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CORK Bibliography: Aftercare

89 citations. 2003 to present

Prepared: March 2008

Alemi F; Haack MR; Nemes S; Aughburns R; Sinkule J; Neuhauser D. Therapeutic emails. Substance Abuse Treatment, Prevention, and Policy 2: article 7, 2007. (40 refs.)

Background: In this paper, we show how counselors and psychologists can use emails for online management of substance abusers, including the anatomy and content of emails that clinicians should send substance abusers. Some investigators have attempted to determine if providing mental health services online is an efficacious delivery of treatment. The question of efficacy is an empirical issue that cannot be settled unless we are explicitly clear about the content and nature of online treatment. We believe that it is not the communications via internet that matters, but the content of these communications. The purpose of this paper is to provide the content of our online counseling services so others can duplicate the work and investigate its efficacy. Results: We have managed nearly 300 clients online for recovery from substance abuse. Treatment included individual counseling (motivational interviewing, cognitive-behavior therapy, relapse prevention assignments), participation in an electronic support group and the development of a recovery team. Our findings of success with these interventions are reported elsewhere. Our experience has led to development of a protocol of care that is described more fully in this paper. This protocol is based on stages of change and relapse prevention theories and follows a Motivational Interviewing method of counseling. Conclusion: The use of electronic media in providing mental health treatment remains controversial due to concerns about confidentiality, security and legal considerations. More research is needed to validate and generalize the use of online treatment for mental health problems. If researchers have to build on each others work, it is paramount that we share our protocols of care, as we have done in this paper.

Alvarez J; Adebanjo AM; Davidson MK; Jason LA; Davis MI. Oxford House: Deaf-affirmative support for substance abuse recovery. American Annals of the Deaf 151(4): 418-422, 2006. (18 refs.)

Deaf individuals seeking substance abuse recovery are less likely to have access to treatment and aftercare services because of a lack of culturally and linguistically specific programs and insufficient information about existing services. Previous research indicates that Oxford House, a network of resident-run recovery homes, serves a diverse group of individuals in recovery. However, research has not addressed the experiences of Deaf Oxford House residents. The present study found no significant differences between Deaf and hearing men living in Oxford House in terms of sense of community and abstinence self-efficacy. However, while most of the hearing participants were employed, none of the deaf Oxford House members were. The study's findings indicate that Oxford House may be a promising deaf-affirmative alternative for individuals seeking recovery from substance abuse. However, since Oxford Houses are self-supporting, Oxford Houses designed for the deaf community may face unique economic challenges.

Babor TF; Steinberg K; Zweben A; Cisler R; Stout R; Tonigan JS et al. Treatment effects across multiple dimensions of outcome. IN: Babor TF; Del Boca FK, eds. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 150-165. (275 book refs.)

The associations between treatments studied in Project MATCH (Cognitive Behavioral therapy (CBT), Motivation Enhancement Therapy (MET), and Twelve Step Facilitation (TSF)) and changes in measures of drinking as well as improvements in psychological, physical, and social functioning are discussed. The findings indicate improvement in outcome status from baseline to follow-up on all measures. For continuous abstinence, a consistent treatment effect favoring Twelve Step Facilitation (TSF) was seen. Outpatient and Aftercare participants showed large improvements in different life areas that were maintained throughout the entire follow-up period. Greater reductions in drinking seem to forecast improvements in other life areas, suggesting an overall consolidation of treatment benefits that extends beyond a narrow focus on drinking reductions alone. Section heads in this chapter include: (1) alternative measures of drinking behavior; (2) secondary outcome measures; (3) interrelatedness of secondary outcome measures; (4) relation between posttreatment drinking and secondary outcome measures; (5) effects of treatment; (6) differences between Outpatient and Aftercare groups. Cross-sectional correlation between primary measures of drinking (percent days abstinent and drinks per drinking day) and seven secondary outcome measures according to study arm and gender are presented in table format.

Public Domain

Bamford Z; Booth PG; Mcguire J; Salmon P. Maximizing patient follow-up after alcohol treatment: The effect of a three-step reminding system on response rates. Journal of Substance Use 9(1): 36-43, 2004. (16 refs.)

Background: Longitudinal research has many strengths, but is often compromised by attrition of participants. This is a particular problem in studies with 'difficult-to-reach' populations. Recommended techniques for maximizing retention are often impractical for routine clinical services. Aims: To examine whether methods that are available in routine practice can achieve satisfactory follow-up of a cohort of patients, 11 months after assessment for alcohol treatment. Methods: Using a longitudinal cohort design, we tested the incremental effect of a simple three-step approach with 124 consecutive patients seeking treatment for alcohol problems: first an interview appointment, then postal questionnaires and, finally, a reminder by telephone or letter. Data on treatment compliance and self-reports of drinking behaviour during the 11-month follow-up period were obtained. Results: Stage of contact was significantly associated with treatment compliance and treatment outcome. The final telephone reminder proved to be an important step in obtaining a sample that more accurately reflected both the treatment attendance and outcome of the original cohort. Conclusions: Intensive resources, contact with multiple agencies and financial incentives were not necessary to achieve a contact rate of 75% and successful follow-up of 67%. Alcohol treatment outcome research is feasible within services with limited time and resources.

Bennett GA; Withers J; Thomas PW; Higgins DW; Bailey J; Parry L; Davies E. A randomised trial of early warning signs relapse prevention training in the treatment of alcohol dependence. Addictive Behaviors 30(6): 1111-1124, 2005. (19 refs.)

A pragmatic randomised trial examined the effects of Early Warning Signs Relapse Prevention Training (EWSRPT) on drinking in alcohol dependent persons with history of relapse. Participants were 124 abstinent alcohol dependent patients with a history of relapse (median five relapses) who entered the trial as they completed a 6-week day treatment programme. They were randomly allocated to receive either (1) Aftercare as Usual (AU) or (2) AU plus 15 individual sessions of EWSRPT using Gorski's protocol. Assessment carried out at entry to the trial, and 4, 8, and 12 months later, included self-report of drinking, blood tests (gamma glutamyl transferase, GGT; serum alanine aminotransferase, ALT) and measures of functioning (Alcohol Problems Questionnaire, APQ; SF36, Brief Symptom Inventory, BSI; Assessment of Warning-signs of Relapse, AWARE). Intention to treat analysis found no significant differences in continuous abstinence during the follow-up year (17% of 58 AU, 31% of 58 EWSRPT, p=0.08). The EWSRPT participants had a significantly lower probability of drinking heavily (74% of AU, 55% of EWSRPT, p=0.04), and significantly fewer days drinking (p=0.05) and heavy drinking (p=0.04). These clinically worthwhile effects for a relapse-prone group justify further research into EWSRPT.

Berglund M. A better widget? Three lessons for improving addiction treatment from a meta-analytical study. Addiction 100(6): 742-750, 2005. (67 refs.)

Objective: To discuss how to develop more effective treatment programmes than those currently available for addictive disorders. Data sources: The Swedish SBU report, published in English in 2003, was used as a database. It includes 641 randomized controlled trials and seven longitudinal prospective studies. Methods: Meta-analytical calculations were performed in several areas using standardized mean differences (d) effect-size estimate and homogeneity testing. Three critical issues have been the focus of the present analysis: the early intervention phase, treatment procedures and their additive properties and the transitional period between early and late effects of treatment. Results: The main findings while integrating the results in a new way were that intervention studies with one single session showed a small but robust homogeneous effect size, whereas studies of interventions with several sessions were heterogeneous with large and small effect sizes among the included studies. Similar effect sizes were found in alcohol, opioid and cocaine treatment studies. Agonist treatment yielded the highest effect sizes. Some evidence was found for a possible additive effect for cognitive behaviour therapy and naltrexone as well as for aversive treatment (disulfiram) and psychosocial treatment in alcohol dependence. So far studies on the transition period between short- and long-term outcome are few and inconclusive. Conclusions: There is a prospect of improving addiction treatment, and the following areas are suggested by meta-analysis for future research: (a) to examine in more detail the process between the first and second session of intervention; (b) to randomize simultaneously for independent categories of psychosocial and psychopharmacological treatment; and (c) to intensify studies on the transitional period between short- and long-term outcome.

Beynon CM; Bellis MA; McVeigh J. Trends in drop out, drug free discharge and rates of re-presentation: A retrospective cohort study of drug treatment clients in the North West of England. BMC Public Health 6(article 205), 2006. (37 refs.)

Background: Governments aim to increase treatment participation by problematic drug users. In the UK this has been achieved by fiscal investment, an expanded workforce, reduced waiting times and coercive measures (usually criminal justice) led). No assessment of these measures on treatment outcomes has been made. Using established monitoring systems we assessed trends in 'dropped out' and 'discharged drug free' (DDF), since the launch of the national drug strategy, and rates of treatment re-presentation for these cohorts. Methods: A longitudinal dataset of drug users (1997 to 2004/05, n = 26,415) was used to identify people who dropped out of, and were discharged drug free from, services for years 1998 to 2001/02, and representations of these people in years to 2004/05. Trends in drop out and discharged drug free, baseline comparisons of those discharged drug free and those who dropped out and outcome comparisons for those referred from the criminal justice system versus other routes of referral were examined using chi square. Logistic regression analyses identified variables predicting drop out versus discharged drug free' and subsequent representation versus no re-presentation. Results: The proportion of individuals dropping out has increased from 7.2% in 1998 to 9.6% in 2001/02 (P < 0.001). The proportion discharged drug free has fallen from 5.8% to 3.5% (P < 0.001). Drop out was more likely in later years, by those of younger age and by criminal justice referrals. The proportion re-presenting to treatment in the following year increased from 27.8% in 1998 to 44.5% in 2001/02 (P < 0.001) for those discharged drug free', and from 22.9% to 48.6% (P < 0.001) for those who dropped out. Older age and prior treatment experience predicted re-presentation. Outcome ( drop out or discharged drug free') did not predict re-presentation. Conclusion: Increasing numbers in treatment is associated with an increased proportion dropping out and an ever-smaller proportion discharged drug free. Rates of drop out are significantly higher for those coerced into treatment via the criminal justice system. Rates of re-presentation are similar for those dropping out and those discharged drug free'. Encouragingly, those who need to re-engage with treatment, particularly those who drop out, are doing so more quickly. The impact of coercion on treatment outcomes and the appropriateness of aftercare provision require further consideration.

Blondell, RD; Smith SJ; Canfield MC; Servoss TJ. Abstinence and initiation of treatment following inpatient detoxification. American Journal on Addictions 15(6): 462-467, 2006

This prospective cohort study compared in-patients who remained abstinent and initiated aftercare treatment following detoxification with those who did not. Of 110 patients enrolled, 58% (46/79) were totally abstinent and 72% (67/93) initiated treatment during the first 30 days following hospital discharge. Patients who relapsed after hospital discharge were more likely than those who remained abstinent to have a primary drug-use disorder (p = 0.05), prior mental health treatment (p = .007), or previous incarceration (p = 0.035). Those who initiated aftercare treatment were less likely to have had prior mental health treatment than those who did not (p = .046).

Blume AW. Treating Drug Problems. Hoboen NJ: Wiley, 2005. (96 book refs.)

This volume is part of a series on Treating Addictions that is directed to health care and mental health workers as well as interested lay people. The book is organized into eight chapters. Chapter 1 provides an overview of drug problems, addressing its prevalence, common features of drug problems, and different pathways, and addresses issues such as abuse versus dependence, psychological versus physical dependence, and transient versus chronic problems. It also considers risk factors, and epidemiology. Chapter 2 "recognizing a drug problem" speaks to what family may encounter, what coworkers may observe, and what may bring someone to the attention of a professional. Chapter 3 is directed to mobilizing care for the individual, and discusses referrals, motivating change, and dealing with crises. Chapter 4 turns to the issue of formal treatment and focuses upon treatment planning, assessment in multiple domains, family involvement. Chapter 5 addressing "recovery tools" discuses different clinical approaches, cognitive-modification strategies, the use of support groups, the treatment of psychiatric co-morbidity. Chapter 6 deals with continuing care, the stages of recover, models of aftercare and resources. Chapters 7 and 8 focus upon management of recovery, relapse prevention tools and strategies and family involvement.

Bodin MC; Romelsjo A. Predictors of 2-year drinking outcomes in a Swedish treatment sample. European Addiction Research 13(3): 136-143, 2007. (50 refs.)

Background: Few studies have investigated predictors of short- and longer-term outcomes in relatively well functioning treatment samples. Methods: Multivariate logistic regression analyses were used to identify predictors of continuous abstinence in 188 individuals during their 2nd year after private 12-step treatment in Sweden, and findings are related to a previous report on 1-year outcomes. Results: Individual baseline characteristics were not directly related to 2nd year outcomes, while a higher 1st-year drinking severity decreased the likelihood of 2nd-year abstinence. Satisfaction with treatment and affiliation with Alcoholics Anonymous, but not program aftercare during the 1st year increased the likelihood of 2nd-year abstinence. Conclusion: Results are consistent with previous studies showing that shorter-term outcomes are likely to be maintained, and that baseline characteristics and treatment factors account less for outcomes over longer terms.

Bodin MC; Romelsjo A. Predictors of abstinence and nonproblem drinking after 12-step treatment in Sweden. Journal of Studies on Alcohol 67(1): 139-146, 2006. (31 refs.)

Objective: The aims of this study were to identify individual predictors of 12 months continuous abstinence and nonproblem drinking after Swedish inpatient Minnesota Model treatment and to evaluate the outcome variance explained by pretreatment, within-treatment, and posttreatment factors for each outcome, separately and in conjunction. Method: One-hundred and twenty-nine men and 47 women were interviewed on admission to Swedish Minnesota Model treatment and after 12 months. Two interviewers who were not involved in treatment delivery performed structured interviews. Statistical analyses included bivariate and multivariate logistic regression models applied to pair-wise contrasts of three types of treatment outcome. Results: The final multivariate models for the three pair-wise contrasts explained 71% (abstinence vs problem drinking), 44% (nonproblem drinking vs problem drinking), and 25% (abstinence vs nonproblem drinking) of outcome variance. Abstention and nonproblem drinking were both differentiated from problem drinking by the completion of aftercare, satisfaction with treatment, and number of public addiction care contacts. When contrasted with nonproblem drinking, abstention was predicted by the endorsement of a baseline goal to stop drinking and a higher degree of posttreatment affiliation with mutual-help groups. Conclusions: Results from this study support the fact that treatment is only one of many factors that contributes to an outcome and suggests issues that may need consideration in similar treatment settings.

Brown BS; O'Grady K; Battjes RJ; Farrell EV. Factors associated with treatment outcomes in an aftercare population. American Journal on Addictions 13(5): 447-460, 2004. (61 refs.)

This study examined six-month outcomes for 194 criminal justice clients exiting outpatient drug-free treatment and assigned to aftercare or standard treatment. It compared sub-samples of those achieving positive (n = 111) and negative outcomes (n = 59), as defined by drug and alcohol use and arrests. Psychologyogical variables and attendance at religious services distinguished significantly between groups. Predictor variables developed from that comparison were employed in logistic regression analyses making use of the full sample. Aftercare was found to be particularly significant for reduction in drug use, with optimism/pessimism about one's future and religious observance also significant predictors for substance use.

Brown NK. Relapsing, running, and relieving: A model for high-risk behavior in recovery. Journal of Addictions Nursing 14(1): 11-17, 2003. (21 refs.)

This research paper reports on a qualitative, grounded theory study of 30 women's progress toward recovery. It identifies processes of "relapsing," "running," and "relieving" and organizes them into an integrated model for high-risk behavior for women in recovery. The model explores high-risk behavior through the dimensions of internality and externality and finds that the process of recovery for women is not linear. The development of this model is important in helping women at various points in the recovery process; alerting these women to issues that they may not completely understand; and giving treatment professionals a strengths-based perspective from which to examine this phenomenon.

Burdon WM; Dang J; Prendergast ML; Messina NP; Farabee D. Differential effectiveness of residential versus outpatient aftercare for parolees from prison-based therapeutic community treatment programs. Substance Abuse Treatment, Prevention, and Policy 2: article 16, 2007. (45 refs.)

Background: Research has indicated that more intense treatment is associated with better outcomes among clients who are appropriately matched to treatment intensity level based on the severity of their drug/alcohol problem. This study examined the differential effectiveness of community-based residential and outpatient treatment attended by male and female drug-involved parolees from prison-based therapeutic community substance abuse treatment programs based on the severity of their drug/alcohol problems. Methods: Subjects were 4,165 male and female parolees who received prison-based therapeutic community substance abuse treatment and who subsequently participated in only outpatient or only residential treatment following release from prison. The dependent variable of interest was return to prison within 12 months. The primary independent variables of interest were alcohol/drug problem severity (low, high) and type of aftercare (residential, outpatient). Chi-square analyses were conducted to examine the differences in 12-month RTP rates between and within the two groups of parolees (residential and outpatient parolees) based on alcohol/drug problem severity (low severity, high severity). Logistic regression analyses were performed to determine if aftercare modality (outpatient only vs. residential only) was a significant predictor of 12-month RTP rates for subjects who were classified as low severity versus those who were classified as high severity. Results: Subjects benefited equally from outpatient and residential aftercare, regardless of the severity of their drug/alcohol problem. Conclusion: As states and the federal prison system further expand prison-based treatment services, the demand and supply of aftercare treatment services will also increase. As this occurs, systems and policies governing the transitioning of individuals from prison- to community-based treatment should include a systematic and validated assessment of post-prison treatment needs and a valid and reliable means to assess the quality of community-based treatment services. They should also ensure that parolees experience a truly uninterrupted continuum of care through appropriate recognition of progress made in prison-based treatment.

Burleson JA; Kaminer Y. Aftercare for adolescent alcohol use disorder: Feasibility and acceptability of a phone intervention. American Journal on Addictions 16(3): 202-205, 2007. (23 refs.)

A lack of continuity of care for adolescents with alcohol and other substance use disorders (AOSUD) is common. The objectives of this brief report are to present the rationale for the use of manualized, individual brief therapeutic phone contacts (IBTPC) integrating motivational interviewing and cognitive behavioral therapies for aftercare in youth with AOSUD; and report the results and discuss the implications of a study on the feasibility and acceptability of IBTPC in youths with AOSUD. Four therapists and forty-three adolescents who completed IBTPC responded to a questionnaire concerning the acceptability, feasibility, and confidentiality of the IBTPC. In general, both subjects and therapists were positively consistent in their endorsement of the common items. In conclusion, aftercare for adolescents with AOSUD utilizing a brief phone intervention is perceived as feasible and acceptable.

Carter RE; Haynes LF; Back SE; Herrin AE; Brady KT; Leimberger JD. Improving the transition from residential to outpatient addiction treatment: Gender differences in response to supportive telephone calls. American Journal of Drug and Alcohol Abuse 34(1): 47-59, 2008. (23 refs.)

Substance use relapse rates are often high in the first months after discharge from inpatient substance abuse treatment, and patient adherence to aftercare plans is often low. Four residential addiction treatment centers participated in a feasibility study designed to estimate the efficacy of a post-discharge telephone intervention intended to encourage compliance with aftercare. A total of 282 participants (100 women, 182 men) with substance use disorders were included in this secondary analysis. The findings revealed that women were more likely than men to attend aftercare. This "gender effect" persisted after adjustment for a number of potential mediators.

Chong J; Herman-Stahl M. Substance abuse treatment outcomes among American Indians in the Telephone Aftercare Project. Journal of Psychoactive Drugs 35(1): 71-77, 2003. (34 refs.)

Thirty American Indians who had successfully completed their residential substance abuse treatment program with Phoenix-based Native American Connections, Inc. agreed to participate in the Telephone Aftercare Program when they returned to their homes on the reservation. They were provided with graduated monthly aftercare contacts through the telephone for a nominal period of six months, during which time they were interviewed monthly regarding their substance use, and on other life domains at three and six months following discharge from their residential program. Using their baseline data as the comparison, results suggest that six months following residential treatment, clients showed decreased drinking and other drug use, had fewer encounters with the criminal justice system, and had improved familial and social interactions and relationships.

Claus RE; Orwin RG; Kissin W; Krupski A; Campbell K; Stark K. Does gender-specific substance abuse treatment for women promote continuity of care? Journal of Substance Abuse Treatment 32(1): 27-39, 2007. (68 refs.)

Research has stressed the value of providing specialized services to women and suggests the importance of treatment duration. This quasi-experimental retrospective study reports on the continuity of care for women with children who were admitted to long-term residential substance abuse treatment. Women were admitted to 7 agencies offering specialized, women's only treatment (SP, n = 747) or to 9 agencies that provided standard mixed-gender treatment (ST, n = 823). Client and treatment data were gathered from administrative sources. We hypothesized that women in specialized treatment would demonstrate higher continuing care rates after controlling for treatment completion and length of stay. Women in SP programs (37%) were more likely than those in ST programs (14%) to continue care. Multivariate analyses revealed that SP clients who completed treatment with longer stays were most likely to continue care. The findings show that specialized treatment for women promotes continuing care and demonstrate the importance of treatment completion.

2007, Elsevier Science

Cochrane Tobacco Addiction Group; Stead LF; Lancaster T; Perera R. Telephone counselling for smoking cessation. (Cochrane Review). IN: Cochrane Library, Volume 1. Update Software: Oxford, 2003. (89 refs.)

Background: Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines. Objectives: To evaluate the effect of proactive and reactive telephone support to help smokers quit. Search strategy: We searched the Cochrane Tobacco Addiction Group trials register for studies using free text term 'telephone*' or the keywords 'telephone counselling' or 'Hotlines' or 'Telephone'. Date of the most recent search: September 2002. Selection criteria: Randomised or quasi-randomised controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters. Data collection and analysis: Trials were identified and data extracted by one person and checked by a second. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Participants lost to follow-up were considered to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention as the control group in the primary analysis. Where interventions were similar, we performed meta-analysis using a fixed effects model (Peto method) to give an odds ratio. Main results: Twenty seven trials met inclusion criteria. Thirteen trials compared proactive counselling to a minimal intervention control. There was statistical heterogeneity, with five trials showing a significant benefit, and eight showing non significant differences. The heterogeneity was associated with trials that provided tailored self-help materials to the control group. Meta-analysis using all less intensive intervention arms as the control removed the heterogeneity and suggests that telephone counselling compared to less intensive intervention increases quit rates (OR 1.56, 1.38 - 1.77). Four trials adding telephone support to a face to face intervention control failed to detect a significant effect on long term quit rates. Four trials failed to detect an additional effect of telephone support in users of nicotine replacement therapy. Providing access to a hotline showed a significant benefit in one trial and no significant difference in two. No differences in outcome were detected in trials that compared different types of telephone counselling. Conclusions: Proactive telephone counselling can be effective compared to an intervention without personal contact. Successful interventions generally involve multiple contacts timed around a quit attempt. The available evidence neither confirms nor rules out a benefit of telephone counselling as an adjunct to face to face counselling or pharmacotherapy. Further trials randomising access to helplines are unlikely to be done but indirect evidence suggests they can be a useful part of a smoking cessation service.

Copeland AL; Martin PD; Geiselman PJ; Rash CJ; Kendzor DE. Smoking cessation for weight-concerned women: Group vs. individually tailored, dietary, and weight-control follow-up sessions. Addictive Behaviors 31(1): 115-127, 2006. (44 refs.)

Postcessation weight gain is of concern to many female cigarette smokers. A multidisciplinary treatment combining psychological, dietary, and exercise components followed a 2-week smoking cessation program. Participants were randomly assigned to receive six follow-up relapse prevention sessions (in a group format or in an individually tailored format) directed by trained representatives from clinical psychology, dietary counseling, and exercise physiology. As predicted, abstinence rates were significantly higher among the individually tailored follow-up participants than among those assigned to the group follow-up condition at 3 and 6 months posttreatment. Differences between conditions in postcessation weight gain were not significant. However, the postcessation weight gain that did occur was significantly associated with subsequent smoking relapse in the group follow-up condition only.

Dasinger LK; Shane PA; Martinovich Z. Assessing the effectiveness of community-based substance abuse treatment for adolescents. Journal of Psychoactive Drugs 36(1): 27-33, 2004. (25 refs.)

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

Davis TM; Baer JS; Saxon AJ; Kivlahan DR. Brief motivational feedback improves post-incarceration treatment contact among veterans with substance use disorders. Drug and Alcohol Dependence 69(2): 197-203, 2003. (69 refs.)

Objectives: To test the efficacy of providing brief motivational feedback to increase post-incarceration substance use disorders (SUD) treatment contact. Design: Randomized clinical trial (feedback vs. control) with a 2-month post-incarceration follow-up. Participants: Veterans (N = 73) incarcerated in a county jail system who met SUD diagnostic criteria. Measures: Baseline assessment included the Addiction Severity Index, the Form-90 assessment of recent alcohol use, and a DSM-IV SUD criteria checklist. The primary outcome was Veterans Adminstration (VA) appointments. Secondary outcomes were the Addiction Severity Index-Followup and the Treatment Services Review. Intervention: All participants received baseline assessment. The feedback condition received personalized feedback and encouragement to explore ambivalence about change and treatment in a single interview. Results: Participants receiving feedback were more likely to schedule appointments at a VA addictions clinic within 60 days of their jail release dates (67 vs. 41%; P <0.03). Though differences were not statistically significant, more feedback participants attended addictions clinic appointments (47 vs. 32%; ns) and were retained in addictions treatment at 90 days (31 vs. 14%; P < 0.08). Treatment appointments were more likely when intervention occurred close to release. Loss of participants to post-release follow-up interviews was > 50%, limiting power to detect significant differences by self-report. Conclusion: Brief motivational feedback shows promise as a way to link incarcerated individuals to SUD treatment services.

Davison JW; Sweeney ML; Bush KR; Correale TMD; Calsyn DA; Reoux JP et al. Outpatient treatment engagement and abstinence rates following inpatient opioid detoxification. Journal of Addictive Diseases 25(4): 27-35, 2006. (31 refs.)

Many patients with chronic opioid dependence are referred to drug-free outpatient treatment following inpatient detoxification even though successful outpatient treatment engagement and abstinence from opioids occur only in a minority of cases. This retrospective cohort analysis of medical records documents the post-discharge outcome in a treatment setting that maximizes the support during transition to abstinence-oriented outpatient care, with comprehensive social, medical and mental health services, including the availability of naltrexone. Participants were male veterans (N = 112) admitted at an urban VA medical center. Most patients (78%) successfully completed acute detoxification, 49% initiated naltrexone, and 76% accepted a VA aftercare plan. At 90-day follow-up, only 22% remained in aftercare, and < 3% had toxicology-verified abstinence from opioids. At one-year follow-up, 1 out of 5 had been readmitted for detoxification and 4.5% had died. Most patients successfully detoxified from opioids, but very few remained engaged and stabilized in abstinence-oriented outpatient treatment.

Dumaine ML. Meta-analysis of interventions with co-occurring disorders of severe mental illness and substance abuse: Implications for social work practice. Research on Social Work Practice 13(2): 142-165, 2003

A quantitative analysis of 15 empirical studies is conducted to determine effective interventions with the dually diagnosed. Client and practitioner characteristics, types of interventions, and treatment effectiveness are examined through meta-analytic techniques. Age of client was positively correlated with effect size. There were no statistically significant correlations between practitioner training or practitioner-to-client ratio and effect size. Intensive case management was associated with the greatest effect size, and a small positive effect size was found for standard aftercare with outpatient psychoeducational treatment groups. Social work practice implications, based on the results of the quantitative analysis and trends identified in the studies, are that there is a unique role for practitioners in advocating for linkage of resources, additional supports for clients, and the dismantling of barriers that impede resource access.

Duroy TH; Schmidt SL; Perry PD. Adolescents' and young adults' perspectives on a continuum of care in a three year drug treatment program. Journal of Drug Issues 33(4): 801-832, 2003. (12 refs.)

Recent discussion in the adolescent treatment community has centered on the therapeutic merits of continuum of care treatment for adolescent and young adult substance abusing populations. However, despite this discussion, few studies to date have actually looked at how adolescents and young adults view continuum of care treatment in practice. In this paper a continuum of care offered within a single treatment approach will be addressed from the perspectives of youths participating in treatment at a three year step-down therapeutic community program with four distinct levels of care: residential treatment, intensive day treatment, day treatment with work/school release, and ambulatory meetings. Adolescents and young adults attending this program must complete all four levels of care before they are eligible for program graduation. Data from 53 qualitative semistructured and open-ended interviews (conducted with 45 adolescents and young adults) indicate that treatment experiences were marked by significant program transition points, during which clients stepped down from one level of care to another. Adolescents and young adults reported experiencing distress at and during these transition points. However they also indicated that overall emotional and psychological stress was minimized due to the following: (1) these transitions were experienced within a single program structure, (2) youths transitioned through a continuum of care with program peers and friends, and (3) the program staff was perceived by adolescents and young adults to be compassionate and encouraging.

Ellis B; Bernichon T; Yu P; Roberts T; Herrell JM. Effect of social support on substance abuse relapse in a residential treatment setting for women. Evaluation and Program Planning 27(2): 213-221, 2004. (27 refs.)

This study looked at the influence of family functioning, activities of friends, and substance abuse by spouses or significant others on women's substance abuse relapse within 6 months following residential treatment. Data were from the Center for Substance Abuse Treatment's national cross-site evaluation of 6-month residential treatment programs for women with children and pregnant/postpartum women (RWC/PPW). At treatment admission 1758 RWC/PPW clients were interviewed, and 1181 were followed up 6 months after discharge from treatment. Relapse was defined as any use of alcohol or drugs other than nicotine. Positive activities such as families getting along and helping each other during the post-discharge period significantly decreased the likelihood of relapse, while negative activities such as family fights and drug use or criminal activity by friends increased the likelihood of relapse. Post-discharge alcohol and other drug abuse by spouses or significant others also significantly increased the likelihood of relapse.

Etter JF; Laszlo E. Postintervention effect of nicotine replacement therapy for smoking reduction: A randomized trial with a 5-year follow-up. Journal of Clinical Psychopharmacology 27(2): 151-155, 2007. (17 refs.)

We tested whether a reduction of cigarette consumption obtained after 6 months of nicotine replacement therapy was maintained 5 years after the end of this treatment. Heavy smokers (mean = 30 cigarettes per day) who had no intention of quitting smoking were randomly assigned to a 6-month treatment of nicotine (15-mg patch, 4-mg gum, and/or 10-mg inhaler, n = 265), placebo (n = 269), or no intervention (n = 389). Products were sent by mail, and education was limited to a booklet. Of 923 participants, 879 (95%) were followed after 6 months and 671 (73%) after 5 years. After 6 months, smoking reduction was larger for nicotine (-10.9 cigarettes per day) than for placebo (-8.7) and no treatment (-4.9, all P <= 0.022). After 5 years, cigarette consumption (20 cigarettes per day, all P >= 0.2) and smoking cessation rates (17% to 21%, all P > 0.2) were similar in all groups. In smokers, 5-year continuous abstinence was higher in those who had reduced their cigarette consumption by at least 50% between baseline and 6 months than in those who did not reduce (11.9% vs 5.6%; P = 0.011; odds ratio, 2.3; 95% confidence interval, 1.2-4.2). Thus, the initial effect of the treatment on smoking reduction was not maintained after 5 years. However, reducing cigarette consumption was associated with a higher chance of subsequently quitting smoking. Nicotine replacement therapy in unmotivated smokers had no deleterious effect on dependence levels and smoking behavior.

Fenster J. Characteristics of clinicians likely to refer clients to 12-Step programs versus a diversity of post-treatment options. Drug and Alcohol Dependence 83(3): 238-246, 2006. (30 refs.)

Most clients in substance abuse treatment are referred for continuing care. However, post-treatment services vary widely in their approaches to helping individuals achieve better substance use outcomes. This study examined the attitudes of outpatient treatment staff who refer clients exclusively to 12-Step groups (12-Step subgroup) and staff who refer clients both to 12-Step groups and to other continuing care options (Diversity subgroup) toward seven mutual-aid and professional psychosocial post-treatment options: Twelve-Step Programs (12-Step), Cognitive-Behavioral Therapy (CBT), Moderation Management (MM), Smart Recovery� (SMART), Psychodynamic-oriented Therapy (PSY), Secular Organizations for Sobriety (SOS), and Women for Sobriety (WFS). A large percentage of clinicians lacked knowledge about the effectiveness of all alternatives to 12-Step programs with the exception of CBT. Clinicians in the 12-Step subgroup were more likely than those in the Diversity subgroup to be unfamiliar with alternatives to 12-Step programs and to believe less strongly in the effectiveness of CBT and PSY. A logistic regression found beliefs about CBT effectiveness and clinician preference for the 12-Step model to be related to the likelihood of referring exclusively to 12-Step groups. Findings suggest that clinicians could benefit from information and training on assessing and referring clients to various options for continuing care.

Festinger DS; Marlowe DB; Croft JR; Dugosh KL; Mastro NK; Lee PA et al. Do research payments precipitate drug use or coerce participation? Drug and Alcohol Dependence 78(3): 275-281, 2005. (47 refs.)

Providing high-magnitude cash incentives to substance abuse clients to participate in research is frequently viewed as unethical based on the concerns that this might precipitate new drug use or be perceived as coercive. We randomly assigned consenting drug abuse outpatients to receive payments of $10, $40, or $70 in either cash or gift certificate for attending a 6-month research follow-up assessment. At the 6-month follow-up, participants received their randomly determined incentive and were then scheduled for a second follow-up appointment 3 days later to detect new instances of drug use. Findings indicated that neither the magnitude nor mode of the incentives had a significant effect on rates of new drug use or perceptions of coercion. Consistent with the contingency management literature, higher payments and cash payments were associated with increased follow-up rates. Finally, the results suggest that higher magnitude payments may be more cost-effective by reducing the need for more intensive follow-up efforts.

Garner BR; Godley MD; Funk RR; Dennis ML; Godley SH. The impact of continuing care adherence on environmental risks, substance use, and substance-related problems following adolescent residential treatment. Psychology of Addictive Behaviors 21(4): 488-497, 2007. (79 refs.)

The effectiveness of adolescent treatment to reduce substance use has been demonstrated by a number of different literature reviews, yet longer term outcome studies have suggested that continued alcohol and other drug use is common. Participation in continuing care services and reductions in environmental risk factors (e.g., peer substance use or alcohol or drug use in the home) have both been found to be associated with improved posttreatment substance use. The authors conducted Path analysis to examine the experimental direct effect of the Assertive Continuing Care Protocol (S. H. Godley, M. D. Godley, & M. L. Dennis, 2001) on general continuing care adherence following residential treatment and the protocol's indirect effect (via general continuing care adherence) on social and environmental risk factors, as well as subsequent substance use and substance-related problems. Supporting previous findings, the final model indicates that greater adherence to continuing care is associated with reductions in environmental risk, which in turn is associated with reduced adolescent substance use and substance-related problems 9 months after discharge from residential treatment.

Gibson AE; Doran CM; Bell JR; Ryan A; Lintzeris N. A comparison of buprenorphine treatment in clinic and primary care settings: A randomised trial. Medical Journal of Australia 179(1): 38-42, 2003. (15 refs.)

Objective: To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice. Design and setting: Randomised controlled trial set in a specialist outpatient drug treatment centre and six off ice-based general practices in inner city Sydney, Australia. Participants: 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91. Interventions: Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone. Main outcome measures: Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure. Results: There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care. Conclusions: Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.

Godley MD; Godley SH; Dennis ML; Funk RR; Passetti LL. The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders. Addiction 102(1): 81-93, 2007. (61 refs.)

This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence. Two-group randomized design. Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States. A total of 183 adolescents, ages 12-17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment. Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits. Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study.

Godley MD; Kahn JH; Dennis ML; Godley SH; Funk RR. The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment for cannabis abuse or dependence. Psychology of Addictive Behaviors 19(1): 62-70, 2005. (59 refs.)

Because alcohol or other drug use following adolescent substance abuse treatment is common, understanding mediators of posttreatment outcome could help improve treatment interventions. The authors conducted path analyses based on data from 552 adolescents (aged 12-18; 82% male) with cannabis abuse or dependence who participated in outpatient treatment. The analysis used the Family Conflict and Cohesion subscales, from the Family Environment Scale, and several scales and indices from the Global Appraisal of Individual Needs. Family conflict, family cohesion, and social support indirectly predicted substance use and substance-related problems as mediated by recovery environment and social risk. This model replicated across 4 follow-up waves (3, 6, 9, and 12 months postintake). These results support the idea of targeting environmental factors during continuing care as a way to improve treatment outcomes for adolescents with cannabis disorders.

Gossop M; Harris J; Best D; Man LH; Manning V; Marshall J; Strang J. Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6-month follow-up study. Alcohol and Alcoholism 38(5): 421-426, 2003. (43 refs.)

Aims: This study investigates the relationship between attendance at Alcoholics Anonymous (AA) meetings prior to, during, and after leaving treatment, and changes in clinical outcome following inpatient alcohol treatment. Methods: A longitudinal design was used in which participants were interviewed at admission (within 5 days of entry), and 6 months following departure. The sample comprised 150 patients in an inpatient alcohol treatment programme who met ICD-10 criteria for alcohol dependence. The full sample was interviewed at admission to treatment. Six months after departure from treatment, 120 (80%) were re-interviewed. Results: Significant improvements in drinking behaviours (frequency, quantity and reported problems), psychological problems and quality of life were reported. Frequent AA attenders had superior drinking outcomes to non-AA attenders and infrequent attenders. Those who attended AA on a weekly or more frequent basis after treatment reported greater reductions in alcohol consumption and more abstinent days. This relationship was sustained after controlling for potential confounding variables. Frequent AA attendance related only to improved drinking outcomes. Despite the improved outcomes, many of the sample had alcohol and psychiatric problems at follow-up. Conclusions: The importance of aftercare has long been acknowledged. Despite this, adequate aftercare services are often lacking. The findings support the role of Alcoholics Anonymous as a useful aftercare resource.

Greenfield SF; Hennessy G; Sugarman DE; Weiss RD. What general psychiatrists ask addiction psychiatrists: A review of 381 substance abuse consultations in a psychiatric hospital. American Journal on Addictions 12(1): 18-28, 2003. (56 refs.)

We reviewed the records of 381 consecutive substance abuse consultations completed by the Substance Abuse Consultation Service (SACS) of McLean Hospital to ascertain (1) the most frequent reasons why general psychiatrists consulted the SACS, and (2) the clinical characteristics of these patients. The most frequent reasons for consultation were to make aftercare recommendations (66.1%) or to make (19.7%) or clarify (6.3%) a substance use disorder (SUD) diagnosis. Mood disorders were the most prevalent co-occurring psychiatric disorder; alcohol use disorders were the most prevalent co-occurring psychiatric disorder; alcohol use disorders were the most prevalent SUDs. The findings indicate the potential utility of a substance abuse consultation service in a psychiatric hospital.

Gruber KJ; Fleetwood TW. In-home continuing care services for substance use affected families. Substance Use & Misuse 39(9): 1379-1403, 2004. (62 refs.)

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

Hall SM; Humfleet GL; Reus VI; Munoz RF; Cullen J. Extended nortriptyline and psychological treatment for cigarette smoking. American Journal of Psychiatry 161(11): 2100-2107, 2004. (26 refs.)

Objective: Accepted treatments for cigarette smoking rarely achieve abstinence rates of >35% at 1 year. Low rates may reflect failure to provide extended and multifocal treatment for this complex and chronic addiction. Using a chronic disease model of smoking, the authors undertook a study to determine the effects of long-term antidepressant and psychological treatment. Method: One hundred sixty smokers of greater than or equal to10 cigarettes/day were randomly assigned to one of four treatment conditions in a two-by-two (nortriptyline versus placebo by brief versus extended treatment) design. All subjects received 8 weeks of a transdermal nicotine patch, five group counseling sessions, and active or placebo treatment. Interventions for subjects in brief treatment ended at this point. Subjects in extended treatment continued taking drug or placebo to week 52 and received an additional 9 monthly counseling sessions, with checkup telephone calls midway through each session. Subjects were assessed at baseline and weeks 12, 24, 36, and 52. The principal outcome variables were repeated abstinence at each assessment after the first over a 1-year period and a point prevalence of 7 days of abstinence. Results: At week 52, point-prevalence abstinence rates with missing subjects imputed as smokers were 30% for placebo brief treatment, 42% for placebo extended treatment, 18% for active brief treatment, and 50% for active extended treatment. With missing subjects omitted, these rates were 32%, 57%, 21 %,and 56%, respectively. Conclusions: Comprehensive extended treatments that combine drug and psychological interventions can produce consistent abstinence rates that are substantially higher than those in the literature.

Harris AHS; McKellar JD; Moos RH; Schaefer JA; Cronkite RC. Predictors of engagement in continuing care following residential substance use disorder treatment. Drug and Alcohol Dependence 84(1): 93-101, 2006. (foreign check/data refs.)

Background: Patients in intensive SUD programs who subsequently participate in continuing care for a longer interval have better outcomes than those who participate for a shorter interval. We sought to identify patient and program factors associated with duration of engagement in SUD continuing care after residential/inpatient treatment. Methods: Patients (n = 3032) at 15 geographically diverse SUD residential treatment programs provided data on demographics, symptom patterns, recovery resources, and perceptions of treatment environment. We identified patient characteristics associated with the number of consecutive months of engagement in continuing care. We then consolidated and classified risk factors into an integrated model. Results: Being African American, having more SUD and psychiatric symptoms, more resources for recovery, and perceiving the treatment staff as being supportive were associated with longer engagement in continuing care. African Americans' engagement in continuing care was 17% longer than Caucasians'. The positive effect of being African American was partially mediated by having taken actions toward changing use, and by the presence of psychotic symptoms. Conclusion: These results extend previous research on the predictors of continuing care engagement after residential SUD programs. Clinicians can use information about characteristics that put patients at risk for shorter engagement in continuing care to target patients who might benefit from interventions to increase engagement in continuing care.

Hser YI; Huang D; Teruya C; Anglin MD. Diversity of drug abuse treatment utilization patterns and outcomes. Evaluation and Program Planning 27(3): 309-319, 2004. (39 refs.)

This study examined the longitudinal patterns of drug abuse treatment utilization over a 36-month period and the associated outcomes. The sample included 430 patients recruited from several treatment programs of different modalities; 335 patients in the single treatment group reported no additional treatment subsequent to the referent treatment, 65 patients in the consecutive treatment group continued in treatment after the referent treatment ended, and 30 patients in the non-consecutive treatment group reentered into treatment at least one month after the referent treatment ended. The three groups did not differ in terms of background characteristics and most of the drug use history and criminal history measures. The cumulative lengths of time in treatment over the 36 months were also similar across the three groups with the mean being 10-13 months. During the 36-month period, more than 60% of the patients across the three groups also reported treatment participation prior to the referent treatment. A logistic regression analysis was conducted to predict the positive outcome (defined as no drug use and no crimes committed while living in the community) at follow-up. Both longer stay in treatment cumulatively across the 36-month period and self-help group participation subsequent to the referent treatment were positively related to the favorable outcome, while prior treatment was negatively related to outcome. Relative to the non-consecutive group, patients in the consecutive group and single treatment group were, respectively, 2.81 times, and 2.49 times more like to have a positive outcome. The study results suggest that continued participation in some kind of treatment or self-help group is critical for sustaining recovery.

Hubbard RL; Leimberger JD; Haynes L; Patkar AA; Holter J; Liepman MR et al. Telephone Enhancement of Long-term Engagement (TELE) in continuing care for substance abuse treatment: A NIDA Clinical Trials Network (CTN) study. American Journal on Addictions 16(6): 495-502, 2007. (21 refs.)

The TELE study examined the feasibility and potential efficacy of phone calls to patients after discharge from short-term inpatient and residential substance abuse treatment programs to encourage compliance with continuing care plans. After review of their continuing care plans, 339 patients from four programs were randomized either to receive calls or to have no planned contact. Ninety-two percent of patients randomized to receive calls received at least one call. No difference was found between groups in self-reported attendance at one or more outpatient counseling sessions after discharge (p=.89). When program records of all participants were examined, those receiving calls had a greater likelihood of documented attendance (48%) than those not called (37%). Results were not statistically significant ( p < .003) because of the Hochberg correction for multiple tests. While the phone calls were feasible, the lack of clear evidence of efficacy of the calls suggests the need for further investigation of the role of telephone intervention to encourage compliance and improve outcomes.

Humphreys K; Moos RH. Encouraging posttreatment self-help group involvement to reduce demand for continuing care services: Two-year clinical and utilization outcomes. Alcoholism: Clinical and Experimental Research 31(1): 64-68, 2007. (20 refs.)

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up. Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n = 887 patients) or cognitive-behavioral (CB, n = 887 patients) treatment programs. The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs. Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p = 0.01). Conclusions: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Jason LA; Olson BD; Ferrari JR; Lo Sasso AT. Communal housing settings enhance substance abuse recovery. American Journal of Public Health 96(10): 1727-1729, 2006. (11 refs.)

Oxford Houses are democratic, mutual help-oriented recovery homes for individuals with substance abuse histories. There are more than 1200 of these houses in the United States, and each home is operated independently by its residents, without help from professional staff. In a recent experiment, 150 individuals in Illinois were randomly assigned to either an Oxford House or usual-care condition (i.e., outpatient treatment or self-help groups) after substance abuse treatment discharge. At the 24-month follow-up, those in the Oxford House condition compared with the usual-care condition had significantly lower substance use, significantly higher monthly income, and significantly lower incarceration rates.

Jason LA; Olson BD; Ferrari JR; Majer JM; Alvarez J; Stout J. An examination of main and interactive effects of substance abuse recovery housing on multiple indicators of adjustment. Addiction 102(7): 1114-1121, 2007. (22 refs.)

Aims To assess the effectiveness of community-based supports in promoting abstinence from substance use and related problems. Design and participants Individuals (n = 150) discharged from residential substance abuse treatment facilities were assigned randomly to either an Oxford House recovery home or usual after-care condition and then interviewed every 6 months for a 24-month period. Intervention Oxford Houses are democratic, self-run recovery homes. Measurements Hierarchical linear modeling was used to examine the effect of predictive variables on wave trajectories of substance use, employment, self-regulation and recent criminal charges. Regressions first examined whether predictor variables modeled wave trajectories by condition (Oxford House versus usual after-care), psychiatric comorbidity, age and interactions. Findings: At the 24-month follow-up, there was less substance abuse for residents living in Oxford Houses for 6 or more months (15.6%), compared both to participants with less than 6 months (45.7%) or to participants assigned to the usual after-care condition (64.8%). Results also indicated that older residents and younger members living in a house for 6 or more months experienced better outcomes in terms of substance use, employment and self-regulation. Conclusions Oxford Houses, a type of self-governed recovery setting, appear to stabilize many individuals who have substance abuse histories.

Jason LA; Roberts K; Olson BD. Attitudes toward recovery homes and residents: Does proximity make a difference? Journal of Community Psychology 33(5): 529-535, 2005. (9 refs.)

The present study investigated the attitudes of neighborhood residents toward a particular type of substance abuse recovery home (i.e., Oxford House). Individuals who lived next to these recovery homes versus those who lived a block away were assessed regarding their attitudes toward substance abuse recovery homes and individuals in recovery. The vast majority of those living next to a self-run recovery home knew of the existence of these recovery homes, whereas most residents living a block away did not know of their existence. Findings suggest that well managed and well functioning substance abuse recovery homes, such as Oxford Houses, elicit constructive and positive attitudes toward individuals in recovery and recovery homes.

Kaminer Y; Burleson JA; Goldston DB; Burke RH. Suicidal ideation among adolescents with alcohol use disorders during treatment and aftercare. American Journal on Addictions 15(Supplement 1): 43-49, 2006. (24 refs.)

The objectives of this study are to assess the magnitude and course of suicidal ideation during outpatient treatment and aftercare for adolescents with alcohol use disorders (AUD). One hundred seventy-seven adolescents meeting eligibility criteria, including no past 30-day suicidal behavior, participated in 9 weeks of outpatient cognitive-behavioral group therapy. Treatment completers were randomized into: (1) No-Active, (2) In-Person, or (3) Telephone aftercare conditions for a period of 12 weeks. No specific intervention for suicidal behavior was provided during the study. The Suicide Ideation Questionnaire (SIQ-JR), Reynolds, 1988) was administered at baseline, end of treatment, and end of aftercare. The results are as follows, a higher baseline suicidal ideation was associated with higher retention at the end of treatment and through aftercare. The In-Person Aftercare condition showed a significant decrease in suicidal ideation, relative to the No-Active Aftercare condition. There was a trend for similarly reduced severity of suicidal ideation in the Telephone Aftercare condition. In conclusion, the type of aftercare and resulting decrease in AUD may play a role in the reduction in suicidal ideation. The mechanism of change by which suicidal ideation is reduced in adolescents in treatment for AUD needs to be further explored.

Kaminer Y; Dennis ML. Symposium: Effectiveness of adolescent substance abuse treatment. IN: Dewey WL, ed. Problems of Drug Dependence 2003: Proceedings of the 65th Annual Scientific Meeting. Rockville MD: National Institute on Drug Abuse, 2004. pp. 118-125. (34 refs.)

This symposium, featuring four papers, presents the results of recently completed studies comparing different approaches to make adolescent substance use disorders treatment more effective. They indicate signficant developments in treatment outcome, aftercare, and cost-effectiveness research.

Public Domain

Kelly JF; Stout R; Zywiak W; Schneider R. A 3-year study of addiction mutual-help group participation following intensive outpatient treatment. Alcoholism: Clinical and Experimental Research 30(8): 1381-1392, 2006. (86 refs.)

Addiction-focused mutual-help group participation is associated with better substance use disorder (SUD) treatment outcomes. However, little has been documented regarding which types of mutual-help organizations patients attend, what levels of participation may be beneficial, and which patients, in particular, are more or less likely to participate. Furthermore, much of the evidence supporting the use of these organizations comes from studies examining participation and outcomes concurrently, raising doubts about cause-effect connections, and little is known about influences that may moderate the degree of any general benefit. Alcohol-dependent outpatients (N=227; 27% female; M age=42) enrolled in a randomized-controlled telephone case monitoring trial were assessed at treatment intake and at 1, 2, and 3 years postdischarge. Lagged-panel, hierarchical linear models tested whether mutual-help group participation in the first and second year following treatment predicted subsequent outcomes and whether these effects were moderated by gender, concurrent axis I diagnosis, religious preference, and prior mutual-help experience. Robust regression curve analysis was used to examine dose-response relationships between mutual-help and outcomes. Mutual-help participation was associated with both greater abstinence and fewer drinks per drinking day and this relationship was not found to be influenced by gender, Axis I diagnosis, religious preference, or prior mutual-help participation. Mutual-help participants attended predominantly Alcoholics Anonymous and tended to be Caucasian, be more educated, have prior mutual-help experience, and have more severe alcohol involvement. Dose-response curve analyses suggested that even small amounts of participation may be helpful in increasing abstinence, whereas higher doses may be needed to reduce relapse intensity. Use of mutual-help groups following intensive outpatient SUD treatment appears to be beneficial for many different types of patients and even modest levels of participation may be helpful. Future emphasis should be placed on ways to engage individuals with these cost-effective resources over time and to gather and disseminate evidence regarding additional mutual-help organizations.

Lash SJ; Burden JL; Monteleone BR; Lehmann LP. Social reinforcement of substance abuse treatment aftercare participation: Impact on outcome. Addictive Behaviors 29(2): 337-342, 2004. (13 refs.)

Although adherence to aftercare therapy in substance abuse treatment is associated with improved outcome, little research has explored the effects of adherence interventions on outcome. We compared 20 graduates of our 28-day intensive treatment program who received a standard aftercare orientation with 20 graduates who received this intervention plus social reinforcement of aftercare group therapy attendance. The social reinforcement group showed less alcohol use than the standard care group at a 6-month follow-up assessment as measured by the Addiction Severity Index (ASI), but not less drug use. Additionally, compared to standard care, the social reinforcement participants were more likely to be abstinent at the 6-month follow up (76% vs. 40%). The groups did not differ on hospital readmission rates over a 12-month follow-up period. Additionally, the social reinforcement group showed better long-term aftercare attendance compared to the standard care group.

Lemke S; Moos RH. Outcomes at 1 and 5 years for older patients with alcohol use disorders. Journal of Substance Abuse Treatment 24(1): 43-50, 2003. (24 refs.)

Older patients with alcohol use disorders who had gone through residential treatment were compared with matched groups of young and middle-aged patients (N = 432 in each age group) on their 1- and 5-year outcomes, use of continuing care services, and outcome predictors. Older patients had better outcomes than did young and middle-aged patients but had comparable levels of continuing substance abuse care and 12-step self-help group involvement. Similar factors predicted outcomes across the age groups. Longer duration of continuing substance abuse care and greater self-help group involvement were related to better outcomes, as were patients' attitudes and coping strategies at program discharge. The findings indicate that older patients with alcohol use disorders respond to age-integrated substance abuse treatment programs at least as well as do younger patients and are equally involved in formal and informal continuing substance abuse care.

Lopez EN; Simmons VN; Quinn GP; Meade CD; Chirikos TN; Brandon TH. Clinical trials and tribulations: Lessons learned from recruiting pregnant ex-smokers for relapse prevention. Nicotine & Tobacco Research 10(1): 87-96, 2008. (45 refs.)

The development of smoking cessation and relapse prevention interventions for pregnant and postpartum women is a public health priority. However, researchers have consistently reported substantial difficulty in recruiting this population into clinical trials. The problem is particularly acute for relapse prevention studies, which must recruit women who have already quit smoking because of their pregnancy. Although these individuals are an important target for tobacco control efforts, they represent an extremely small subgroup of the general population. This paper describes multiple recruitment strategies used for a clinical trial of a self-help relapse prevention program for pregnant women. The effectiveness of the strategies and the direct expense per participant recruited are provided. A proactive recruitment strategy (telephoning women whose phone numbers were purchased from a marketing firm) was ultimately much more successful than a variety of reactive strategies (advertisements, press releases, direct mail, Web placement, health care provider outreach). We found few differences between proactively and reactively recruited participants on baseline variables. The primary difference was that the former had smoked fewer cigarettes per day and reported lower nicotine dependence prior to quitting. Strengths and limitations of the recruitment strategies are discussed.

Magura S. The relationship between substance user treatment and 12-step fellowships: Current knowledge and research questions. Substance Use & Misuse 42(2-3): 343-360, 2007. (59 refs.)

This article reviews and synthesizes information about the relationship between two distinct approaches to helping substance users, formal "addiction treatment" and 12-step mutual aid. The following issues are addressed: Extent of formal treatment and 12-step fellowship participation for persons with substance use-related problems; overlap between treatment and 12-step participation; early attempts to "integrate" treatment and 12-step mutual aid; differences and similarities between the 12-step program and treatment; issues ofspirituality in the 12-step program; effectiveness of 12-step participation as treatment aftercare; and whether help-seekers can be "matched" to 12-step. The article poses pertinent questions that could answered by additional research, including life cycle patterns of usage of treatment and 12-step, outcomes of such episodes, reasons for using different interventions at different times, feasibility of 12-step participation as a primary intervention, the relative contributions of striving for spiritual values vs. social support factors to the effectiveness of 12-step, and the comparative effectiveness of secular vs. 12-step, mutual aid. The article concludes with a proposed reconceptualization of the relationship between formal treatment and 12-step mutual aid that may help in structuring future research.

Magura S; Fong C; Staines GL; Cleland C; Foote J; Rosenblum A et al. The combined effects of treatment intensity, self-help groups and patient attributes on drinking outcomes. Journal of Psychoactive Drugs 37(1): 85-92, 2005. (36 refs.)

Better understanding of the diverse factors that predict alcoholism treatment outcomes is essential to improving treatment strategies. Patients accepted for treatment at a multimodality program were inter-viewed and followed-up at three months and one year after admission. The study tested a set of hypotheses relating to the effects on drinking outcomes of treatment modality, modality matching, treatment retention, aftercare, self-help group participation and patient attributes at admission. Drinking frequency diminished substantially between baseline and the two follow-ups. Outcomes for inpatient were better than for outpatient treatment in bivariate analysis, but outcomes for these modalities were equal after adjusting for the effect of patient-treatment mismatching. Aftercare treatment, time in treatment for outpatients, community 12-Step group participation, and several patient attributes such as motivation for change and psychiatric severity significantly predicted drinking outcomes at one or both follow-ups. Clinical implications of the results are discussed.

Mark TL; Dilonardo JD; Chalk M; Coffey RM. Factors associated with the receipt of treatment following detoxification. Journal of Substance Abuse Treatment 24(4): 299-304, 2003. (21 refs.)

This paper examines the determinants of whether an individual received continuing treatment/rehabilitation services 30 days after receiving inpatient substance abuse detoxification. Data came from 1997-1999 employer health insurance claims. Only 49.4% of detoxification episodes were followed by continuing mental health or substance abuse treatment within 30 days after discharge. Some of the factors positively associated with receiving continuing treatment after receiving detoxification included: female gender, being in a behavioral health carve-out plan, and lower cost-sharing requirements for an outpatient substance abuse visit.

Mark TL; Song X; Vandivort R; Duffy S; Butler J; Coffey R et al. Characterizing substance abuse programs that treat adolescents. Journal of Substance Abuse Treatment 31(1): 59-65, 2006. (19 refs.)

Few systematic studies have examined the characteristics of substance abuse treatment programs serving adolescents. An expert panel recently identified nine key elements of effective adolescent substance abuse treatment. We measured the percentage of treatment programs in the United States with at least 10 adolescent clients on a given day that reported these elements using data from the 2003 National Survey of Substance Abuse Treatment Services. This first look into the characteristics of facilities serving significant numbers of adolescents indicates that many facilities may be lacking in components considered important. The most significant measured potential areas for improvement occurred in the areas of including mental health as well as medical issues in comprehensive assessments and developing curricula to meet the developmental and cultural needs of clients. On a more encouraging note, many facilities were conducting discharge planning and providing aftercare, although the specifics of these services were not determined.

Marlowe DB; Festinger DS; Dugosh KL; Lee PA. Are judicial status hearings a "key component" of drug court? Six and twelve months outcomes. Drug and Alcohol Dependence 79(2): 145-155, 2005. (41 refs.)

Substantial evidence indicates that drug courts can be superior to traditional probation programs for enhancing treatment retention and reducing substance use and crime among drug offenders. Few studies have isolated the effects of the hypothesized "key components" of drug courts to determine their contributions to outcomes. This article presents outcomes at 6 and 12 months post-admission for misdemeanor drug court clients who were randomly assigned to different dosages of judicial status hearings. Although earlier work [Festinger, D.S., Marlowe, D.B., Lee. P.A., Kirby, K.C., Bovasso, G., McLellan, A.T., 2002. Status hearings in drug court: when more is less and less is more. Drug Alcohol Depend. 68, 151-157] revealed superior during-treatment effects for high-risk participants who were assigned to more frequent bi-weekly hearings, those effects did not extend post-treatment. The results did reveal significant pre-to-post improvements for participants, as a whole, in self-reported drug use, alcohol use, and criminal recidivism; however, lacking a no-drug court control condition, it is not possible to discern the magnitude of the effect of the drug court program. Approximately, half of the participants resumed drug or alcohol use within 12 months of admission to drug court, and approximately 10-15% resumed illegal activities. These findings lend credence to the potential effectiveness of drug courts; however, continuing-care strategies are required to extend the effects of drug courts beyond the initial active phases of the program.

Marlowe DB; Festinger DS; Lee PA; Dugosh KL; Benasutti KM. Matching judicial supervision to clients' risk status in drug court. Crime & Delinquency 52(1): 52-76, 2006. (47 refs.)

This article reports out comes from a program of experimental research evaluating the risk principle in drug courts. Prior studies revealed that participants who were high risk and had (a)antisocial personality disorder or (b)a prior history of drugabuse treatment performed better in drug court when scheduled to attend biweekly judicial status hearings in court. In contrast, participants who were low risk performed equivalently regardless of the court hearings schedule. This study prospectively matches drug court clients to the optimal schedule of court hearings based on an assessment of their risk status and compares outcomes to clients randomly assigned to the standard hearings schedule. Results confirmed that participants who were high risk and matched to biweekly hearings had better during-treatment outcomes than participants assigned to status hearings as usual. These findings provide confirmation of the risk principle in drug courts and yield practical information for enhancing the efficacy and cost-efficiency of drug courts.

McCrady BS; Epstein EE; Kahler CW. Alcoholics Anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes. Journal of Consulting and Clinical Psychology 72(5): 870 -878, 2004. (40 refs.)

Ninety men with alcohol problems and their female partners were randomly assigned to I of 3 outpatient conjoint treatments: alcohol behavioral couples therapy (ABCT), ABCT with relapse prevention techniques (RP/ABCT), or ABCT with interventions encouraging Alcoholics Anonymous (AA) involvement (AA/ABCT). Couples were followed for 18 months after treatment. Across the 3 treatments, drinkers who provided follow-up data maintained abstinence on almost 80% of days during follow-up, with no differences in drinking or marital happiness outcomes between groups. AA/ABCT participants attended AA meetings more often than ABCT or RP/ABCT participants, and their drinking outcomes were more strongly related to concurrent AA attendance. For the entire sample, AA attendance was positively related to abstinence during follow-up in both concurrent and time-lagged analyses. In the RP/ABCT treatment, attendance at posttreatment booster sessions was related to posttreatment abstinence. Across treatment conditions, marital happiness was related positively to abstinence in concurrent but not time-lagged analyses.

McKay JR; Foltz C; Leahy P; Stephens R; Orwin RG; Crowley EM. Step down continuing care in the treatment of substance abuse: Correlates of participation and outcome effects. Evaluation and Program Planning 27(3): 321-331, 2004. (34 refs.)

This study examined the predictors of participation in step down continuing care in publicly funded substance abuse treatment programs, and the relation between participation in step down care and alcohol and crack cocaine use outcomes over a 36-month follow-up. The sample included patients in residential/inpatient programs (IP; N = 134) and intensive outpatient programs (TOP; AT = 370). About one-third of patients in the IP sample received step down TOP or standard outpatient (OP) continuing care, and less than a quarter of those in the TOP sample received step down OP care. Patients who received step down continuing care following IP had greater social support at intake and were more likely to be female and White than those who did not receive continuing care. Patients who received continuing care following TOP were more likely than those who did not to be female and employed, and were older, had higher self-efficacy, and shorter lengths of stay in TOP. Participation in step down care was not associated with other factors assessed at intake. In the IP sample, receiving step down continuing care was not associated with better alcohol or crack cocaine use outcomes over the 36-month follow-up. In the TOP sample, there were also no main effects favoring continuing care for either alcohol or crack cocaine use outcomes. However, patients who received continuing care did have less crack cocaine use in the first six months of the follow-up. These findings suggest that new models of continuing care are needed that are more acceptable to patients, produce better outcomes, and are cost-effective.

McKay JR; Lynch KG; Pettinati HM; Shepard DS. An examination of potential sex and race effects in a study of continuing care for alcohol- and cocaine-dependent patients. Alcoholism: Clinical and Experimental Research 27(8): 1321-1323, 2003. (5 refs.)

There is agreement that continuing care, or "aftercare" is important for those treated for alcohol and drug use disorders. However, there is little research on this phase of treatment, nor whether outcomes vary as a function or face or sex. This article presents data from a randomized study that compared three continuing car treatments for patients who complete a 1-month community-based, intensive outpatient treatment program (IOP). The treatments were (1) standard 12-step-based group sounseling (STND), (2) individualzed relapse prevention (RP_ and (3) brief telephone monitoring and counseling (TEL). All conditons were 12 weeks in duration with twice weekly session in STND and RP and weekly contacts in TEL. The main analyses reported examined potential differences by gender and between blacks and whites with regard to alcohol and cocaine outcomes druing and after continuing care. The results suggest that women entered continuing care with greater severity in a number of area, including alcohol use during IOP, but that outcome was in fact slightly better than that of men. However, there was sub-group of women with particularly bad outcomes. Those in the telephone monitoring and counseling has somewhat better outcomes. In respect to race, there were greater differences between blacks and whites than were found by gender, respect to process measures. Thus while outcomes may be similar, the routes for achieving these may differ by race. Increased self-efficacy and attendence at self-help mutual help programs are greater predictors of outcome in whites than among blacks.

McKay JR; Lynch KG; Shepard DS; Morgenstern J; Forman RF; Pettinati HM. Do patient characteristics and initial progress in treatment moderate the effectiveness of telephone-based continuing care for substance use disorders? Addiction 100(2): 216-226, 2005. (44 refs.)

Aims: To determine whether substance use severity, psychiatric severity, social support, self-help attendance or motivation moderated substance use outcomes in a telephone-based continuing care intervention. Design: A randomized study comparing three 12-week continuing care interventions: weekly telephone monitoring and counseling combined with a support group in the first 4 weeks (TEL), twice-weekly individualized relapse prevention (RP) and twice-weekly standard group counseling (STND). Methods Following completion of 4-week intensive out-patient programs (IOP), 3 59 patients with alcohol and/or cocaine dependence were assigned randomly to a continuing care condition and followed quarterly for 12 months. Ten potential moderator variables were examined in separate analyses. Two of these variables reflected pretreatment status, whereas the other variables were focused on performance while in the IOP. A composite risk measure was also constructed from dichotomized versions of seven of these variables, with higher scores indicating greater potential for relapse. The dependent measures were total abstinence and percentage of days abstinent from alcohol and cocaine in each quarter. Findings Of 40 interaction contrasts that were examined with individual risk indicator measures, only one reached the 0.05 level of significance. Patients with any alcohol use in IOP had a higher percentage of days abstinence in STND than in TEL. In addition, high scores on the composite risk indicator predicted higher total abstinence rates in STND than in TEL, whereas low to moderate scores predicted higher abstinence rates in TEL than in STND. Conclusion: For most graduates of IOPs, the combination of brief weekly telephone therapeutic contacts and a support group in the first month produced outcomes that are as good as those obtained in more intensive face-to-face continuing care interventions. However, patients with current dependence on both alcohol and cocaine who make little progress towards achieving the central goals of IOP may have better outcomes if they receive twice-weekly group counseling following IOP.

McKay JR; Lynch KG; Shepard DS; Pettinati HN. The effectiveness of telephone-based continuing care for alcohol and cocaine dependence: 24-month outcomes. Archives of General Psychiatry 62(2): 199-207, 2005. (57 refs.)

Context: Telephone-based disease management protocols have shown promise in improving outcomes in a number of medical and psychiatric disorders, but this approach to continuing care has received little stud), in alcohol- and drug-dependent individuals. Objective: To compare telephone-based continuing care with 2 more intensive face-to-face continuing care interventions. Design: A randomized 3-group clinical trial with a 2-year follow-up. Setting: Two outpatient substance abuse treatment programs, one community-based and the other at a Veterans Affairs medical center facility. Patients: Alcohol- and/or cocaine-dependent patients (N=359) who had completed 4-week intensive outpatient programs. Interventions: Three 12-week continuing care treatments: weekly telephone-based monitoring and brief counseling contacts combined with weekly supportive group sessions in the first 4 weeks (TEL), twice-weekly cognitive-behavioral relapse prevention (RP), and twice weekly standard group counseling (STND). Main Outcome Measures: Percentage of days abstinent from alcohol and cocaine, total abstinence from alcohol and cocaine, negative consequences of substance use, cocaine urine toxicological results. and gamma-olutamyltransferase. Results: Participants in TEL had higher rates of total abstinence over the follow-up than those in STND (P<.05). In alcohol-dependent participants. 24-month gamma-glutamyltransferase levels were lower in TEL than in RP (P=.005). In cocaine-dependent participants, there was a significant group X time interaction (P=.03) in which the rate of cocaine-positive urine samples increased more rapidly in RP as compared with TEL. On percentage of days abstinent or negative consequences of substance use, TEL did not differ from RP or STND. Participants with high scores on a composite risk indicator, based on co-occurring alcohol and cocaine dependence and poor progress toward achieving intensive outpatient program goals. had better total abstinence outcomes up to 21 months if they received STND rather than TEL, whereas those with lower scores had higher abstinence rates in TEL than in STND (P =.04). Conclusions: Telephone-based continuing care appears to be an effective form of step-down treatment for most patients with alcohol and cocaine dependence who complete an initial stabilization treatment, compared with more intensive face-to-face interventions. However, high-risk patients may have better outcomes if they first receive group counselling continuing care after completing intensive outpatient programs.

Miguez MC; Becona E. Evaluating the effectiveness of a single telephone contact as an adjunct to a self-help intervention for smoking cessation in a randomized controlled trial. Nicotine & Tobacco Research 10(1): 129-135, 2008. (34 refs.)

This study evaluated the effects of including a single brief prequit telephone counseling session in a self-help program for smoking cessation conducted through the mail, by comparison with the effects of the self-help program alone. Volunteer participants from northwestern Spain (N=228) were randomly assigned to one of two groups: (a) the self-help-only group (n=110, mean age=37.4 years, pretreatment cigarette consumption=26.5 cigarettes/day) or (b) the telephone-support group (n=118, mean age=36.8 years, pretreatment cigarette consumption=27.7 cigarettes/day). Using a conservative data analysis method (missing data considered as treatment failures), we found that the point-prevalence abstinence rate was significantly higher in the telephone-support group than in the self-help-only group at the end of treatment (44.9% vs. 21.8%) and at the 3-month follow-up (39.0% vs. 26.4%). Likewise, sustained abstinence was significantly higher in the telephone-support group at the 3-month follow-up (33.9% vs. 13.6%), the 6-month follow-up (25.4% vs. 12.7%), and the 12-month follow-up (21.2% vs. 9.1%). The results of this randomized controlled trial indicate that both treatments are an effective aid for smoking cessation, and that a single brief telephone call before the quit date is a low-cost and effective procedure for improving abstinence rates in a mailed self-help program.

Mueller SE; Petitjean S; Boening J; Wiesbeck GA. The impact of self-help group attendance on relapse rates after alcohol detoxification in a controlled study. Alcohol and Alcoholism 42(2): 108-112, 2007. (33 refs.)

Aims: Self-help groups such as Alcoholics Anonymous (AA) are widely recommended for aftercare of alcohol-dependent persons, even though scientific knowledge of its effectiveness is inconsistent. The aim of the present analysis was to elucidate whether persons attending AA groups regularly after detoxification have lower relapse rates within 1 year, compared to persons without self-help group attendance. Methods: Data for the present analysis were derived from the placebo-group of a multi-centre study in Germany (Wiesbeck et al., 2001). Patients were free to choose either self-help group attendance (N = 50) or no support (N = 28). Results: After 1-month of follow-up, there was a lower relapse rate in patients attending a self-help group as compared to the control group, a difference, however, that leveled off during the following months. Moreover, relapse rates did not differ significantly at any point of time between both groups. Levels of social functioning improved in both groups over 1 year. Conclusions: The present study was unable to show an advantage of self-help group attendance in reducing relapses compared to the control group.

Mundt JC; Moore HK; Bean P. An interactive voice response program to reduce drinking relapse: A feasibility study. Journal of Substance Abuse Treatment 30(1): 21-29, 2006. (38 refs.)

Substance-abusing patients often relapse soon after undergoing treatment, thus requiring intensive aftercare or re-treatment. More efficient monitoring and follow-up of patients could contribute to better treatment outcomes. This study evaluated the feasibility of a computer-automated interactive voice response (IVR) system to reduce relapse following discharge from residential treatment. Sixty participants completing a residential treatment program and meeting DSM-IV criteria for alcohol dependence were randomized to three groups: (1) daily IVR reporting with personal follow-up on noncompliant callers; (2) daily IVR reporting without follow-up; or (3) no IVR reporting (control group). At 30, 90, and 180 days after discharge, participants were interviewed to obtain timeline follow-back drinking data and completed the Work and Social Adjustment Scale, Obsessive-Compulsive Drinking Scale, SF-36, and Drinker Inventory of Consequences. This pilot study suggests that using automated IVR technology to monitor clients after discharge is feasible and warrants further research and development. IVR systems also provide the potential for delivering individualized feedback.

Needels K; Jarnes-Burdurny S; Burghardt J. Community case management for former jail inmates: Its impacts on rearrest, drug use, and HIV risk. Journal of Urban Health 82(3): 420-433, 2005. (19 refs.)

Dramatically increasing incarceration rates in the United States have led to large concentrations of formerly imprisoned people in poverty-stricken urban areas. Therefore, identifying ways to help inmates who exhibit multiple, serious problems and who are at great risk of experiencing poor postrelease outcomes is especially important to urban communities, as well as to service providers and policymakers concerned about these communities. Our research provides evidence about the effectiveness of one strategy, called Health Link, which recruited adult women and adolescent men while they were incarcerated in a New York City jail and offered case management services during the especially challenging first year after release. About 1,400 participants who enrolled during a 3-year period were randomly assigned either to a group that was eligible for intensive discharge planning services and community-based case management services or to a group eligible for less-intensive discharge planning and no community-based services. We investigated whether the availability of these services reduced rates of drug use, HIV risk, and rearrest. Using data from interviews and hair analysis to measure impacts during a 1-year follow-up period after clients? release from jail, we detected increased participation in drug treatment programs and weak evidence for reduced drug use. However, we did not observe reductions in rearrest rates or in activities with high risk of HIV infection. We conclude that a well-executed case management program can make modest differences in a few short-term outcomes of former inmates. However, the intervention did not lead to the hoped-for changes across a range of outcomes that would clearly indicate greater success in community reintegration or improved health.

Neighbors CJ; Zywiak WH; Stout RL; Hoffmann NG. Psychobehavioral risk factors, substance treatment engagement and clinical outcomes as predictors of emergency department use and medical hospitalization. Journal of Studies on Alcohol 66(2): 295-304, 2005. (49 refs.)

Objective: Prior research on health care utilization after treatment for substance misuse disorders has not accounted for posttreatment clinical outcomes as well as putative confounds associated with both substance use and health care. This study examined the association of posttreatment health care utilization with treatment factors (program type and time in treatment) and baseline psychological/behavioral risk factors (smoking status and level of depressive, alcohol and drug dependence symptoms). The study also examined whether posttreatment clinical outcomes-participation in aftercare, Alcoholic Anonymous (AA) attendance, substance use, depressive symptoms and smoking-were associated with subsequent health care utilization. Method: We analyzed predictors of posttreatment medical hospitalizations and emergency department (ED) use among 15,041 participants in a multistate treatment evaluation project conducted from 1987 to 1995. Results: Greater time in treatment reduced the likelihood of future hospitalizations and ED use, whereas clients in outpatient treatment were less likely to be hospitalized. Baseline measures of depressive, alcohol and drug dependence symptoms were each independently associated with subsequent health care use. Posttreatment aftercare participation reduced the likelihood of future hospitalization and ED use, whereas AA attendance also reduced the likelihood of hospitalization. In addition, posttreatment counts of depressive symptoms increased the likelihood of future hospitalization and ED use. Substance relapse increased the likelihood of subsequent ED use. Conclusions: The study supports the public health importance of substance misuse disorders treatment, with greater treatment involvement associated with lower high-cost medical utilization. Treatment clinical outcomes-posttreatment relapse and depressive symptoms-partially mediate the effect of treatment on health care utilization.

Neto D; Lambaz R; Tavares JE. Compliance with aftercare treatment, including disulfiram, and effect on outcome in alcohol-dependent patients. Alcohol and Alcoholism 42(6): 604-609, 2007. (16 refs.)

Aim: To delineate the features of treatment compliance which predicted outcome during aftercare treatment in a series of patients that completed an inpatient program at the Lisbon Regional Alcohology Centre (CRAS). Methods: Seventy-four alcohol dependent patients, sequentially admitted to the inpatient treatment of CRAS, were followed over 6 months after discharge. This study focused on the predictive value of the aftercare therapies, which included: attending Alcoholics Anonymous (AA) meetings, attending aftercare groups (AG), attending outpatient consultations with the medical assistant. Disulfiram was prescribed to 83.3% of the patients. At the end of the 6-months follow-up period, the patients and their significant others (co-responsible persons) were interviewed on the telephone by an independent interviewer. The data collected for analysis consists of information from the interviews, and also of data from the patient clinical files. Results: Survival analysis revealed that, after 6months of follow-up, 39.2% of the patients had attained total abstinence of alcohol ingestion; 71% of the relapses on alcohol consumption occurred within the first 3 months. The median number of days taking disulfiram was significantly related to the number of days of abstinence. Demographic variables, pre-treatment variables, attendance at AA meetings, AGs and outpatient appointments were not significant predictors of outcome. Conclusions: Consistently taking disulfiram is associated with good outcome, but this may reflect committment to abstinence as well as a treatment effect.

Parthasarathy S; Weisner CM. Five-year trajectories of health care utilization and cost in a drug and alcohol treatment sample. Drug and Alcohol Dependence 80(2): 231-240, 2005. (57 refs.)

Background: The study examined the effect of individual characteristics on longitudinal patterns of health care utilization and cost among individuals entering chemical dependency (CD) treatment. Method: Structured interviews and computerized administrative databases were linked to obtain severity, utilization and cost data. Total medical costs and their components were examined for the 6 months prior to intake through 5 years post-intake. Statistical analyses were conducted using the hierarchical linear modeling framework. Results: Age was positively correlated with total medical costs. Women had higher inpatient utilization and higher inpatient, primary care and total cost at baseline (p <.05). However, they had steeper decline in primary care costs. While age was not related to inpatient and ER use at baseline (after controlling for psychiatric and medical severity), older individuals had smaller declines in hospital days and inpatient cost over time. Individuals with high medical and psychiatric severity had higher utilization and costs (p <.01). Those who were abstinent had higher costs. Conclusions: There are important differences in patient characteristics and treatment outcomes that influence utilization and cost trajectories. The relationship between medical severity at intake and primary care cost pre-intake among patients with drug and alcohol problems suggests an opportunity to identify and treat drug and alcohol problems in primary care settings. It also suggests that medical evaluations and treatment should not be overlooked during CD treatment. The positive association between abstinence and trajectories of primary care and total medical costs suggests that maintaining abstinence over a long term requires some kind of continuing care either in primary care settings or via additional contacts with specialty CD departments.

Pelissier B; Cadigan T. Interagency priorities at the crossroads: Aftercare among drug users. Federal Probation 68(1): 10-14, 2004. (12 refs.)

Among those who have evaluated the effectiveness of prison-based drug treatment programs, considerable discussion has arisen about the need to provide aftercare services and ensure continuity of care. The effects of in-prison treatment might not be maintained without continuity of care after release. The recent focus upon reentry draws attention to the issue of treatment after release from prison by suggesting that treatment contact be initiated before releasing an individual from prison. But more generally, the emphasis on reentry issues calls for collaboration between various criminal justice agencies. Overcoming the cultural, procedural and systematic differences to develop an effective reentry infrastructure and process will require tremendous commitment and creativity from staff in both agencies. The purpose of this study is to provide a measure of impact of that memorandum of understanding (MOU) on post-release substance abuse treatment. Our research indicates that changing certain policies would likely improve the federal "system" of substance abuse treatment for offenders. Future research will be required to examine the impact of these policies.

Randall CL; Del Boca FK; Mattson ME; Rychtarik R; Cooney NL; Donovan DM et al. Primary treatment outcomes and matching effects: Aftercare arm. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 135-149. (275 book refs.)

Primary treatment outcomes and matching effects for the aftercare arm of Project MATCH are discussed. The authors note that residential and day-hospital rehabilitation programs play an important role in the treatment of people with alcohol dependence, particularly those with more severe and persistent problems. Project MATCH investigated treatment matching for clients who had just completed a program of conventional inpatient or day-hospital treatment. The results of the study revealed no evidence for the superiority of any one treatment over another on the primary outcomes measures. Clients improved from baseline through a 15-month follow-up period, both in frequency and intensity of drinking. Only 1 of the 21 a priori matching hypotheses was confirmed. Clients with more severe dependence had better treatment outcomes with Twelve Step Facilitation (TSF) therapy and the lower scoring clients had better outcomes with Cognitive-Behavioral Therapy (CBT). Section headings in this book chapter include: (1) methods: recruitment sites and research participants; (2) statistical approach; (3) trends over time; (4) treatment effects; (5) prognostic effects; (6) tests of matching hypotheses; (7) exploratory analyses; (8) causal chain analyses and clinical significance of matching.

Public Domain

Rush BR; Dennis ML; Scott CK; Castel S; Funk RR. The interaction of co-occurring mental disorders and recovery management checkups on substance abuse treatment participation and recovery. Evaluation Review 32(1): 7-38, 2008. (93 refs.)

This article examines the effectiveness of quarterly Recovery Management Checkups (RMCs) for people with substance disorders by level of co-occurring mental disorders (34% none, 27% internalizing disorders, and 39% internalizing and externalizing) across two randomized experiments with 92% to 97% follow-up. The 865 participants are 82% African American, 53% female, and age 37 on average. RMC involves identification of those in need of treatment, motivational interviews, and treatment linkage assistance. It is effective in linking participants in need to treatment, with equal or better outcomes among those with more mental disorders. The data support the utility of monitoring and re-intervention for clients with co-occurring disorders.

Sannibale C; Hurkett P; Van den Bossche E; O'Connor D; Zador D; Capus C et al. Aftercare attendance and post-treatment functioning of severely substance dependent residential treatment clients. Drug and Alcohol Review 22(2): 181-190, 2003. (66 refs.)

The present study evaluated the impact of a structured aftercare programme following residential treatment for severe alcohol and/or heroin dependent clients. Over 17 months, 77 participants were recruited to the study and allocated randomly to either a structured aftercare (SA) programme or to unstructured aftercare (UA) of crisis counselling on request. Independent clinicians interviewed participants and collaterals, at 4-month (median) intervals, for 12 months following residential treatment. SA compared to UA was associated with a fourfold increase in aftercare attendance and one-third the rate of uncontrolled principal substance use at follow-up. Participants who attended either type of aftercare relapsed a median of 134 days later than those who attended no aftercare. Overall, 23% of monitored participants remained abstinent throughout, 21% maintained controlled substance use and 56% relapsed, within a median of 36 days following residential treatment. The only significant predictor of days to relapse, controlling for age, was pretreatment use of additional substances. Participants with pretreatment additional substance use relapsed a median of 192 days earlier than those who had used no other substances. The degree of agreement between participant self-reports and collateral reports was fair-to-moderate and moderate among collaterals. Intention-to-treat analyses revealed significant and clinically meaningful reductions in substance use in this sample of severely dependent residential treatment clients. The generalizability of these results is limited because of significant differences in age and presenting substance between the study sample and other clients admitted to the service during the study. This latter group of younger, male, heroin-dependent clients with polydrug use who refuse opioid pharmacotherapy, are more likely to drop out of treatment or relapse early following treatment and continue to present a challenge to treatment services.

Schaefer JA; Ingudomnukul E; Harris AHS; Cronkite RC. Continuity of care practices and substance use disorder patients' engagement in continuing care. Medical Care 43(12): 1234-1241, 2005. (35 refs.)

Background: Substance use disorder (SUD) patients who engage in more continuing care have better outcomes, but information on practices associated with greater patient engagement and retention in continuing care remains elusive. Objectives: The objectives of this study were to determine if staff's continuity of care practices predict patients' engagement in continuing care in the 6 months after discharge from intensive SUD treatment and to determine if the impact of continuity of care practices on patients' engagement in continuing care differs for patients treated in inpatient/residential versus outpatient programs. Research Design: Staff in 28 Veterans Affairs (VA) intensive SUD treatment programs with varying continuity of care practices provided data on 878 patients' alcohol and drug problems at treatment entry. At discharge, staff provided data on patients' motivation, treatment intensity, and on the continuity of care practices they used with each patient. VA administrative databases supplied data on patients' subsequent engagement in continuing care. Mixed-effects modeling was used to examine predictors of patients' engagement in care. Results: Patients in outpatient programs who received more continuity of care engaged in continuing care significantly longer. More highly motivated outpatients, those with fewer alcohol problems at treatment entry, and patients who used VA services in the year before treatment also remained in continuing care longer. These findings did not hold for patients treated in inpatient/residential programs. Conclusions: Continuity of care practices predicted engagement in continuing care only for patients treated in outpatient SUD programs. More research is needed to identify effective continuity of care practices for patients treated in inpatient/residential programs.

Schmitt SK; Phibbs CS; Piette JD. The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment. Addictive Behaviors 28(6): 1183-1192, 2003. (20 refs.)

This study examined whether substance abuse patients who live farther from their source of outpatient mental health care were less likely to obtain aftercare following an inpatient treatment episode. For those patients who did receive aftercare, distance was evaluated as a predictor of the volume of care received. A national sample of 33,952 veterans discharged from Department of Veterans Affairs (VA) inpatient substance abuse treatment programs was analyzed using a two-part choice model utilizing logistic and linear regression. Patients living farther from their source of outpatient mental health care were less likely to obtain aftercare following inpatient substance abuse treatment. Patients who traveled 10 miles or less were 2.6 times more likely to obtain aftercare than those who traveled more than 50 miles. Only 40% of patients who lived more than 25 miles from the nearest aftercare facility obtained any aftercare services. Patients who received aftercare services had fewer visits if they lived farther from their source of aftercare. Lack of geographic access (distance) is a barrier to outpatient mental health care following inpatient substance abuse treatment, and influences the volume of care received once the decision to obtain aftercare is made. Aftercare services must be geographically accessible to ensure satisfactory utilization.

Severance TA. Concerns and coping strategies of women inmates concerning release: "It's Going to Take Somebody in My Corner". Journal of Offender Rehabilitation 38(4): 73-97, 2004. (31 refs.)

This article examines reintegration issues as experienced by women inmates approaching release. The data, based on unstructured, in-depth interviews with 40 incarcerated women, highlight the practical concerns that the inmates anticipate upon release and how they plan to overcome the obstacles before them. Housing, employment, familial reintegration, and substance abuse issues were commonly discussed. Coping strategies for overcoming these obstacles included education, 12-step programs, and prayer. Their accounts reveal the anxiety and fear associated with release and highlight the need for programs and policies to assist reintegration efforts.

Simpson TL; Kivlahan DR; Bush KR; McFall ME. Telephone self-monitoring among alcohol use disorder patients in early recovery: A randomized study of feasibility and measurement reactivity. Drug and Alcohol Dependence 79(2): 241-250, 2005. (50 refs.)

Frequent symptom self-monitoring protocols have become popular tools in the addiction field. Interactive Voice Response (IVR) is a telephone monitoring system that has been shown to be feasible for collecting frequent self-reports from a variety of research populations. Little is known, however, about the feasibility of using IVR monitoring in clinical samples, and few controlled trials exist assessing the impact of any type of frequent self-report monitoring on the behaviors monitored. This pilot study with patients in early recovery from an alcohol use disorder (n =98) evaluated compliance with two IVR monitoring protocols, subjective experiences with monitoring, and change in symptoms associated with monitoring (i.e., measurement reactivity). Participants were randomly assigned to call an IVR system daily for 28 days, once per week for 4 weeks, or only to complete 28-day follow-up assessment including retrospective drinking reports. Monitoring calls assessed alcohol craving, substance use, emotional well-being, and PTSD symptoms. Most monitoring participants completed calls on at least 75% of scheduled days (72.2% and 59.2% for daily and weekly, respectively). Including reconstructed data from follow-up of missed calls yielded 77.8% and 74.1% of maximum data points, respectively. Most monitoring participants indicated the protocol was manageable and reported positive or no effects of monitoring on urges to use alcohol, actual drinking, and PTSD symptoms. Analyses of measurement reactivity based on assessment one month after randomization found no significant group differences on drinking, craving for alcohol, or PTSD-related symptoms. Results suggest that IVR technology is feasible and appropriate for telephone symptom monitoring in similar clinical samples.

Sowers WE; Rohland B. American Association of Community Psychiatrists' principles for managing transitions in behavioral health services. Psychiatric Services 55(11): 1271-1275, 2004. (34 refs.)

Continuous engagement in treatment and recovery services is one of the most important aspects of addressing acute episodes of severe behavioral health problems and the ongoing disabilities associated with them. Traditionally, fragmentation in systems of care has been common, and the transition from one provider, location, or intensity of service to another has not been prioritized