actual experiment; (20) using appropriate and sensitive standard deviation terms; (21) partializing out variance due to design or known sources prior to estimating experimental effect sizes; (22) using dimensional, interval and ratio measures to increase sensitivity to change; (23) using path or structural equation models; (24) integrating qualitative and quantitative analysis into reporting; and (25) using quasi-experiments, economic or organizational studies to answer other likely policy questions. Most of these strategies have been tried and tested in this and other areas, but are not widely used. Improving the state of the art of health services research and bridging the gap between research and practice do not depend upon using the most advanced methods, but rather upon using the most appropriate methods. Dennis, M.L., Perl, H.I., Huebner, R.B., and McLellan, A.T. Addiction, 95, S281-S308, Suppl. November 3, 2000.
Sources of Motivation for Abstinence: A Replication Analysis of the Reasons for Quitting Questionnnaire
The Reasons for Quitting Questionnaire (RFQ) as modified by McBride and colleagues (C. M. McBride et al., 1994) for use with substance users other than tobacco smokers, was administered to individuals approved for public-sector addiction treatment. Four motivation dimensions, similar to those found by McBride et al., were identified: self-concept issues, health concerns, legal issues, and social influence. A forced two-component solution yielded dimensions interpretable as intrinsic and extrinsic motivation. Self-concept issues provided the highest levels of motivation for abstinence in this sample, with moderate levels provided by health concerns, and the lowest levels provided by legal and social influence components. Intrinsic motivation was higher than extrinsic motivation. Logistic regression models, with adjustment for total motivation, tested the association of successful abstinence during a follow-up period with baseline extrinsic and intrinsic motivation, and with the difference between intrinsic and extrinsic levels. All three associations were significant: intrinsic motivation (positive association), extrinsic motivation (negative association), and the difference score (positive association). The results suggest the usefulness of the 20-item modified RFQ in evaluating motivation for abstinence among treatment seekers exhibiting severe negative consequences of addiction. Testing with samples varying in severity of addiction consequences is recommended. Downey, L., Rosengren, D.B., and Donovan, D.M. Addictive Behaviors, 26 (1), pp. 79-89, January-February 2001.
Placement Matching: Challenges and Technical Progress
Although it is highly desirable, standardized placement matching for substance use disorders poses challenges due to variability in settings, services, and syndromes; multidimensionality of clinical problems; multiplicity of outcome constructs; and temporal phenomena in the course of recovery. Despite these obstacles, progress is being made in developing patient placement criteria that are comprehensive with adequate reliability, feasibility, and resolution. With these methodological advances, it has been possible to initiate controlled research with placement criteria. The first such studies provide early evidence supporting such criteria and indicate areas for refinement. Gastfriend, D.R., Lu, S.H., and Sharon, E. Substance Use & Misuse 35(12-14), pp. 2191-2213, 2000.
Modeling Year 1 Outcomes with Treatment Process and Post-Treatment Social Influences
Follow-up studies of drug user treatment generally find significant improvements in client functioning, but information about the therapeutic components associated with client behavioral changes over time is limited. An integrative model developed previously to predict treatment retention was expanded and applied to post-treatment outcomes. This study is based on 321 daily opioid users treated in three methadone treatment clinics. Effects of pre-treatment motivation, treatment process measures representing therapeutic relationship, counseling session attendance, and length of treatment are examined in relation to measures of family relations, peer deviancy, return to treatment, drug use, and criminality in the year after treatment. Models were tested in two stages. The first was built on a during-treatment process model for predicting time in treatment to include post-treatment outcomes. The second model was expanded further to include the effects of intervening social support variables as predictors of post-treatment drug and criminality outcomes. The results supported both models and emphasize the importance of considering social influences and related community contextual factors that affect recovery dynamics. Simpson, D.D., Joe, G.W., Greener, J.M., and Rowan-Szal, G.A. Substance Use & Misuse, 35(12-14), pp.1911-1930, October-December 2000.
Drug Abuse Treatment on Demand in San Francisco: Preliminary Findings
This article reports on a process and capacity evaluation of San Francisco's Treatment on Demand Initiative, which was launched in 1997 to increase availability of publicly-funded substance abuse treatment. For the process evaluation, data from public documents, interviews with community key informants, and newspaper articles were analyzed. For the capacity evaluation, budget documents and admissions data for publicly-funded substance abuse treatment in San Francisco for fiscal years 1995-1998 were analyzed. Results from the process evaluation document the development of the community-oriented Treatment on Demand Planning Council, and its efforts to not only expand treatment, but to create a continuum of services to address the needs of San
Francisco's richly diverse communities, to provide service enhancements, and to prioritize service needs. Process evaluation results also highlight the complexities of implementing treatment on demand, including the difficulty of opening new programs. Results from the capacity evaluation indicate that the San Francisco budget supporting publicly-funded treatment increased from $32 million to $45.2 million over four years. During the same period, the number of persons entering the system in a single year increased by 18%, and the number of admissions in a single year increased by 15%. Implications of these findings are discussed. Guydish, J., Moore, L., Gleghorn, A., Davis, T., Sears, E., and Harcourt, J. Journal of Psychoactive Drugs 32 (4), pp. 363-370, October-December 2000.
Adolescent Substance Abuse Treatment Outcome: The Role of Substance Abuse Problem Severity, Psychosocial, and Treatment Factors
A structural equation model incorporating substance abuse problem severity, psychosocial risk and protection, and treatment variables was used to examine adolescent drug abuse treatment outcome pathways across 6- and 12-month follow-up points. Findings on resiliency factors and an empirical method adapted from previous research were used to select and assign 10 psychosocial factors to either a multiple protective factor index or a risk factor index. Gender, substance abuse problem severity, treatment modality, treatment length, and aftercare participation were also examined as outcome predictors. The findings suggest that treatment intensity decisions may be better informed by pretreatment psychosocial risk level rather than by substance abuse problem severity. The present study also suggests that drug-abusing adolescents who receive sufficiently long treatment, participate in aftercare, and possess at least 1 individual or interpersonal protective factor during their recovery process have the best chance to maintain gains made during treatment. Latimer, W.W., Newcomb, M., Winters, K.C., and Stinchfield, R.D. Journal of Consulting and Clinical Psychology, 68(4), pp. 684-696, August 2000.
Demographic, Individual, and Interpersonal Predictors of Adolescent Alcohol and Marijuana Use Following Treatment
A vulnerability model of adolescent substance abuse treatment outcome provided the basis for selection of demographic, individual, interpersonal, and treatment factors to predict the follow-up use of alcohol and marijuana in a sample of adolescents (N = 225) with psychoactive substance use disorders. Pretreatment levels of sibling substance use and aftercare participation predicted alcohol and marijuana use during the first 6 months post treatment. Pretreatment levels of deviant behavior also predicted the use of marijuana at 6-month follow-up. Peer substance use at intake and 6-month post treatment both predicted substance use frequency outcomes at 12-month follow-up. Alcohol and marijuana use frequencies at 6-month follow-up also predicted continued use for these substances throughout the remainder of the 1st post treatment year. Shorter treatment length and being male were risk factors for alcohol use during the 2nd half of the 1st post treatment year. Elevated psychological substance dependence at 6-month follow-up was a unique risk factor for subsequent marijuana use. Findings support conceptual models that attempt to explain adolescent substance abuse treatment outcome in terms of relationships among demographic, individual, interpersonal, and treatment factors. Latimer, W.W., Winters, K.C., Stinchfield, R., and Traver, R.E. Psychology of Addictive Behaviors, 14(2), pp. 162-173, June 2000.
Therapeutic Communities: Diversity in Treatment Elements
The authors address the need to describe the diversity-of therapeutic community (TC) programs. The Survey of Essential Elements Questionnaire (SEEQ) was used to develop a typology of TC programs based on 19 programs that identified themselves as traditional or modified TCs in the Drug Abuse Treatment Outcome Studies (DATOS). These traditional and modified TCs differed in adherence to the elements of TC treatment, on operational characteristics, and in client mix. Differences in treatment philosophy and approach included the emphasis on self-reliance and the use of work as a therapeutic agent for traditional TCs. There were also trends for traditional TC programs to utilize community-as-method, provide educational and vocational training, and include family members as part of therapy. Modified programs showed a greater tendency to rely on counselors. Implications of the findings for program quality, health care policy, and research are discussed. Melnick, G., De Leon, G., Hiller, M.L., and Knight, K. Substance Use & Misuse, 35(12-14), pp. 1819-1847, 2000.
Program Factors and Treatment Outcomes in Drug Dependence Treatment: An Examination Using Meta-Analysis
In comparison with studies of client characteristics and treatment processes, limited research has been conducted on how program features of drug dependence treatment programs may affect client outcomes. Of particular interest are those characteristics of programs that may have a clinically significant impact on outcomes and that are amenable to change within programs. The authors examine the impact of various program factors on client outcomes using data from a meta-analysis of drug dependence effectiveness studies (n = 143). Because of heterogeneity among studies, the data are analyzed in terms of type of outcome variable (drug use and crime), type of design (single-group and treatment-comparison group), and type of treatment (methadone maintenance, therapeutic communities, outpatient drug free, and detoxification). For the more valid treatment-comparison group studies, the weighted mean effect size was 0.29 for drug use outcomes and 0.17 for crime outcomes. Program factors found to be significantly correlated with effect size in one or more modalities were decade of treatment, researcher involvement in treatment delivery, maturity of the program, counselor/client ratio, treatment implementation, treatment exposure, and methadone dosage. Prendergast, M.L., Podus, D., and Chang, E. Substance Use & Misuse, 35(12-14), pp. 1931-1965, 2000.
Social Relationships of Crime-Involved Women Cocaine Users
Social relationships play a significant role in drug use and recovery, perhaps especially for women. Research on social relationships among crime-involved women drug users is reviewed, including both well established findings and more recent topics of inquiry. Several open questions about social relationships of women drug users are then examined in data from a study conducted in the Miami (Florida) metropolitan area in 1994-1996. For a study of barriers to drug treatment for crime-involved women cocaine users, over 400 women were interviewed in treatment programs and an equal number were recruited on the street. Respondents were asked about their social relationships during the last 30 days on the street in regard to both legal and illegal activities. This included crime partnerships, help obtaining cocaine, living arrangements, help with living expenses, children and help with child care, help with several ordinary problems, and pressures to enter treatment. The analysis looks at how much social support crime-involved women cocaine users have in their ordinary daily activities and who provides this support. Pottieger, A.E., and Tressell, P.A. Journal of Psychoactive Drugs, 32(4), pp. 445-460, October-December 2000.
The Impact of Women's Family Status on Completion of Substance Abuse Treatment
This study examines the role of family status and demographic characteristics in explaining the nearly 60% dropout rate for women in substance abuse treatment. Data from the administrative record files of the Illinois Office of Alcoholism and Substance Abuse (OASA) for the fiscal year 1996-1997 were analyzed for women age 12 or older who completed intake for publicly funded substance abuse treatment and whose outpatient treatment records were closed at year-end. Multivariate logistic regression models found that the likelihood of not completing treatment was greatest for women who were African American, pregnant, had custody of minor children, or were younger than age 21. However, African American women who had children in foster care were more likely to complete treatment. Implications for treatment and research are discussed. Scott-Lennox, J., Rose, R., Bohlig, A., and Lennox, R. J Behav Health Serv Res, 27(4), pp. 366-379, November 2000.
The Relationship Between the Quality of Drug User Treatment and Program Completion: Understanding the Perceptions of Women in a Prison-based Program
To determine why some women offenders complete prison-based drug user treatment and others leave early, clients' (N = 101) perceptions of various aspects of the quality of the treatment experience were compared. Analyses of both quantitative and qualitative data indicate that clients who completed the program had a more favorable perception of staff and felt empowered by the experience in treatment. Most of the clients who left early did so because of conflicts or disagreements with the program's rules. We discuss how a supportive approach to personal development may enhance client perceptions of program quality and increase retention rates. Strauss, S.M., and Falkin, G.P. Substance Use & Misuse, 35(12-14), pp. 2127-2159, October-December 2000.
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