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CORK Bibliography: Inpatient Treatment

84 citations. January 2005 to present

Prepared: March 2009

AbuMadini MS; Rahim SIA; Al-Zahrani MA; Al-Johi AO. Two decades of treatment seeking for substance use disorders in Saudi Arabia: Trends and patterns in a rehabilitation facility in Dammam. Drug and Alcohol Dependence 97(3): 231-236, 2008. (21 refs.)

Background: Treatment provision and treatment seeking for substance use disorders is a relatively new phenomenon in the Middle East. The present study aims to study these trends among first admissions to the specialized addiction treatment Amal Hospital of Dammam over its first two decades (1986-2006). The main outcome measures were: annual inception number (AIN), relative frequency of substances (RFS), relative frequency of drug combinations (RFDC), mean number of substances (MNS), and sociodemographic changes. Results: A total of 12.743 patients were admitted between 1986 and 2006. The majority were aged 20-39 years (83%), never married (60%), and with low education (81%). In the second decade, subjects were significantly older and less unemployed than in the first decade (28.9 years versus 30.2 years: 27% versus 19%). The mean AIN rose from 509 in the first decade to 765 in the second decade. In the same periods, the RFS increased for amphetamines and cannabis (from 12.1 and 17.5% to 48.1 and 46.5%, respectively), decreased for heroin, sedatives and volatile substances (from 51.1. 15.1. and 6.1% to 22.5, 7.3, and 2.5%, respectively). and remained stable for alcohol (froth 27.1 to 26.7%). The overall RFDC increased from 25.5 to 43.2% with significant pair-wise increases of cannabis/amphetamine, alcohol/cannabis and alcohol/amphetamine, and heroin/alcohol. The mean number of substances per subject increased from 1.32 to 1.56%. Conclusions: Significant shifts have occurred in the types and patterns substances use among treatment-seeking subjects. These findings underscore the need for community-based epidemiologic studies and for the establishment of a. comprehensive drug information system in Saudi Arabia.

Alessi H; Ballard M; Kirk A; Montalbo N. Cognitive impairment and substance abuse: implications for treatment planning. Journal of Alcohol and Drug Education 50(4): 55-66, 2006. (19 refs.)

The cognitive abilities of 24 males at an in-patient substance abuse facility were assessed using the Neurobehavioral Cognitive Status Examination (Cognistat). Findings suggested that there were significant changes in cognitive functioning during the 21-day in-patient treatment as measured by the Cognistat. Implications for mental health professionals working with this population are discussed

Ames SC; Croghan IT; Clark MM; Patten CA; Stevens SR; Schroeder DR et al. Change in perceived stress, partner support, decisional balance, and self-efficacy following residential nicotine dependence treatment. Journal of Addictive Diseases 27(1): 73-82, 2008. (35 refs.)

The primary aim was to examine the effect of an eight day residential treatment for nicotine dependence on perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking. Whether these variables predicted six months post treatment abstinence following residential treatment was also examined. Participants included 170 adult cigarette smokers. Perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking were assessed on the first and last day of treatment. In addition, six month continuous tobacco abstinence was evaluated. Residential treatment was: found to produce significant (p < 0.001) treatment changes in all psychosocial factors except one aspect of decisional balance (i.e., cons of smoking). Psychosocial factors did not predict six month tobacco abstinence. Only age (p = 0.014) and history of mental illness (p = 0.012) were found to predict six month continuous abstinence following residential treatment. This study provides new information about how residential treatment impacts psychosocial factors considered to be important predictors of tobacco abstinence in outpatient settings.

Amodeo M; Chassler D; Oettinger C; Labiosa W; Lundgren LM. Client retention in residential drug treatment for Latinos. Evaluation and Program Planning 31(1): 102-112, 2008. (71 refs.)

Client drop out from treatment is of great concern to the substance abuse field. Completion rates across modalities vary from low to moderate, not ideal since length of stay has been positively and consistently associated with better client outcomes. The study explored whether client characteristics shown to be related to retention were associated with treatment completion and treatment duration for a sample of 164 Latino substance users who entered a culturally focused residential program. In-person client interviews were conducted within a week of program admission. Logistic regression analysis was used to examine research questions. Clients most likely to drop out had self-reported co-occurring psychiatric diagnoses; they were 81% less likely to complete the program, suggesting that clients with mental health problems have a more difficult time remaining in residential treatment. Clients using drugs in the three months prior to entry were three and a half times more likely to be in the shorter stay group, and clients who lived in institutions prior to program entry were three times more likely to be in the longer-stay group. Factors contributing to drop out for this Latino sample were similar to those identified in the literature for non-Latino samples. Methods for addressing the needs of clients with co-occurring disorders are discussed.

Ana EJS; Wulfert E; Nietert PJ. Efficacy of group motivational interviewing (GMI) for psychiatric inpatients with chemical dependence. Journal of Consulting and Clinical Psychology 75(5): 816-822, 2007. (21 refs.)

Dually diagnosed patients with chemical dependency and a comorbid psychiatric disorder typically show poor compliance with aftercare treatment, which may result in costly and pervasive individual and societal problems. In this study, the authors investigated the effect of adding motivational interviewing in a group format to standard treatment for dually diagnosed psychiatric inpatients. The patients (n = 101) all received standard care and in addition were assigned to either group motivational interviewing (GMI) or a therapist attention activity control group (TAAC). Of patients who attended aftercare and who used alcohol or drugs, those who participated in GMI attended significantly more aftercare treatment sessions, consumed less alcohol, and engaged in less binge drinking at follow-up compared with those in TAAC. Differences between conditions in the overall percentage of participants who achieved complete abstinence or who attended aftercare treatment were not significant, possibly because of a lack of power. These results provide preliminary evidence for the efficacy of GMI when added at the outset to an inpatient program.

Baird C. Treating women with children: What does the evidence say? Journal of Addictions Nursing 19(2): 83-85, 2008. (12 refs.)

This systematic review of the literature examines the barriers women, especially women who are pregnant and parenting, experience when they attempt to access treatment for a substance use problem. These barriers impact their rate of entering and successfully completing treatment thus preventing them from returning to full participation in society. A provider of residential treatment for women with substance use disorders wants to develop a program that can reduce or remove some of these barriers. Does the evidence support a practice change to a gender specific, comprehensive inpatient residential treatment program for women who are pregnant and parenting?.

Banerjee K; Howard M; Mansheim K; Beattie M. Comparison of health realization and 12-step treatment in women's residential substance abuse treatment programs. American Journal of Drug and Alcohol Abuse 33(2): 207-215, 2007. (20 refs.)

The purpose of this study was to compare a relatively new therapeutic option for substance abuse treatment, Health Realization, and 12-Step approaches offered in women's residential programs. The study was sponsored by a large California county's Department of Alcohol and Drug Services, which had offered Health Realization treatment for a number of years. This study constitutes the first systematic evaluation of Health Realization as a substance abuse treatment program for adult women in a residential treatment setting. This was a randomized study with two observations-admission and 9 months post-admission. The results showed that clients in both Health Realization and 12-Step treatment exhibited comparable outcomes on domains such as substance use, criminal justice involvement, employment, housing, adverse effects of substance use and psychological well being. Substance use declined significantly between admission and follow-up in both treatment groups, irrespective of duration of treatment. Similarly, adverse effects of substance use declined between admission and 9-month follow-up. Health Realization and 12-Step treatment offered comparable benefits for women in residential substance abuse treatment programs.

Bell E. Self, meaning, and culture in service design: Using a hermeneutic technique to design a residential service for adolescents with drug issues. International Journal of Drug Policy 17(5): 425-435, 2006. (69 refs.)

This paper aims to contribute to a relatively untheorised and unresearched area of adolescent drug and alcohol literature-designing residential services. In a context in which the researcher was given the 'hands on' task of designing a model residential service for adolescents with drug issues in the Australian state of Tasmania, it explores techniques that might be useful to understanding and placing young people's views at the centre of service design. The paper begins with discussion of the international literature on residential service design for adolescents with drug issues, and the nature of a Tasmanian service design project. It then explores young Tasmanians' idealisations of residential services needed for youth with drug issues. These young people offered their thoughts along five major dimensions of the operationalisation of a residential service: service mission, activities and programs, location of the service, nature of staff, and service rationale or benefits. Their comments were analysed using a hermeneutic technique exploring the 'life-worlds' suggested by their vision of the ideal residential service. Youth data are contrasted with the broad findings of interviews with adult professionals in Tasmanian youth services to question the assumptions implicit in research, policy and practice at the international level.

Bell E. Time, space and body in adolescent residential services: Re-imagining service research. (review). Addiction Research & Theory 15(1): 97-111, 2007. (70 refs.)

The objective of this article, which emerges from the pragmatic dissatisfactions of a service designer, is to explore the way forward for developing more socially useful research evidence for adolescent substance abuse services. Analysis is made of the limitations of existing substance abuse research, driven by classical experimental models that rely on traditional quantitative techniques. Theoretical propositions about the nature of an ideal service are developed from interviews with professionals in twenty of Australia's twenty-three adolescent residential services. These suggest the configurational nature of the service, arising from its multi-dimensional temporal, spatial and material properties, and the importance of the service's capacity to combine diverse service elements in complementary ways to meet individual client needs. A social sciences methodology - qualitative comparative analysis (QCA) - has the potential to better analyse the configurational nature of such services, allowing identification of effective service element combinations, especially in small-N studies.

Berglund K; Berggren U; Fahlke C; Balldin J. Self-reported health functioning in Swedish alcohol-dependent individuals: Age and gender perspectives. Nordic Journal of Psychiatry 62(5): 405-412, 2008. (49 refs.)

The aim of this study was to investigate health functioning and drinking patters in a Swedish alcohol-dependent treatment sample. Gender and two age groups were, respectively, compared in these characteristics. Data for demographic characteristics, substance use and health functioning were collected by a structured interview, using the Addiction Severity Index. A total sample of 125 individuals (30 women and 95 men) was interviewed shortly after arrival to the inpatient treatment. Differences between genders were found in drinking patterns, where men had earlier onset of first drink, earlier onset of problematic alcohol consumption and longer duration of problematic consumption. No differences between genders were found regarding somatic and psychiatric health. When comparing the two age groups (29-47 years and 49-69 years), the younger individuals had more lifetime and current psychiatric symptoms (including depression, anxiety, suicidal ideation etc.), whereas the older individuals had more chronic somatic disorders. The younger individuals had also an earlier onset of first drink of alcohol and had started a problematic consumption at earlier ages. They had also more lifetime experience of illicit drugs (including benzodiazepines and analgesics). The findings from the present study indicate that an age-perspective in treatment planning may be of more importance than a gender perspective, where younger individuals probably need more of psychiatric consultation and their older counterparts need more of consultations by medical professionals.

Bluthenthal RN; Jacobson JO; Robinson PL. Are racial disparities in alcohol treatment completion associated with racial differences in treatment modality entry? Comparison of outpatient treatment and residential treatment in Los Angeles County, 1998 to 2000. Alcoholism: Clinical and Experimental Research 31(11): 1920-1926, 2007. (28 refs.)

Objective: To determine whether racial and ethnic disparities in publicly funded alcohol treatment completion are due to racial differences in attending outpatient and residential treatment. Methods: Statistical analysis of alcohol treatment completion rates using alcohol treatment patients' discharge records from all publicly funded treatment facilities in Los Angeles County from 1998 to 2000 (n = 10,591). Results: Among these patients, African American (OR = 0.52; 95% CI 0.47, 0.57) and Hispanic (OR = 0.89; 95% CI 0.81, 0.99) patients were significantly less likely to complete treatment as compared with White patients. We found that the odds of being in outpatient versus residential care were 1.42 (95% CI 1.29, 1.55) and 2.05 (95% CI 1.85, 2.26) for African American and Hispanic alcohol treatment patients, respectively, compared with White patients. Adjusting for addiction characteristics, employment, other patient-level factors that might influence treatment enrollment, and unobserved facility-level differences through a random effects regression model, these odds increased to 1.89 (95% CI 1.22, 2.94) for African American and to 2.12 (95% CI 1.40, 3.21) for Hispanics. We developed a conditional probability model to assess the contribution of racial differences in treatment modality to racial disparities in treatment completion. Estimates from this model indicate that were African American and Hispanic patients observed in outpatient care in this population to have the same probability of receiving residential care as White patients with otherwise similar characteristics, the White-African American difference in completion rates would be reduced from 13.64% (95% CI 11.58%, 15.71%) to 11.09% (95% CI 8.77%, 13.23%) and the White-Hispanic difference would disappear, changing from 2.63% (95% CI 0.29%, 4.95%) to -0.45% (-3.52%, 2.43%). Conclusion: It appears that reductions in racial disparities in treatment completion could be gained by increasing enrollment in residential alcohol treatment for African American and Hispanic alcohol abusers in Los Angeles County. Further research addressing why minority alcohol abusers are less likely to receive residential alcohol treatment should be conducted, as well as research that examines why African American alcohol treatment patients have lower completion rates as compared with White patients regardless of treatment modality.

Bray JW; Zarkin GA; Miller WR; Mitra D; Kivlahan DR; Martin DJ; Couper DJ; Cisler RA. Measuring economic outcomes of alcohol treatment using the economic form 90. Journal of Studies on Alcohol and Drugs 68(2): 248-255, 2007. (35 refs.)

Objective: This article assesses the ability of the economic outcome measures in the Economic Form 90 to detect differences across levels of alcohol dependence as measured by the Alcohol Dependence Scale. Method: We used baseline data from the Combining Medications and Behavioral Interventions (COMBINE) Study, a large, multisite clinical trial, to assess the extent to which the economic items on the Economic Form 90 instrument can detect differences across levels of alcohol dependence. Results: After adjusting for differences in demographic characteristics, the Economic Form 90 can detect significant differences across a range of dependence severity levels for the economic outcomes of inpatient medical care, emergency-department medical care, behavioral health care, being on parole or probation, and missed workdays, conditional or being employed. We did not detect significant differences across dependence severity for employment status, outpatient medical care, other criminal justice involvement, or motor vehicle accidents. Conclusions: The Economic Form 90 can identify differences in many economic outcomes associated with differing levels of alcohol dependence. This suggests that the Economic Form 90 may be useful in assessing changes in economic outcomes that result from changes in alcohol dependence.

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.

Cacciola JS; Camilleri AC; Carise D; Rikoon SH; Mckay JR; McLellan AT et al. Extending residential care through telephone counseling: Initial results from the Betty Ford Center Focused Continuing Care protocol. Addictive Behaviors 33(9): 1208-1216, 2008. (30 refs.)

There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the "real world". This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described.

Callaghan R; Taylor L; Victor JC; Lentz T. A case-matched comparison of readmission patterns between primary methamphetamine-using and primary cocaine-using adolescents engaged in inpatient substance-abuse treatment. Addictive Behaviors 32(12): 3101-3106, 2007. (8 refs.)

Objective: In the United States and Canada, elevated patterns of methamphetamine-related treatment admissions among youth have triggered questions about appropriate substance-abuse treatment strategies for methamphetamine-using adolescents. This study aimed to provide a comparative examination of the readmission patterns of primary methamphetamine-using and primary cocaine-using adolescents to a cognitive behavioral therapy (CBT)-based alcohol-and-drug inpatient treatment program. Methods: The current study employed a 5-year medical-chart review of all consecutive admissions to an inpatient, hospital-based substance-abuse treatment program for adolescents in northern British Columbia, Canada. After using a propensity-score-matching approach to construct a case-matched sample (n = 202) of primary methamphetamine-using and primary cocaine-using adolescents, we employed a Kaplan-Meier survival analysis technique to test group differences in time-to-readmission. Results: The findings demonstrated that the methamphetamine group did not have a more severe time-to-readmission profile. Conclusions: General CBT-based treatment-as-usual approaches appear to produce similar long-term readmission outcomes for these two groups of treatment-seeking adolescents.

Callaghan RC; Brewster JM; Johnson J; Taylor L; Beach G; Lentz T. Do total smoking bans affect the recruitment and retention of adolescents in inpatient substance abuse treatment programs? A 5-year medical chart review, 2001-2005. Journal of Substance Abuse Treatment 33(3): 279-285, 2007. (32 refs.)

Adolescents engaged in substance abuse treatment manifest a rate of cigarette smoking approximately four times higher than that of youth in the general population (similar to 80% vs. 20%) and a high rate of smoking persistence into adulthood. Although there has been a shift toward the implementation of no-smoking policies in substance abuse treatment programs, few studies have examined the relation between cigarette-smoking bans and key clinical outcomes. The current study examined the medical charts of all adolescents (N = 520) admitted to the only adolescent hospital-based substance abuse treatment program in the northern two thirds of the province of British Columbia, Canada. During the span of the study period (March 2001-December 2005), the treatment site moved from a partial smoking ban to a total smoking ban, and then retreated to partial smoking ban. The total smoking ban was not associated with a lower proportion of adolescent smokers seeking treatment at the facility or a lower treatment completion rate among smokers. Total smoking bans do not appear to be an obstacle for adolescent smokers seeking residential substance abuse treatment, nor do total smoking bans appear to compromise the treatment completion rates of smokers in comparison to nonsmokers. Despite these null findings, the effective implementation of smoke-free policies in adolescent substance abuse treatment programs requires not only large-scale organizational change but also the transformation of current commonly held beliefs about tobacco dependence in addictions treatment and recovery communities.

Callaghan RC; Cull R; Vettese LC; Taylor L. A gendered analysis of Canadian aboriginal individuals admitted to inpatient substance abuse detoxification: A three-year medical chart review. (review). American Journal on Addictions 15(5): 380-386, 2006. (44 refs.)

This study examined gender differences within a sample of Canadian Aboriginal individuals admitted to an inpatient, hospital-based substance abuse detoxification program. Even though alcohol was the most frequent primary drug of detoxification for both genders, women received proportionately higher rates of cocaine or opiate detoxification diagnoses. In addition to a younger age, females reported higher rates of physical and sexual abuse. Women were also administered antidepressants, antibiotic medication protocols, and more medical evaluation tests. It appears that Canadian Aboriginal women have a diverse set of psychological and medical needs. This study demonstrates the need for detoxification programs to address the substantial rates of intravenous drug use and the associated risk of infectious disease (eg, Hepatitis C, HIV) among this treatment-seeking population.

Callaghan RC; Hathaway A; Cunningham JA; Vettese LC; Wyatt S; Taylor L. Does stage-of-change predict dropout in a culturally diverse sample of adolescents admitted to inpatient substance-abuse treatment? A test of the Transtheoretical Model. Addictive Behaviors 30(9): 1834-1847, 2005. (50 refs.)

The Transtheoretical Model (TTM) (Prochaska, Diclemente, & Norcross, 1992) proposes that the stages-of-change construct can serve as useful tool for identifying those most at-risk of treatment dropout [Prochaska, J. O. (1999). How do people change, and how can we change to help many more people? In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change (pp. 227255). Washington: American Psychological Association]. While researchers have found mixed support for this claim in adult samples, studies have not yet tested this issue in adolescent substance-abuse treatment settings. This paper reports findings from a Canadian study of adolescents (n = 130: 80 Caucasians, 50 Aboriginals) admitted to a hospital-based, residential substance-abuse treatment program. Two approaches were used to test the TTM's claim: (1) a hierarchical logistic regression model of dropout was developed using the subscales of the University of Rhode Island Change Assessment instrument (URICA), demographic variables, and subscales of the Addiction Severity Index (ASI); and (2) a chi-square analysis was employed to test the hypothesized relation between stage-of-change and dropout status. The findings demonstrated that the best predictive model of dropout included only the Precontemplation subscale of the URICA (OR: 4.3; 95% CI: 2.0-9.0). In addition, adolescents assigned to the Precontemplation stage manifested significantly higher rates of treatment attrition than individuals in the Contemplation or Preparation/Action stages. This study provides important empirical support for the predictive utility of the stage-of-change construct among a culturally diverse sample of adolescents admitted to an inpatient substance-abuse treatment program.

Collins ED; Horton T; Reinke K; Amass L; Nunes EV. Using buprenorphine to facilitate entry into residential therapeutic community rehabilitation. Journal of Substance Abuse Treatment 32(2): 167-175, 2007. (33 refs.)

For opioid-dependent patients, the need for detoxification has been a barrier to entry into long-term residential treatment. This report describes a retrospective observational cohort study with the first 38 opioid-dependent patients entering First Step, a 14-day buprenorphine-naloxone (Suboxone) detoxification regimen integrated into a long-term residential therapeutic community (TC) program. Eighty-nine percent (34 of 38) of First Step patients completed a 14-day buprenorphine taper protocol, 50% (19 of 38) completed an initial 3- to 4-weck stay, and 39% (15 of 38) completed at least 3 months of residential treatment at the TC. Retention did not differ significantly in a demographically matched concurrently admitted control group without impending opioid withdrawal, in which 65% (24 of 37) completed an initial 3- to 4-week stay (p =.20) and 57% (21 of 37) completed at least 3 months of treatment (p --.14). Withdrawal symptoms were mild, and there were no instances of precipitated withdrawal. The findings suggest the potential for buprenorphine to serve as a bridge, improving the viability of long-term residential treatment for managing opioid dependence.

Darke S; Williamson A; Ross J; Teesson M. Residential rehabilitation for the treatment of heroin dependence: Sustained heroin abstinence and drug-related problems 2 years after treatment entrance. Addictive Disorders and their Treatment 5(1): 9-18, 2006. (27 refs.)

To determine levels of sustained heroin abstinence, current drug use, and drug-related problems of residential rehabilitation (RR) admissions 24 months after entering treatment. Longitudinal cohort study of 100 heroin users admitted to short-term (1 month) or long-term (3-6 months or longer) RR. Separation in the first week was uncommon in both short-term (7%) and long-term (16%) programs. Eighteen percent successfully graduated, 47% self-discharged, and 30% were expelled. Postindex treatment exposure was widespread (82%), with additional RR the most common treatment. At 24 months, 71% were heroin abstinent over the month preceding interview, and 18% reported heroin abstinence over the entire follow-up period. There had been large declines in levels of recent needle borrowing, crime, psychopathology, and improvements in global and injection-related health. Independent predictors of continuous heroin abstinent were female sex (odds ratio [OR] 5.00), successful graduation from the index program (OR 9.05), and post-treatment MT exposure (OR 0.08). The study confirms the effectiveness of RR and highlights and the impact of program graduation.

Day E; Best D; Ison J; Keaney F; Strang J; Buntwal N. Do psychiatrists make a difference? Impact of levels of medical input to the range of treatment provided in in-patient drug detoxification services. Drugs: Education, Prevention and Policy 13(6): 577-585, 2006. (8 refs.)

Aims: There is limited research evidence about the role of in-patient detoxification for drug users and in determining where this form of treatment should occur and with what level of medical support and supervision. Methods: The current study is based on a national survey of National Health Service (NHS) providers of drug detoxification in residential settings in England. Of the 76 services identified, 56 (74%) completed and returned the survey, including 19 specialist providers and 37 general medical or psychiatric wards that had beds available for residential drug detoxification. Findings: There was marked variability across providers in the level of medical and non-medical staffing, and in the characteristics of the treatment programmes available. These factors differed systematically by whether the unit was a specialist provider, particularly with regard to levels of medical input. There was greater medical input in the specialist units (statistically significant for staff grade and SHO psychiatrists) while there was greater input from occupational therapy on the general medical or psychiatric wards. There was also a higher ratio of nursing staff for each drug bed in the specialist units. Conclusions: Although better medical support is available in specialist units, the marked variability across participating units suggests an inconsistency in residential drug treatment that is worrying and requires further investigation.

Day E; Ison J; Strang J. Inpatient versus other settings for detoxification for opioid dependence. (review). Cochrane Database of Systematic Reviews 2: CD004580.pub2, 2005. (39 refs.)

Background: There are a complex range of variables that can influence the course and subjective severity of opioid withdrawal. There is a growing evidence for the effectiveness of a range of medically-supported detoxification strategies, but little attention has been paid to the influence of the setting in which the process takes place. Objectives To evaluate the effectiveness of any inpatient opioid detoxification programme when compared with all other time-limited detoxification programmes on the level of completion of detoxification, the intensity and duration of withdrawal symptoms, the nature and incidence of adverse effects, the level of engagement in further treatment post-detoxification, and the rates of relapse post-detoxification. Search strategy Electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL-The Cochrane Library Issue 3, 2004); MEDLINE (January 1966-March 2004); EMBASE (January 1988-March 2004); PsycInfo (January 1967-March 2004); CINAHL (January 1982-March 2004). In addition the Current Contents, Biological Abstracts, Science Citation Index and Social Sciences Index were searched. Selection criteria: Randomised controlled clinical trials comparing inpatient opioid detoxifocation (any drug or psychosocial therapy) with other time limited detoxification programmes (including residential units that are not staffed 24 hours per day, day-care facilities where the patient is not resident for 24 hours per day, and outpatient or ambulatory programmes, and using any drug or psychosocial therapy). Data collection and analysis: All abstracts were independently inspected by two reviewers (ED & JI) and relevant papers were retrieved and assessed for methodological quality using Cochrane Reviewers' Handbook criteria. Main results Only one study met the inclusion criteria. This did not explicitly report the number of participants in each group that success fully completed the detoxification process, but the published data allowed us to deduce that 7 out of 10 (70%) in the inpatient detoxification group were opioid-free on discharge, compared with 11 out of 30 (37%) in the outpatient group. There was very limited data about the other outcomes of interest. Authors' conclusions: This review demonstrates that there is no good available research to guide the clinician about the outcomes or cost-effectiveness of in patient or out patient approaches to opioid detoxification.

De Leon G; Melnick G; Cleland CM. Client matching: A severity-treatment intensity paradigm. Journal of Addictive Diseases 27(3): 99-113, 2008. (34 refs.)

Despite considerable effort to develop matching strategies and client placement protocols, research studies fail to yield compelling results regarding the benefits of matching to treatment. The most consistent findings suggest a matching paradigm, which defines a successful placement as the least treatment intensity required addressing the severity of the disorder. The purpose of the present study is to provide further empirical support for the validity of a severity-intensity paradigm utilizing data from the Drug Abuse Treatment Outcome Studies. A "passive match" approach employed the Client Matching Protocol decision algorithm, which recommended clients to long-term residential or outpatient drug-free treatment. One-year outcomes for clients matched to long-term residential treatment were better on all outcome variables compared to those undertreated in outpatient drug-free treatment. Findings supported the validity of the severity-intensity paradigm in that undertreated clients showed less improvement compared to matched and overtreated clients.

Edman J. Treatment of what? Class, gender and work ethics within the compulsory institutional care of alcohol abusers in Sweden during the 20th century. Nordic Studies on Alcohol and Drugs 22(English Supplement): 45-62, 2005. (43 refs.)

Aims: The aim of this article is to investigate the problem formulations -- the preconceptions about causes and effects and the possible solutions to the problems of alcohol abuse -- that characterized the compulsory institutional care of alcohol abusers in Sweden in the 20th century. The article focuses on problem formulations that actually were practiced in the institutions. Methods and Data: The main source material is to be found in the archives of four institutionalized care establishments and consists of official reports, correspondence, supply estimate, circulars of consideration and -- above all -- patient records. From this material you can learn about the institutions' struggle for autonomy, expansions and legitimacy, and also about the clients' characteristics and how the clients were viewed. The study of the archives allows you to form a picture of the problem formulations that affected the activities in the institutions directly, a picture that goes beyond the more abstract expectations proffered by official reports and legislation. Results: Within the compulsory institutional care actually carried out, the problem formulations that were stipulated in the gender-neutral legislation and vague regulations became gender-specific and precise. The treatment of alcohol abusers was class and gender related project, aimed not only at encouraging male diligence and the fulfilling of a man's maintenance obligation but also at female virtuousness and concern for the family. Conclusions: The history of alcohol abusers' treatment shows that alcohol itself has been a secondary factor in problem definitions which have let themselves be attached -- via perceived links with either cause of effect -- to more overarching social issues in Sweden. The concerns of emergent family policy in the 1940s, the development optimism and scientific passions of the 1950s and the systemically critical protest movements of the 1970s are all clearly reflected in trends within social care services for alcohol abusers -- albeit much more often at the level of discourse than of praxis.

Egel D; Torino TM. Violence intervention prevention. Journal of Addictions Nursing 17(1): 13-19, 2006. (9 refs.)

The Office of Alcoholism and Substance Abuse Services (OASAS) operates 13 Addiction Treatment Centers located across New York State. This article examines the issues and problems faced by a joint labor/management team that designed and implemented a workplace violence intervention prevention program for inpatient drug addiction treatment programs.

Evren C; Evren B; Yancar C; Erkiran M. Temperament and character model of personality profile of alcohol- and drug-dependent inpatients. Comprehensive Psychiatry 48(3): 283-288, 2007. (32 refs.)

The aims of this study were to evaluate the differences in dimensions of temperament and character in Turkish alcohol- and drug-dependent inpatients, and to examine which dimensions would predict drug dependency. The subjects consisted of 111 alcohol-dependent and 93 drug-dependent inpatients according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Subjects were tested using Cloninger's Temperament and Character Inventory (TCI). Among the temperament dimensions, novelty seeking score was higher and reward dependency score was lower in drug-dependent patients than in alcohol-dependent patients. Among the character dimensions, self-directedness and cooperativeness scores were lower in drug-dependent patients. Low age and novelty seeking predicted drug dependency in forward logistic regression model. Subscales that predicted drug dependency other than young age were lower scores on compassion vs revengefulness (C4) and helpfulness (C3), and higher score on spiritual acceptance vs rational materialism (ST3). As in previous studies, which indicate an association between personality and substance choice, in the present study, TCI was shown to be an efficient tool in discriminating alcohol and drug dependents; thus, it seems to be important to consider TCI dimensions in planning the treatment of substance dependency.

Faw L; Hogue A; Liddle HA. Multidimensional implementation evaluation of a residential treatment program for adolescent substance abuse. American Journal of Evaluation 26(1): 77-94, 2005. (39 refs.)

The authors applied contemporary methods from the evaluation literature to measure implementation in a residential treatment program for adolescent substance abuse. A logic model containing two main components was measured. Program structure (adherence to the intended framework of service delivery) was measured using data from daily activity logs completed by program staff. Treatment process, conceptualized as therapeutic milieu, was measured using an adapted version of a scale used to measure implementation in therapeutic communities. In addition, variability in implementation was measured using statistical process control (SPC) procedures. Adolescents completed, on average, 50% of the weekly prescribed services. The milieu of the program was rated by the adolescents as highly therapeutic. Moreover, preliminary psychometrics suggest therapeutic milieu can be measured reliably in adolescents. These two main variables were implemented with consistency across adolescents. These findings are discussed along with implications for evaluation work in similar fields.

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.

Gossop M; Stewart D; Marsden J. Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study. Addiction 103(1): 119-125, 2008. (44 refs.)

Aims This study investigates the relationship between frequency of attendance at Narcotics Anonymous and Alcoholics Anonymous (NA/AA) meetings and substance use outcomes after residential treatment of drug dependence. It was predicted that post-treatment NA/AA attendance would be related to improved substance use outcomes. Methods Using a longitudinal, prospective cohort design, interviews were conducted with drug-dependent clients (n = 142) at intake to residential treatment, and at 1 year, 2 years and 4-5 years follow-up. Data were collected by structured interviews. All follow-up interviews were carried out by independent professional interviewers. Findings Abstinence from opiates was increased throughout the 5-year follow-up period compared to pre-treatment levels. Clients who attended NA/AA after treatment were more likely to be abstinent from opiates at follow-up. Abstinence from stimulants increased at follow-up but (except at 1-year follow-up) no additional benefit was found for NA/AA attendance. There was no overall change in alcohol abstinence after treatment but clients who attended NA/AA were more likely to be abstinent from alcohol at all follow-up points. More frequent NA/AA attenders were more likely to be abstinent from opiates and alcohol when compared both to non-attenders and to infrequent (less than weekly) attenders. Conclusions: NA/AA can support and supplement residential addiction treatment as an aftercare resource. In view of the generally poor alcohol use outcomes achieved by drug-dependent patients after treatment, the improved alcohol outcomes of NA/AA attenders suggests that the effectiveness of existing treatment services may be improved by initiatives that lead to increased involvement and engagement with such groups.

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.

Iglesias C; Lopez G; Alonso MJ. Effects of smoking ban in a general hospital psychiatric unit. Actas Espanolas de Psiquiatria 36(1): 60-62, 2008. (10 refs.)

Introduction. Many psychiatric facilities allow patients to smoke cigarettes even though this habit is especially harmful for mental patients. Methods. We studied the untoward effects produced by the smoking ban in 40 consecutive inpatients admitted to a psychiatric ward of a general hospital. Results. A total of 52.2% out of 40 patients were smokers; the mean Fagerstrom score was 5.9. The most frequent diagnostic groups were: schizophrenia and delusional disorders; mood disorders; and personality disorders. There were only two untoward effects related with the smoking ban during the study period. Conclusions. This study shows that the smoking ban can be successfully implemented in a general hospital psychiatric unit without causing unfavorable effects.

Ilgen MA; Jain A; Lucas E; Moos RH. Substance use-disorder treatment and a decline in attempted suicide during and after treatment. Journal of Studies on Alcohol and Drugs 68(4): 503-509, 2007. (30 refs.)

Objective: Suicide attempts are common in patients being treated for substance-use disorders (SUDS). However, little is known about the frequency of suicidal behavior during and after SUD treatment or about aspects of treatment that predict subsequent suicidal behavior. The present study examines whether treatment setting, length of treatment, and availability/use of psychiatric services are associated with a reduced likelihood of a suicide attempt during and 1 year after treatment. Method: A national sample of 3,733 patients was assessed at the start of an episode of SUD treatment and again at discharge and/or I year after treatment. Mixed-model logistic regression analyses examined treatment-related predictors of in-treatment and posttreatment suicide attempts. Results: The rate of suicide attempts was significantly lower in the year following treatment (4%) than in the year before treatment (9%). Additionally, a total of 2% of patients reported a suicide attempt during treatment. Suicide attempts made during treatment were less likely in patients treated in residential as compared with outpatient settings. A longer course of treatment was associated with a lower likelihood of a posttreatment suicide attempt. Conclusions: A sizable minority of patients report a suicide attempt either during or within I year after completion of SUD treatment. Even after controlling for baseline suicidality, aspects of the SUD treatment episode are associated with a lower risk of a future suicide attempt. Treatment providers should consider placing patients in residential settings to reduce suicide attempts made during treatment and providing a longer course of treatment to reduce the likelihood of suicide following treatment.

Ilgen MA; Moos RH. Exacerbation of psychiatric symptoms during substance use disorder treatment. Psychiatric Services 57(12): 1758-1764, 2006. (31 refs.)

Objective: This study examined psychiatric symptom exacerbation (or deterioration) among patients treated for substance use disorders. The study examined several questions. What is the prevalence of deterioration during residential treatment? Compared with patients who show improvement in psychiatric symptoms, do those with deterioration of symptoms report poorer functioning during treatment and one year after treatment entry? Do patients who experience deterioration of symptoms one year after treatment entry enter treatment with more problems and poorer coping skills? Is the prevalence of deterioration associated with treatment orientation, and do patients whose psychiatric symptoms deteriorate view the treatment environment more negatively than patients whose symptoms improve? Methods: A total of 3,322 male patients were recruited at 15 residential substance abuse treatment programs in the Department of Veterans Affairs health care system between 1992 and 1995. On the basis of changes in psychiatric symptoms during treatment, these patients were categorized as having either deteriorated or improved psychiatric symptoms. Patients whose symptoms deteriorated were compared with a matched group of patients with improved symptoms. Results: A total of 426 patients (13 percent) reported a worsening of psychiatric symptoms during treatment. Compared with patients in the improved group (N=426), patients in the deteriorated group reported more psychiatric problems and substance use one year after treatment. Patients in the deteriorated group were more likely to have a psychotic diagnosis, lower self-efficacy, and more reliance on coping by expression of emotions and to view the treatment experience more negatively. Conclusions: Thirteen percent of the patients experienced an exacerbation of psychiatric symptoms during residential substance use disorder treatment. Improved monitoring procedures, such as regular assessments for changes in psychiatric symptoms, are needed to routinely obtain information about declines in psychiatric conditions during treatment.

Isralowitz R; Reznik A. Gender differences among Israeli adolescents in residential drug treatment. Drugs: Education, Prevention and Policy 14(2): 167-172, 2007. (17 refs.)

Aims: The use of licit and illicit drugs is considered to be primarily a male problem. Numerous studies, however, question the extent of gender differences. This article reports on last 30 day drug use and related problem behaviour among male and female youth prior to residential treatment. Methods: Self-report data were collected from 95 male and female adolescents, age 13 to 18 years, at intake for treatment. Findings: Gender was not a factor differentiating the youth for cigarette, alcohol, cannabis, ecstasy, inhalant, and amphetamine use. Males were more likely to report hashish use. Females, however, were more likely to report use of prescription drugs, cocaine and heroin. No gender differences were found for binge drinking, driving a car after drinking or being a passenger in a car after the driver had been drinking, selling drugs, deterioration of relations with friends and family, gambling, taking loans or using personal money to buy drugs. Conclusion: Drug use and related behaviour among adolescents in residential treatment does not appear to be predominately a male problem. Further research is needed to understand the role of gender status in relation to what drugs are used and how for prevention, treatment and public health purposes.

Johnson JE; Finney JW; Moos RH. Predictors of 5-year mortality following inpatient/residential group treatment for substance use disorders. Addictive Behaviors 30(7): 1300-1316, 2005. (52 refs.)

This study examined the prevalence and predictors of 5-year mortality following treatment for substance use disorders. The predictors were assessed at baseline, at discharge, and at a 1-year follow-up for 3698 male veterans, and included demographic, substance use, medical, and psychological functioning, social support, and continuing care. The annual mortality rate was 2.38%, with an observed/expected ratio of 3.05. After accounting for significant demographic, substance use, psychological, and medical conditions, not having a spouse or partner at intake independently predicted 5-year mortality. After accounting for intake variables, more depression at discharge and more medical conditions, a diagnosis of HIV or AIDS, more ounces of ethanol on a maximum drinking day, and lack of a spouse or partner at the 1-year follow-up independently predicted 5 -year mortality. Unexpectedly, good quality relationships were related to a higher mortality risk. Results can be used to increase at-risk patients' motivation for recovery.

Kaskutas LA; Zavala SK; Parthasarathy S; Witbrodt J. Costs of day hospital and community residential chemical dependency treatment. Journal of Mental Health Policy & Economics 11(1): 27-32, 2008. (22 refs.)

Background: Patient placement criteria developed by the American Society of Addiction Medicine (ASAM) have identified a need for low-intensity residential treatment as an alternative to day hospital for patients with higher levels of severity. A recent clinical trial found similar outcomes at social model residential treatment and clinically-oriented day hospital programs, but did not report on costs. Aims: This paper addresses whether the similar outcomes in the recent trial were delivered with comparable costs, overall and within gender and ethnicity stratum. Method: This paper reports on clients not at environmental risk who participated in a randomized trial conducted in three metropolitan areas served by a large pre-paid health plan. Cost data were collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP). Costs per episode were calculated by multiplying DATCAP-derived program-specific costs by each client's length of stay. Differences in length of stay, and in per-episode costs, were compared between residential and day hospital subjects. Results: Lengths of stay at residential treatment were significantly longer than at day hospital, in the sample overall and in disaggregated analyses. This difference was especially marked among non-Whites. The average cost per week was $575 per week at day hospital, versus $370 per week at the residential programs. However, because of the longer stays in residential, per-episode costs were significantly higher in the sample overall and among non-Whites (and marginally higher for men). Discussion: These cost results must be considered in light of the null findings comparing outcomes between subjects randomized to residential versus day hospital programs. The longer stays in the sample overall and for non-White clients at residential programs came at higher costs but did not lead to better rates of abstinence. The short stays in day hospital among non-Whites call into question the attractiveness of day hospital for minority clients. Conclusion: Outcomes and costs at residential versus day hospital programs were similar for women and for Whites. For non-Whites, and marginally for men, a preference for residential care would appear to come at a higher cost. Implications for Health Care Provision and Use: Lengths of stay in residential treatment were significantly longer than in day hospital, but costs per week were lower. Women and Whites appear to be equally well-served in residential and day hospital programs, with no significant cost differential. Provision of residential treatment for non-Whites may be more costly than day hospital, because their residential stays are likely to be 3 times longer than they would be if treated in day hospital. For men, residential care will be marginally more costly. Implications for Health Policy Formulation: Residential treatment appears to represent a cost-effective alternative to day hospital for female and White clients with severe alcohol and drug problems who are not at environmental risk. Implications for Further Research: The much shorter stays in day hospital than at residential among non-Whites highlight the need for research to better understand how to best meet the needs and preferences of non-White clients when considering both costs and outcomes.

Keizer I; Eytan A. Variations in smoking during hospitalization in psychiatric in-patient units and smoking prevalence in patients and health-care staff. International Journal of Social Psychiatry 51(4): 317-328, 2005. (27 refs.)

Background: Smoking and exposure to smoke are important concerns, especially in psychiatric in-patient services. Aims: Our aims were to study variations in smoking after hospitalization for psychiatric in-patients, and to evaluate smoking-related concerns and prevalence for both patients and health-care staff. Methods: A similar survey was mailed to staff members and proposed individually to all recently admitted patients; participation rates were 39% and 79% respectively. Results: Three days after admission, 4/10 patients had increased and 3/10 had decreased their daily tobacco use. Univariate analysis of variance showed nicotine dependence scores to be associated with variations in consumption (p =.005): whereas 74% of heavy smokers decreased cigarette consumption, 80% of light and 57% of moderate smokers increased their consumption. The prevalence of current smoking was twice as high in patients (72%) as compared to health-care professionals (31%). Patients were also more nicotine dependent (Heaviness of Smoking Index (HSI) = 3.97/vs. 1.81), and half of the patients were heavy smokers (> 20 cigarettes/day), as opposed to only 6.3% of the staff. Conclusions: Smoking prevalence and daily tobacco consumption are very high in psychiatric patients. After hospitalization, light and moderate smokers increased whereas heavy smokers decreased smoking.

Lauber C; Lay B; Rossler W. Homelessness among people with severe mental illness in Switzerland. Swiss Medical Weekly 135(3-4): 50-56, 2005. (29 refs.)

Questions under study. This study addresses socio-demographic and clinical characteristics among homeless people in Switzerland admitted to inpatient care, the use of and pathways to inpatient care by this group and, the extent to which psychiatric disorders contribute to the risk of homelessness. Methods: Based on data of a psychiatric case register we analysed 16247 people consecutively referred to psychiatric hospitals of a catchment area in Switzerland between 1998 and 2001. Results: 1.6% of all admitted patients (N = 2 5 7) were homeless (mean age: 34.4 years; women: 30.0%). The homeless as compared to other psychiatric inpatients had higher rates of substance use disorders, equal rates of psychotic and personality disorders, but lower rates of organic and affective disorders. Homeless people were more often compulsorily or as an emergency admitted. General practitioners (GPs) were less involved in the admission. The homeless had a shorter inpatient stay and their health status did not equally improve like in other patients. Risk factors of being homeless at psychiatric admission were: young age, male gender, single, low education level, urban residence, abuse of illicit drugs, especially multiple substance use, and having a dual diagnosis. Conclusions: Social factors and psychopathology are independently contributing to the risk of homelessness. Health care inequalities were found with regard to pathways to inpatient care (high rate of compulsory and emergency admissions, low involvement of GPs) and hospital stay (shorter stay, less improvement). Compared to other countries, disproportionate use of inpatient resources by homeless people could not be confirmed.

Lay B; Lauber C; Stobler R; Rossler W. Utilisation of inpatient psychiatric services by people with illicit substance abuse in Switzerland. Swiss Medical Weekly 136(21-22): 338-345, 2006. (40 refs.)

Questions under study: The study aims to examine the utilisation of inpatient psychiatric services by people with substance use disorders (SUD), and to identify factors that predict inpatient service use. Methods: Out of a sample of consecutively referred first-admitted patients from a catchment area in Switzerland, a cohort of 563 individuals with behavioural and mental disorders due to (illicit) substance use was followed over a period of 5 years by means of register data. Results: Every fourth individual of the first-admission sample was admitted for a SUD. Over the 5-year period, average number of inpatient episodes (1.7) was comparable to that of patients with other diagnoses; time in hospital, however, was by far shorter (cumulative: 21 days). 61.6% of the individuals with SUD were treated as inpatients only once; 41.4% were not regularly dis-charged. Clinical patient characteristics (psychiatric co-morbidity, admission state, clinical improvement during first inpatient stay) and treatment measures (psychotherapy during first inpatient stay, planned aftercare) were the most important predictors of inpatient psychiatric service use over the 5-year period. Associations with socio-demographic background factors were only weak. Conclusions: These findings suggest that a high number of patients with SUD are contacting inpatient services, but retention in treatment so far is not sufficient for an adequate drug treatment. Efforts need to be intensified to advance the diagnostic process and to improve current treatment strategies in order to achieve better clinical outcomes.

Lejuez CW; Paulson A; Daughters SB; Bornovalova MA; Zvolensky MJ. The association between heroin use and anxiety sensitivity among inner-city individuals in residential drug use treatment. Behaviour Research and Therapy 44(5): 667-677, 2006. (39 refs.)

The current study represents an initial investigation of the association between heroin use and anxiety sensitivity (AS). Within a sample of 172 inner-city treatment seeking drug users, AS was compared across past year (1) heroin users with no crack/cocaine use (n = 12); (2) crack/cocaine users with no heroin use (n = 66); (3) users of both heroin and crack/cocaine (n = 45); and (4) individuals with no use of heroin or crack/cocaine (n = 49). Consistent with expectations, primary heroin users evidenced higher levels of AS than all other groups, with these differences also evidenced for the physical and social subscales. Differences in AS total score and physical subscale score persisted after controlling for demographic variables, depressive symptoms, and primary use of drugs other than heroin and crack/cocaine including alcohol, nicotine, marijuana, and hallucinogens. Findings suggest a unique relationship between AS and heroin, and set the stage for future work explicating the direction of the observed association.

Lewandowski CA; Hill TJ. The impact of foster care and Temporary Assistance for Needy Families (TANF) on women's drug treatment outcomes. Children and Youth Services Review 30(8): 942-954, 2008. (52 refs.)

This study assesses the impact of having a child in foster care and receiving cash benefits through Temporary Assistance for Needy Families (TANF) on women's completion of a residential drug treatment program. The study's hypothesis was that drug treatment completion rates for women who had children in foster care and/or who were receiving TANF would differ from women who did not receive these services. The sample included 117 women age 19 to 54, in a Midwestern state. Findings suggest that women with a child or children in foster care were less likely to complete treatment. Women receiving cash benefits were also somewhat less likely to complete treatment than women not receiving these services. Women with children in foster care had similar levels of psychological, employment, and drug and alcohol concerns as other women, as measured by the Addiction Severity Index. Future research should focus on identifying strategies that enhance retention rates of these vulnerable women. Implications for improving treatment retention are discussed in light of the Adoption and Safe Families Act of 1997 and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

Majer JM; Jason LA; North CS; Ferrari JR; Porter NS; Olson B et al. A longitudinal analysis of psychiatric severity upon outcomes among substance abusers residing in self-help settings. American Journal of Community Psychology 42(1/2): 145-153, 2008. (50 refs.)

A longitudinal analysis of psychiatric severity was conducted with a national sample of recovering substance abusers living in Oxford Houses, which are self-run, self-help settings. Outcomes related to residents' psychiatric severity were examined at three follow-up intervals over one year. Over time, Oxford House residents with high versus low baseline psychiatric severity reported significantly more days using psychiatric medication, decreased outpatient psychiatric treatment, yet no significant differences for number of days abstinent and time living in an Oxford House. These findings suggest that a high level of psychiatric severity is not an impediment to residing in self-run, self-help settings such as Oxford House among persons with psychiatric comorbid substance use disorders.

Martin TC; Josiah-Martin JA; Kosakoski J; Norton K; Sinnott T. A comparison of patients relapsing to addictive drug use with non-relapsing patients following residential addiction treatment in Antigua. West Indian Medical Journal 54(3): 196-201, 2005. (52 refs.)

The outcome of a 29-day residential addiction treatment programme for persons from Antigua and Barbuda with addiction to drugs or alcohol was assessed All 100 patients entering the drug and alcohol treatment programme at Crossroads Centre Antigua between November 1998 and October 2002 were included All patients were assessed with regards to drug or alcohol use or abstinence in November 2002 using telephone and mail follow-up as well as informal follow-up with families and other community contacts. Crossroads Centre Antigua is a 35 bed, 29-day residential treatment centre for drug and alcohol addiction serving patients from developed countries (85%) and from the Caribbean region (15%). Patients records were also reviewed to obtain age, gender ethnicity, drug of choice, years of problematic use, completion of the 29 day programme, family member participation at Crossroads Centre Antigua (a four-day programme) and acceptance of halfway house placement, Of the 100 Antiguan patients admitted, 46 (46%) were abstinent (non-relapsers) at average 20.7 +/- 14.7 months after treatment. Abstinence did not have to be continuous. Forty-nine were known to be using drug or alcohol (49%) and five (5%) were lost to follow-up and considered to be using drugs (relapsers). Age (37.5 vs 41.1 years), gender (28% vs 22% female), ethnicity, (87% vs 87% Afro-Caribbean), years of harmful use (12.7 vs 12.5 years) did not differ significantly between relapsers and non-relapsers. Crack cocaine use (67% vs 65%) and alcohol use (26% vs 31%) as primary addiction did not differ significantly between relapsers and non-relapsers. Relapsers were significantly less likely to complete the 29-day programme (81% vs 100%, p < 0.01), have family members participate at Crossroads (32% vs 54%, p < 0.05) or accept halfway house placement (4% vs 54%, p < 0.001). In conclusion, abstinence was achieved in 46% of those entering treatment, in 51% completing treatment, in 60% whose families participated and in 92% of those accepting halfway house placement.

Matthews CR; Lorah P. An examination of addiction treatment completion by gender and ethnicity. Journal of Addictions & Offender Counseling 25(2): 114-125, 2005. (39 refs.)

The authors examined the discharge status of all clients admitted to an intensive substance abuse outpatient facility over the course of 1 year, specifically exploring differences based on client gender and ethnicity. Although there were no differences based on gender or ethnicity, almost half of all clients who were discharged had less than successful treatment experiences. The article argues the need for more culturally sensitive addiction treatment and addresses some alternative approaches

McNeese-Smith D; Nyamathi A; Longshore D; Wickman M; Robertson S; Obert J et al. Processes and outcomes of substance abuse treatment between two programs for clients insured under managed care. American Journal of Drug and Alcohol Abuse 33(3): 439-446, 2007. (11 refs.)

The purpose of this research (N = 160) was to describe and compare substance abuse treatment in two programs under managed care: one residential (RT) and one outpatient (OP). Clients in both settings improved significantly from before to after treatment in relation to substance use and quality of life. However, intensity of treatment (hours of care/week) was much greater in RT and days of sobriety were significantly higher after treatment in RT than in OP (p = .04). Intensity was negatively related to incidents of substance use during treatment (SUdT), which predicted substance use after treatment; SUdT averaged 2 for RT, and 1.6 for OP (p = .0001). Importantly, treatment was completed by 74 patients (over 90%) from RT, with 8 dropping out, and 53 (almost 70%) of those in OP completed treatment while 25 dropped out. Intensity, as seen in the RT program, rather than duration, was more effective in substance use reduction and treatment completion.

Meier PS; Donmall MC; McElduff P; Barrowclough C; Heller RF. The role of the early therapeutic alliance in predicting drug treatment dropout. Drug and Alcohol Dependence 83(1): 57-64, 2006. (54 refs.)

Background: To investigate the role of the therapeutic alliance in predicting length of retention in residential drug treatment. Methods: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and the average total scores of client and counsellor ratings on the WAI-S (obtained during weeks 1-3) were use as the alliance measure. Length of retention and treatment completion (stay beyond 90 days) were used as measures of retention. Results: Clients with weak counsellor rated alliances dropped out of treatment significantly sooner than clients with strong counsellor rated therapeutic alliances, whether or not the model adjusted for individual counsellor effects and potential confounders including psychological wellbeing, treatment motivation and readiness, coping strategies, and attachment style. The client rated alliance did not predict length of retention. Apart from the alliance, pre-treatment crack use, secure attachment style and better coping strategies were associated with shorter retention, whereas greater confidence in treatment, older client age and better education predicted treatment completion. Counsellors with greater experience of delivering drug counselling retained clients longer. Conclusions: The findings of this study stress the importance of treatment professionals attending to the therapeutic alliance in drug treatment, as counsellors alliance ratings were found to be amongst the strongest predictors of dropout. Using alliance measures as clinical tools may help treatment practitioners to become aware of the risk of disengagement early on. Prospective studies are needed to evaluate whether strategies of reallocating clients with poor alliances to different counsellors lead to improvements in retention.

Nocon A; Berge D; Astals M; Martin-Santos R; Torrens M. Dual diagnosis in an inpatient drug-abuse detoxification unit. European Addiction Research 13(4): 192-200, 2007. (44 refs.)

In Spain, detoxification in general hospitals plays an important role in the medical care of patients. We aim to provide clinicians with information on the prevalence and correlates of psychiatric co-morbidity in drug abusers in detoxification. A sample of 115 substance-abuse inpatients (mean age 31.9 +/- 6.4 years) in a Detoxification Unit of a general university hospital was studied using the Spanish version of the PRISM. Most of the patients had multiple dependence diagnoses and co-morbid axis I or axis II psychiatric disorders. Patients with dual diagnosis showed lower psychosocial functioning than patients without co-morbidity and more dependence diagnoses due to cannabis and sedatives. A total of 80% of the patients successfully completed the detoxification process. The present results enhance the value of detoxification in a general hospital as a first step of the overall treatment strategy.

Novins DK; Fickenscher A; Manson SM. American Indian adolescents in substance abuse treatment: Diagnostic status. Journal of Substance Abuse Treatment 30(4): 275-284, 2006. (67 refs.)

The goal of this study was to describe the prevalence of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) psychiatric disorders among a sample of American Indian adolescents in residential substance abuse treatment. Data on 89 Al adolescents admitted to a tribally operated residential substance abuse treatment program were collected. Participants reported using a mean of 5.26 substances; 20% percent met DSM-IV criteria for four or more substance use disorders. Marijuana abuse/dependence was the most common substance use disorder (84.3%). Eighty-two percent met criteria for at least one DSM-IV nonsubstance use disorder, the most common of which was conduct disorder (74.2%). These results suggest strong diagnostic parallels between these American Indian adolescents and their non-American Indian counterparts who have participated in similar studies, including the considerable diagnostic complexity that was common among the participants in this study. These diagnostic patterns suggest that emerging practices for treating substance-abusing adolescents that have been developed for use With non-American Indian adolescents warrant consideration for use with American Indian youths.

O'Farrell TJ; Murphy M; Alter J; Fals-Stewart W. Brief family treatment intervention to promote aftercare among substance abusing patients in inpatient detoxification: Transferring a research intervention to clinical practice. Addictive Behaviors 33(3): 464-471, 2008. (11 refs.)

Two earlier studies showed that a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification increased aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member with whom the patient lived to review aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Based on the earlier research results, we trained a newly hired staff person to continue providing BFT. We monitored key process benchmarks derived from the earlier research studies to ensure ongoing fidelity in delivering BFT. This method proved successful in transferring BFT from delivery in a research study to ongoing delivery in routine clinical practice after the research ended. It also ensured that a high proportion of patients had their families contacted and included in. planning the patients' aftercare.

O'Farrell TJ; Murphy M; Alter J; Fals-Stewart W. Brief family treatment intervention to promote aftercare among male substance abusing patients in inpatient detoxification: A quasi-experimental pilot study. Addictive Behaviors 32(8): 1681-1691, 2007. (18 refs.)

We developed a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification to promote aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member (spouse or parent) with whom the patient lived to review and recommend potential aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Results indicated that male substance abusing patients who received BFT (N= 14), as compared with a matched treatment as usual (TAU) comparison group (N= 14) that did not, showed a trend toward being more likely to enter an aftercare program and to attend more days of aftercare in the 3 months after detoxification. The magnitude of these differences favoring BFT over TAU was midway between a medium and a large effect size. Days using alcohol or drugs in the 3 months after detox were lower for treatment-exposed BFT patients who had an in-person family meeting than TAU counterparts (trend, medium effect), and for patients who entered aftercare regardless of treatment condition (significant large effect).

Office of Applied Studies, Substance Abuse and Mental Health Administration. The DASIS Report: Length of Stay for Outpatient Discharges Completing Treatment: 2004 (May 10, 2007). Rockville MD: Substance Abuse and Mental Health Administration, 2007. (11 refs.)

SAMHSA's annual Treatment Episode Data Set (TEDS) provides data on the median length of stay for substance abuse treatment patients who completed outpatient treatment in the nation's specialty substance abuse treatment facilities. "Outpatient" care included not only regular outpatient visits but also intensive outpatient treatment (defined as a minimum of 2 hours per day on 3 or more days per week), detoxification, and day treatment with partial hospitalization. Outpatient treatment episodes where methadone use was planned were not included in this analysis of median length of stay (LOS). Increased length of stay has been associated with improved treatment outcomes. The length of stay among those who completed outpatient substance abuse treatment in 2004 varied by primary substance of abuse, race/ethnicity, completed education, and source of referral. Treatment completers who reported stimulants as their primary substance of abuse had the longest median length of stay (137 days) compared with treatment completers with alcohol as their primary substance who had the shorted median length of stay (98 days). The median length of stay among outpatient substance abuse treatment completers was longest among Hispanics(126 days) and shortest among American Indians/Alaska Natives (84 days).

Public Domain

Office of Applied Studies. National Survey of Substance Abuse Treatment Services (N-SSATS): 2004. Data on Substance Abuse Treatment Facilities. DASIS Series S-34. Rockville MD: Substance Abuse and Mental Health Services Administration, 2006. (0 refs.)

This report is one in an annual series on the characteristics of treatment facilities in the US. it is based on data for a single, index day. The report is organized in six chapters. The first chapters describes the Survey. Chapter 2 describes the trends found in facility characteristics, for example, in terms of number and type of care offered. Chapter 3 describes the trends in client characteristics -- the number of clients, type of care received, and the substances involved. Chapter 4 deals with the facility characteristics and services, size, utilization rates, programs offered for specific populations -- adolescents, those with co-occurring disorders, with criminal justice involvement, gays and lesbians, seniors, those HIV/AIDS, women, DWI offenders, and pregnant or postpartum women. Chapter 5 describes the client characteristics. Data is drawn from almost 14,000 facilities. Chapter 6 deals with state data. The highlights present trends in facility and client characteristics. Over 13,400 faculties reported, with over 1 million persons in treatment on the index date. About 55% were in treatment within private, non-profit programs. There was an increase in for-profit facilities, and represented about 27% of those in care. Eighty-nine percent of those in treatment were receiving outpatient care; 10% were in non-hospital residential care; and 1% in hospital inpatient care. Adolescents made up about 8% of all clients, and the majority were in special adolescent treatment programs. Of those providing substance abuse treatment, 62% of the facilities, representing 69% of clients, were primarily involved in substance abuse treatment. Twenty-seven percent of programs, representing 24% of those in care, were treated in combined mental health/substance abuse treatment. Outpatient care was provided by 72% of all programs, and had 53% of those in care. Outpatient/partial hospitalization was offered by 14% of facilities and was provided to 12% of all clients in the index date. Nearly half of clients (47%) were being treated for both alcohol and drug abuse. Nationally the rate for treatment was 431 clients per 100,000 population age 18 or over. The median number of clients was 40 persons. Data is summarized and presented in 88 figures and tables.

O'Malley SS; Martin DJ; Hosking JD; Mason BJ. How pilot studies improve large-scale clinical trials: Lessons learned from the COMBINE study. Journal of Studies on Alcohol Supplement 15: 66-71, 2005. (13 refs.)

Objective: The design of a clinical trial to evaluate a potential therapy requires decisions about issues that include safety efficacy, measurement, feasibility and training. Experience from the COMBINE Study, which tests the combination of medications and behavioral therapies for alcohol dependence, is presented as an example of how pilot studies improve large-scale clinical trials. Method: The COMBINE Pilot 1 inpatient study was designed to inform the main trial about the safety and tolerability of the doses of acamprosate (3 g/day) and naltrexone (100 mg/day) selected for study, alone and in combination. Pilot 2 was conducted as a feasibility study for the main trial, with the goals of (1) assessing the length of and compliance with research assessments, (2) developing methods for subject recruitment and staff training and (3) assessing the safety of the medications under less controlled outpatient conditions. Results: Results from Pilot 1 provided safety information to support testing the medications in an outpatient study and contributed to the decision to incorporate dose reductions into the main trial protocol to manage adverse events. The results of Pilot 2 formed a basis for (1) reducing the length of the assessment battery, (2) having staff fully trained and recruitment procedures established for the main trial and (3) extending the drug safety results of Pilot I to outpatient conditions similar to those of the main trial. Conclusions: The COMBINE Study provides several examples of the successful application of pilot studies to inform the design of a clinical trial.

Paik L. Are you truly a recovering dope fiend? Local interpretive practices at a therapeutic community drug treatment program. Symbolic Interaction 29(2): 213-234, 2006. (27 refs.)

Previous qualitative research on treatment programs for drug addiction/alcoholism has primarily focused on those processes whereby participants are expected to construct a new sense of self according to institutional parameters. The present article builds on that research and explores how contemporary programs attempt to resolve the problem that it is almost impossible to tell if someone has engaged in this self-construction process. Informed by five months of ethnographic fieldwork at an adult residential drug treatment facility, the article asks: under what circumstances do program members call into doubt a client's efforts to create an institutional self, and how do they express this skepticism? The article reveals that staff and clients employ a set of local interpretive practices about community and emotions to assess whether clients are constructing the institutional self of a "recovering dope fiend." It specifically considers how they interpret a client's emotional displays to represent that client's current self under construction. That is, a client's ability to control anger appropriately or to handle anxiety demonstrates s/he is effectively "doing the program" of self-construction.

Perron BE; Bright C. The influence of legal coercion on dropout from substance abuse treatment: Results from a national survey. Drug and Alcohol Dependence 92(1/3): 123-131, 2008. (38 refs.)

Legal coercion is frequently used to leverage substance abuse treatment upon persons who would otherwise not seek it voluntarily. Various methodological and conceptual problems of the existing research have prevented a clear understanding of its effectiveness. The influence of legal coercion on retention in substance abuse treatment was examined using a national survey of programs in the public sector of care and three different treatment modalities including short-term residential (N = 756), long-term residential (N = 757), and outpatient treatment (N = 118 1). Legal coercion was found to reduce the risk of dropout across all three treatment modalities. The greatest effect was among persons in short-term residential treatment. The smallest effect was observed in outpatient treatment. This study shows that legal coercion significantly reduces the risk of dropout in substance abuse treatment. However, the differential effects across treatment conditions must be carefully considered when using coercion to involve individuals in treatment.

Ravndal E; Vaglum P; Lauritzen G. Completion of long-term inpatient treatment of drug abusers: A prospective study from 13 different units. European Addiction Research 11(4): 180-185, 2005. (29 refs.)

Completion of treatment is an important predictor of favourable outcome. We need more knowledge about predictors of completion in the inpatient psychosocial treatment modality. This prospective study from 13 such programmes follows a consecutive sample of clients (n = 307) from admission to completion/dropout. Instruments: EuropASI, MCMI II, SCL-25. The mean completion rate was 40% (20 - 71%), with no difference between clients with no ('debutants') or previous ('veterans') inpatient stays. Among 'debutants', the number of years of heroin use was negatively related to completion. Among 'veterans', age and amphetamine use were positively related, while the presence of a personality disorder and number of previous inpatient treatments were negatively related to completion. Specific strategies for involving clients with personality disorders are needed. After three inpatient stays, other types of treatment should be offered.

Ries RK; Yuodelis-Flores C; Comtois KA; Roy-Byrne PP; Russo JE. Substance-induced suicidal admissions to an acute psychiatric service: Characteristics and outcomes. Journal of Substance Abuse Treatment 34(1): 72-79, 2008. (36 refs.)

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients.

Robles E; Crone CC; Whiteside-Mansell L; Conners NA; Bokony PA; Worley LLM et al. Voucher-based incentives for cigarette smoking reduction in a women's residential treatment program. Nicotine & Tobacco Research 7(1): 111-117, 2005. (38 refs.)

Participants were women (N=16) living with their children in a residential substance abuse treatment facility. In this within-subjects repeated measures study, a 1-week baseline was followed by a 4-week intervention and a 2-week follow-up (same as the baseline). The intervention consisted of exposure to an educational video and a smoking cessation workbook, brief individual support meetings, and an escalating schedule of voucher-based reinforcement of abstinence. Throughout the study, three daily breath samples (8 A.M., noon, and 4 P.M.) were collected Monday through Friday to determine carbon monoxide (CO) concentration. In addition, urine cotinine (COT) was assessed on Monday mornings to monitor weekend tobacco use. Participants received vouchers of escalating value for CO-negative breath and COT-negative urine samples. Positive samples reset the voucher value. Significantly more negative tests were submitted during the intervention than during baseline and follow-up. The intensive behavioral intervention evaluated in this study produced a substantial reduction in cigarette smoking, and 25% of participants remained abstinent 2 weeks after the intervention was suspended. Nevertheless, the percentage of CO-negative samples submitted during the follow-up returned to baseline levels. While retaining many real-world characteristics, residential treatment facilities provide important opportunities for smoking cessation treatment and research.

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.

Shin SH; Lundgren L; Chassler D. Examining drug treatment entry patterns among young injection drug users. American Journal of Drug and Alcohol Abuse 33(2): 217-225, 2007. (14 refs.)

Using a longitudinal state data base, 1996-2002, of all Injection Drug Users (IDU) (n = 37,227) admissions to all state-licensed drug treatment programs, this study examined differences in drug treatment entry patterns between younger IDUs (ages 18-25) compared to middle-age IDUs (ages 26-39) and older IDUs (over 40 years of age). Most of the younger IDUs were male, unemployed, and dependent on heroin. After controlling for factors known to affect type of drug treatment entered, younger IDUs were significantly more likely than their older counterparts to only use detoxification services and not enter additional treatment. Further, younger IDUs were significantly less likely to enter methadone maintenance and significantly more likely to enter residential treatment compared to older IDUs. Development of strategies to promote transition from detoxification to more comprehensive treatments and especially to methadone maintenance treatment is warranted.

Silins E; Sannibale C; Larney S; Wodak A; Mattick R. Residential detoxification: Essential for marginalised, severely alcohol- and drug-dependent individuals. Drug and Alcohol Review 27(4): 414-419, 2008. (52 refs.)

Introduction and Aims. In an era of health care rationalisation, residential detoxification services catering for drug- and alcohol-dependent homeless people are being closed. The principal findings of a recent evaluation of a non-medicated residential detoxification service are presented. The aims were to describe the characteristics of residents, their experience of admission, rates of withdrawal completion, referral patterns, staff and key informant perceptions of the service and its role within the wider treatment system. Design and Methods. A process evaluation was utilised incorporating interviews with residents (n=80) and key informants (n=13); a survey of all service staff (n=10); and demographic and clinical data for all residents (n=392) admitted over one calendar year. Results. Residents were heavily substance-dependent and marginalised, with many exhibiting substantial mental and physical health impairments. Polydrug use and frequent prior engagement with drug and alcohol services were common. The majority completed withdrawal and were referred to further treatment. Residents who presented for heroin and other opiate withdrawal were more likely than other residents to leave before completing treatment (odds ratio 2.47, 95% confidence interval 1.48-4.15). Information from key informants, service staff and residents converged in underscoring the important role performed by the service. Discussion and Conclusion. Out-patient detoxification for homeless and severely drug- and alcohol-dependent populations is unrealistic. For this group, access to residential detoxification is vital as it provides an environment where potentially serious medical and psychological complications can be managed. There continues to be a clear role for supervised withdrawal in such a setting.

Sims B, ed. Substance Abuse Treatment with Correctional Clients: Practical Implications for Institutional and Community Settings. Binghamton NY: Haworth Press, 2005. (Chapter refs.)

This volume with 12 chapters and 21 contributors is organized into three sections. It cover the current research finds and their policy implications for treating alcohol- and drug-addicted correctional clients. The first section, entitled "the Nature of the Problem" provides a review of the theoretical explanations for substance abuse, evidence-based treatment programs for substance abusers, predictors of treatment outcome, and the role of motivation. The second section, "Institutional-Based Treatment Programs" addresses the substance-addicted offender in the institutional setting. Individual chapters deal with the therapeutic community and residential programs. Section three looks at community-based treatment of criminal justice populations. Individual chapters deal with drug-diverseion courts and their impact on recidivism, initiating treatment, and a restrictive intermediate punishment programming. The fourth section addresses three special populations, with chapters on treating juveniles in an institutional setting, the effectiveness of counseling with adolescent females, adult women and the role of gender-specific programs.

Sinclair JMA; Latifi AH; Latifi AW. Co-morbid substance misuse in psychiatric patients: prevalence and association with length of inpatient stay. Journal of Psychopharmacology 22(1): 92-99, 2008. (37 refs.)

Improved management of mental illness with co-morbid substance misuse is an important clinical objective. This study aimed to assess the prevalence of substance misuse in psychiatric inpatients, and to examine the relationship between alcohol misuse and length of hospital admission. A prevalence study conducted over four months, examined rates of co-morbid substance misuse in patients admitted for psychiatric inpatient care. Demographic details and length of hospital stay were collected for all patients and those who gave informed consent were screened for levels of alcohol and substance misuse. Two hundred and thirty-eight patients were admitted during the study period in which 178 ( 74.8%) consented to take part in the study. A group of 44 ( 50.6%) men and 26 ( 29.2%) women were screened positive for alcohol misuse (chi(2) = 8.7, P = 0.003). Cannabis use was acknowledged by 31 ( 35.2%) men and 10 ( 11.2%) women (chi(2) = 13.5, P = 0.0001). Presence of co-morbid alcohol misuse was associated with a significantly shorter hospital admission ( z = 3.34, P = 0.0008). Co-morbid substance misuse ( including alcohol) was reported significantly more frequently by men than women. Overall, patients with co-morbid alcohol misuse had shorter hospital admissions, suggesting different patterns of presentation and progress in hospital. Hospital admission presents an opportunity to identify substance misuse and evaluate treatments for co-morbid conditions within a safe environment.

Sridharan S; Kawata JH; Campbell B; Tseng CWM. Contemporaneous relationship between substance abuse treatment and poly-substance use: Evidence from the Persistent Effect of Treatment Studies. Journal of Substance Abuse Treatment 28(2, Supplement 1): S83-S90, 2005. (25 refs.)

Data from the Persistent Effect of Treatment Studies (PETS) are used to explore the relationship between duration of substance use treatment and simultaneous poly-substance using behaviors. Studying such contemporaneous relationships is especially important given the chronic nature of the substance-using population (McLellan, 2002) in the PETS study. Data were collected at intake to treatment programs and follow-up interviews were performed periodically at treatment program sites. One of the features of the analysis was the development of a poly-substance scale to measure multiple substance use. Multilevel models were implemented to examine the relationship between three levels of care (i.e., intensive outpatient, outpatient, and residential) and simultaneous poly-substance use. Contemporaneous effects of treatment were obtained such that higher duration of treatment was associated with drops in substance-using behaviors. This result supports the need for sustaining treatment for a population of chronic substance abusers.

Stahler GJ; Kirby KC; Kerwin ME. A faith-based intervention for cocaine-dependent black women. Journal of Psychoactive Drugs 39(2): 183-190, 2007. (45 refs.)

The purpose of the present study was to obtain preliminary data on the effectiveness of a faith-based treatment adjunct for cocaine-using homeless mothers in residential treatment. The Bridges intervention utilizes various Black church communities to provide culturally-relevant group activities and individual mentoring from volunteers. Eighteen women who were recent treatment admissions were randomly assigned to receive Standard Treatment plus Bridges or Standard Treatment with an Attention Control. Participants were assessed at intake and three and six months after intake. Bridges treatment resulted in significantly better treatment retention (75% vs. 20% at six months) than standard residential treatment alone. In addition, Bridges produced superior outcomes at the six month follow-up assessment on a secondary measure of cocaine abstinence. Creating a community of social support through Black churches appears feasible and promising, and may be a cost-effective means of providing longer-term post-treatment support for cocaine-addicted women.

Sterling RC; Weinstein S; Hill P; Gottheil E; Gordon SM; Shorie K. Levels of spirituality and treatment outcome: A preliminary examination. Journal of Studies on Alcohol 67(4): 600-606, 2006. (32 refs.)

Objective: The primary aim of this study was to examine whether admission differences in levels of spirituality predisposed alcohol-dependent individuals to favorable or unfavorable outcomes following admission to facilities that differed in the degree to which spirituality was emphasized. It was hypothesized that individuals whose admission level of spirituality was congruent with the treatment program's orientation and who as such were considered optimally placed (i.e., "matched") for treatment would evince better in-treatment outcomes. Method: Four hundred and five participants completed measures of spirituality and psychosocial well-being at intake and at end of treatment. Results: In examining the entire sample, no matching effects were observed on discharge status, abstinence efficacy, or desire to drink. When analyses were restricted to those cases scoring in the upper or lower quartiles in spirituality, we observed a paradoxical effect, as individuals recording lower levels of spirituality at the less spiritual program evinced significantly poorer outcomes (i.e., less abstinence efficacy, greater desire to drink). Conclusions: These findings hint at the importance of spirituality in the environment of care, indicating that individuals low in spirituality were at risk for poorer outcomes, but exposure to a program that emphasized spirituality lowered that risk.

Strauss SM; Astone JM; Munoz-Plaza C; Hagan H; Des Jarlais D. Residential substance user treatment programs as venues for HCV pharmacological treatment: Client and staff perspectives. Substance Use & Misuse 40(12): 1811-1829, 2005. (45 refs.)

Hepatitis C virus (HCV) infection is highly prevalent among drug users. While there are antiviral medications available to combat the virus, the medication regimen is quite arduous, presenting special issues for drug users. We examined the challenges and benefits of using residential substance user treatment programs as venues for clients to undergo HCV medication regimens. Analyses of qualitative data collected from clients and staff in 2003 at four residential substance user treatment programs in the U.S. indicate that challenges primarily include issues involving the medications' side effects, and both financial and communication concerns. Benefits especially involve clients' feelings that they are being proactive in addressing health issues in an environment that provides much-needed support. Findings illuminate the complex issues involved for both clients and the programs, and some steps that programs can take to better support HCV-infected clients regarding HCV medication concerns.

Subramaniam GA; Stitzer MA; Clemmey P; Kolodner K; Fishman MJ. Baseline depressive symptoms predict poor substance use outcome following adolescent residential treatment. Journal of the American Academy of Child and Adolescent Psychiatry 46(8): 1062-1069, 2007. (46 refs.)

Objective: To characterize baseline depressive symptoms among substance-abusing adolescents and determine their association with post residential treatment substance use outcomes. Method: In total, 153 adolescents (mean age 6.6 years, +/- 0.11) entering residential treatment were assessed at intake and at 3, 6, 9, and 12 months. Beck Depression Inventory (BDI) and Global Appraisal of Individual Needs were administered to assess depression, other risk factors, and substance use. A regression model was developed with 10 risk factors including BDI scores of >= 11 versus <11 to predict the outcome measure mean percentage of days in the past 90 days with any (nonnicotine) substance use. Results: At intake, 55% had BDI scores of >= 11. A baseline BDI score of >= 11 was significantly associated with greater mean percentage of days of substance use (27.5 +/- 3.8% versus 15.4 +/- 4.0% days, p < .01) across 1-year follow-up. Two other factors were significant: length of drug career >2 years and having an opioid use disorder. Conclusions: Results from this prospective study, although preliminary, suggest the association of depressive symptoms with poorer substance outcomes and the utility of the BDI as a prognostic tool. They highlight the need for interventions targeting co-occurring depressive symptoms that may improve adolescent substance treatment outcomes.

Thorndike AN; Regan S; McKool K; Pasternak RC; Swartz S; Torres-Finnerty N. Depressive symptoms and smoking cessation after hospitalization for cardiovascular disease. Archives of Internal Medicine 168(2): 186-191, 2008. (41 refs.)

Background: Although smoking cessation is essential for prevention of secondary cardiovascular disease (CVD), many smokers do not stop smoking after hospitalization. Mild depressive symptoms are common during hospitalization for CVD. We hypothesized that depressive symptoms measured during hospitalization for acute CVD would predict return to smoking after discharge from the hospital. Methods: This was a planned secondary analysis of data from a placebo-controlled, double-blind, randomized trial of bupropion hydrochloride therapy in 245 smokers hospitalized for acute CVD. All subjects received smoking counseling in the hospital and for 12 weeks after discharge. Depressive symptoms were measured during hospitalization with the Beck Depression Inventory (BDI), and smoking cessation was biochemically validated at 2-week, 12-week, and 1-year follow-up. The effect of depressive symptoms on smoking cessation was assessed using multiple logistic regression and survival analyses. Results: Twenty-two percent of smokers had moderate to severe depressive symptoms (BDI >= 16) during hospitalization. These smokers were more likely to resume smoking by 4 weeks after discharge (P=.007 incidence rate ratio, 2.40; 95% confidence interval, 1.48-3.78) than were smokers with lower BDI scores. Smokers with low BDI scores were more likely to remain abstinent than were those with high BDI scores at 3-month follow-up (37% vs 15%; adjusted odds ratio, 3.02; 95% confidence interval, 1.28-7.09) and 1-year follow-up (27% vs 10%; adjusted odds ratio, 3.77; 95% confidence interval, 1.31-10.82). We estimate that 27% of the effect of the BDI score on smoking cessation was mediated by nicotine withdrawal symptoms. Conclusions: Moderate to severe depressive symptoms during hospitalization for acute CVD are independently associated with rapid relapse to smoking after discharge and lower rates of smoking cessation at long-term follow-up. The relationship was mediated in part by the stronger nicotine withdrawal symptoms experienced by smokers with higher depressive symptoms.

Tiet QQ; Ilgen MA; Byrnes HF; Harris AHS; Finney JW. Treatment setting and baseline substance use severity interact to predict patients' outcomes. Addiction 102(3): 432-440, 2007. (29 refs.)

Aims: This study tested the hypothesis that patients with more severe substance use disorders (SUDs) at intake respond better when treated in more structured and intensive settings (i.e. in-patient/residential versus out-patient), whereas patients with less severe SUD problems have similar outcomes regardless of treatment setting. Design, setting and participants: Up to 50 new patients were selected randomly from each of a random and representative sample of 50 Department of Veterans Affairs (VA) SUD treatment programs (total n = 1917 patients), and were followed- up an average of 6.7 months later (n = 1277). Measures: Patients completed a brief self-report version of the Addiction Severity Index (ASI) at baseline and at follow-up. Findings In mixed- model regression analyses, baseline substance use severity predicted follow-up substance use severity and there were no main effects of treatment setting. However, interaction effects were found, such that more severe patients experienced better alcohol and drug outcomes following in-patient/residential treatment versus out-patient treatment; on the other hand, patients with lower baseline ASI drug severity had better drug outcomes following out-patient treatment than in-patient treatment. Treatment setting was unrelated to alcohol outcomes in patients with less severe ASI alcohol scores. Conclusions: Results provide some support to the matching hypothesis that for patients who have higher levels of substance use severity at intake, treatment in in-patient/residential treatment settings is associated with better outcomes than out-patient treatment. More research needs to be conducted before in-patient/residential settings are further reduced as a part of the SUD continuum of care in the United States.

Timko C; DeBenedetti A; Moos BS; Moos RH. Predictors of 16-year mortality among individuals initiating help-seeking for an alcoholic use disorder. Alcoholism: Clinical and Experimental Research 30(10): 1711-1720, 2006. (86 refs.)

Background and Methods: We examined rates and predictors of mortality in individuals (47% women) who had just initiated help-seeking for their alcohol use disorders (AUDs) at the start of the study (n=628) and were followed for 16 years. Results: For both women and men, the observed-to-expected mortality ratio (1.4) was lower than rates found in samples of treated individuals with AUDs, suggesting that those initiating help-seeking careers have better chances of long-term survival. Of the individuals for whom cause of death was known, 68% died of alcohol-related causes. Men were more likely to die than were women. When gender was controlled, individuals who were older and unmarried and had more alcohol dependence symptoms at baseline were more likely to die over the 16-year period. When these baseline characteristics were controlled, better drinking outcomes at 1 year were associated with a lower likelihood of subsequent death. The combination of a shorter duration of inpatient/residential care and better drinking outcomes at 1 year was related to a lower probability of death, as was the combination of a longer duration of outpatient care or Alcoholics Anonymous attendance and better drinking outcomes at 1 year. Conclusions: Efforts should be made to help providers identify individuals who are not responding positively to inpatient or residential treatment and intervene to motivate participation in continuing outpatient care and community 12-step self-help groups to reduce the likelihood of a chronic and fatal AUD course.

Toussaint DW; VonDeMork NR; Bornemann A; Graeber CJ. Modifications to the trauma recovery and empowerment model (TREM) for substance-abusing women with histories of violence: Outcomes and lessons learned at a Colorado substance abuse treatment center. Journal of Community Psychology 35(7): 879-894, 2007. (38 refs.)

A growing body of literature demonstrates the co-occurrence of posttraumatic stress disorder and substance use disorder for females seeking substance abuse treatment. Nonetheless, relatively few trauma-specific treatments have been implemented or evaluated with this population. In this quasi-experimental study (N = 170), the Trauma Recovery and Empowerment Model (TREM) was modified for use in an existing residential substance abuse program. Women who participated in the TREM showed significantly better outcomes than those who received treatment-as-usual on trauma-related symptoms, although not on alcohol or drug use. TREM appears to be a promising model that can be embedded in a residential substance abuse treatment setting. Implications for practice and further research are discussed.

Tracy SW. Alcoholism in America: From Reconstruction to Prohibition. Baltimore MD: Johns Hopkins University Press, 2005. (Chapter refs.)

The author, a historian, traces the origins of the modern alcohol field, focusing on the era between Reconstruction and Prohibition. This was the period in which the inebriate asylums were founded. It was also the beginning of the medicalization of the perceptions of alcoholism. In 1870, a small group formed the American Association for the Cure of Inebriates and endeavored to promote the view that intemperance was a disease and should be treated as such. Six years later, in 1876, the American Medical Association endorsed the concept, in part as an opportunity to expand its professional authority. In 1920, with the coming of national Prohibition, the asylums were closed. The book has three major threads. One is the change in medical thinking. Another is the emergence of the asylums, the various groups which promoted them and those who opposed, some of which were state funded, and the treatment efforts. The third thread present the perspective of patients, their friends and families based on letters, diaries, and institutional records.

Tuten M; Jones HE; Lertch EW; Stitzer ML. Aftercare plans of inpatients undergoing detoxification. American Journal of Drug and Alcohol Abuse 33(4): 547-555, 2007. (17 refs.)

Drug use relapse rates are high following residential detoxification. This study examined the aftercare plans and desired services of participants currently enrolled in residential detoxification programs. Participants completed a survey regarding their aftercare plans and services that they desired from an aftercare program. Participants (98%) reported some form of aftercare plans following detoxification. Among the services that participants endorsed wanting were individual counseling, help with finding a job, and Narcotics Anonymous (NA) meetings. With low rates of enrollment in aftercare programs, the findings of this study may be of help in determining what services will best assist individuals recovering from addiction.

Weis R; Wilson NL; Whitemarsh SM. Evaluation of a voluntary, military-style residential treatment program for adolescents with academic and conduct problems. Journal of Clinical Child and Adolescent Psychology 34(4): 692-705, 2005. (53 refs.)

This study evaluated the effectiveness of a military-style residential treatment program for adolescents with academic and conduct problems. Two hundred twelve referred adolescents were separated into 3 groups for analyses: (a) adolescents who completed the 22-week program, (b) adolescents who prematurely withdrew, and (c) wait-list controls. Adolescents' socioemotional and behavioral functioning were measured at baseline and 6 months after treatment. Results showed statistically and clinically significant reductions in externalizing symptoms and increases in adaptive behavior associated with treatment. Treatment was also associated with increased likelihood of high school completion or employment and decreased likelihood of alcohol or drug problems and arrest. The relation between treatment participation and outcomes was moderated by adolescents' living environments after treatment, but it was not moderated by age of symptom onset. The benefits of treatment may be partially attributable to the voluntary nature of the intervention.

Weithmann G; Hoffmann M. A randomised clinical trial of in-patient versus combined day hospital treatment of alcoholism: Primary and secondary outcome measures. European Addiction Research 11(4): 197-203, 2005. (22 refs.)

In Germany, the treatment system for alcoholics is predominantly in-patient (IP) oriented, but no randomised trials of setting effects have been conducted until now. We examined if detoxification treatment offered in a day clinic setting would lead to results comparable to the usual IP treatment. After initial IP detoxification, patients (n = 109) at a standard withdrawal treatment unit were randomly assigned to IP or day hospital groups. In both settings, identical psychosocial treatment was given. In this article, results of primary ( percent days abstinent and drinks per drinking day) and secondary outcome measures ( relapses during treatment, premature termination, additional hospitalisation during follow-up, percent of voluntary abstinent days and continuous abstinence) are reported. Outcome measures were assessed quarterly during a 1-year follow-up period. Patients improved significantly after both treatments, but we found no significant setting or setting x time interaction effects for any primary or secondary outcome measure.

Williams JM; Foulds J; Dwyer M; Order-Connors B; Springer M; Gadde P et al. The integration of tobacco dependence treatment and tobacco-free standards into residential addictions treatment in New Jersey. Journal of Substance Abuse Treatment 28(4): 331-340, 2005. (33 refs.)

New Jersey was the first state to implement a licensure standard for all residential addiction treatment programs to assess and treat tobacco dependence in the context of entirely tobacco-free facilities (including grounds). A program evaluation of the first year of the policy (2001-2002) assessed the impact on programs, clients, and staff. At 1-year follow-up, all 30 residential programs surveyed provided some tobacco dependence treatment and 50% had tobacco-free grounds. Eighty-five percent of the programs accepted the state's offer to provide free NRT, reaching more than 2,326 clients. Seventy-seven percent of all clients were smokers, and 65% of the smokers reported they wanted to stop or cut down tobacco use. Forty-one percent of the smokers reported that they did not use any tobacco during their entire residential stay. There was no increase in irregular discharges, or reduction in proportion of smokers among those entering residential treatment, compared with prior years. Licensure standards regulation can be an effective mechanism for increasing the quantity and quality of tobacco dependence treatment in residential addictions programs.

Williamson A; Darke S; Ross J; Teesson M. Changes and predictors of change in the physical health status of heroin users over 24 months. Addiction 104(3): 465-470, 2009. (31 refs.)

Purpose: (i) To describe the course of physical health among the Australian Treatment Outcome Study (ATOS) cohort over 24 months; and (ii) to examine the effects of treatment, drug use patterns and social and psychological factors on health status over 24 months. Longitudinal cohort. Sydney, Australia. A total of 615 heroin users recruited for the Australian Treatment Outcome Study. The general health of the cohort improved significantly over 24 months. Significant predictors of poor health over 24 months were: being older, being female, past month heroin, other opiate and tobacco use, past month unemployment and current major depression. Spending a greater proportion of time in residential rehabilitation (RR) was associated with better health over 24 months. No other treatment factors demonstrated a significant, independent relationship with health. The physical health of dependent heroin users is affected by drug use and psychosocial problems. RR treatment appears to be particularly beneficial to the health of heroin users, suggesting the importance of a comprehensive approach to improving health among this group.

Worley LLM; Conners NA; Crone CC; Williams VL; Bokony PA. Building a residential treatment program for dually diagnosed women with their children. Archives of Women's Mental Health 8(2): 105-111, 2005. (36 refs.)

The epidemic of drug and alcohol abuse in our nation impacts millions of women, mothers, and children. Addicted mothers with complex problems and numerous co-morbidities present unique treatment challenges. This intergenerational cycle of abuse and addiction is difficult to stop. Arkansas CARES (Center for Addictions Research Education and Services, referred to in this article as CARES) initially was created to treat addicted pregnant and postpartum women and their infants. CARES evolved into a residential treatment program for dually diagnosed mothers with their children. This paper is a synopsis of a presentation delivered at the North American Society for Psychosocial Obstetrics and Gynecology. It shares a glimpse inside the treatment program and lessons learned along the way in an effort to assist others who are interested in building treatment programs for addicted women with their children.

Zemore S; Kaskutas LA. 12-Step involvement and peer helping in day hospital and residential programs. Substance Use & Misuse 43(12-13): 1882-1903, 2008. (43 refs.)

This study compares peer helping and 12-step involvement among participants receiving chemical dependency treatment at day hospital (N = 503) and residential (N = 230) programs, and examines relationships between both variables and outcomes. Findings show that residential (vs. day hospital) participants reported significantly more peer helping and 12-step involvement during treatment, and marginally more 12-step involvement at 6 months. Both peer helping and 12-step involvement predicted higher odds of sobriety across follow-ups; helping showed an indirect effect on sobriety via 12-step involvement. Results contribute to the 12-step facilitation literature; confirm prior results regarding benefits of mutual aid; and highlight methodological issues in helping research. The study's limitations are noted.

Zemore SE; Kaskutas LA. Services received and treatment outcomes in day-hospital and residential programs. Journal of Substance Abuse Treatment 35(3): 232-244, 2008. (45 refs.)

This longitudinal health services study (N = 733) (1) examines the impact of services received on 6-month outcomes, and (2) compares day-hospital to residential programs on services received. Services were measured at 2, 4, and 8 weeks postbaseline using a version of the Treatment Services Review. Higher odds of total sobriety at 6 months were associated with greater participation in (a) extracurricular (but not curricular) 12-step meetings, (b) sober recreational events, and (c) educational sessions. Program effects also emerged. Unexpectedly, extracurricular 12-step meeting attendance and the odds of having a sponsor were lower among residential (vs. day hospital) participants through 4 weeks, despite higher participation in curricular 12-step meetings among residential participants at 2 weeks. Still, residential participants reported higher involvement in sober recreation and informal peer socialization across most analyses. Findings suggest that residential and day-hospital programs might maximize outcomes by facilitating optional 12-step involvement and sober recreation, respectively. ,