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CORK Bibliography: Treatment Intensity

85 citations. 2003 to present

Prepared: June 2011

Barnett PG; Trafton JA; Humphreys K. The cost of concordance with opiate substitution treatment guidelines. Journal of Substance Abuse Treatment 39(2): 141-149, 2010. (30 refs.)

The Multisite Opiate Substitution Treatment study compared four opioid substitution programs that were highly concordant with clinical practice guidelines to four programs that were less concordant. Program staff were surveyed, and consenting new patients from highly concordant (n = 164) and less-concordant programs (n = 91) were assessed. After 12 months, treatment of new clients of highly staffed, guideline concordant sites cost $10,252, which is significantly more than the $6,476 cost at less-concordant programs (p < .01). Clients at highly concordant sites received significantly more group visits (M = 37.0 vs. 13.1, p < .01) but fewer dosing visits. There were no significant differences in medical care costs. Opioid substitution therapy was effective at reducing heroin use, especially at sites that were highly concordant with treatment guidelines. Annual mortality was 3.0% and did not differ by type of care. Preference-based quality of life significantly improved only at highly concordant sites.

Crevecoeur-MacPhail D; Ransom L; Myers AC; Annon JJ; Diep N; Gonzales R et al. Inside the black box: Measuring addiction treatment services and their relation to outcomes. Journal of Psychoactive Drugs Supplement 6: 269-276, 2010. (17 refs.)

The adoption of performance-based management has been under consideration by addiction treatment funding agencies, and, recently, many state and county agencies have developed performance-based measurement/management systems in an attempt to improve their treatment system. This article describes one such effort in Los Angeles County, California. The Performance-Based Pilot Project linked treatment encounters (counseling sessions, drug testing, case management, and methadone dosing) with client outcomes (abstinence or reduced drug use at discharge) and longer lengths of stay in treatment. Eleven outpatient counseling programs and three narcotic treatment programs participated in the nine-month project. Results indicated that for both outpatient counseling and narcotic treatment programs, more sessions attended in the first 30 days was associated with better client outcomes and longer lengths of stay. Furthermore, in outpatient counseling programs, more group sessions during the first 30 days predicted abstinence or greater reductions in primary drug use; in narcotic treatment programs, more doses received during the first 30 days was correlated to longer treatment retention. This research implies that increasing the availability of counseling sessions for a client's first 30 days and engaging clients early is a promising area for program efforts to improve treatment outcomes and program performance.

De Leon G; Melnick G; Cleland CM. Matching to sufficient treatment: Some characteristics of undertreated (Mismatched) clients. Journal of Addictive Diseases 29(1): 59-67, 2010. (24 refs.)

A previous study by the investigative team using Drug Abuse Outcome Study data supported the validity of a sufficient treatment matching paradigm, which defines successful placement as the least treatment intensity required to address the severity of a disorder. The least favorable outcomes were obtained in the under-treated clients who received insufficient treatment intensity. The purpose of the current study was to further clarify characteristics of the undertreated clients. Four groups, those matched and mismatched to long-term residential (LTR) and drug-free outpatient (ODF) treatment, were compared on several baseline variables. Results indicated that the severity levels of drug use, social and psychological problems, and motivation for those mismatched to ODF (undertreated) were significantly lower than the clients matched to LTR but generally higher than the clients matched to ODF and those mismatched to LTR (overtreated). These findings underscore the importance of identifying clients at risk for under-treatment and facilitating their entry into treatments of sufficient intensity. More generally, they highlight the need to develop a range of treatment options of sufficient intensity to meet severity differences among clients.

Grella CE; Needell B; Shi YF; Hser YI. Do drug treatment services predict reunification outcomes of mothers and their children in child welfare? Journal of Substance Abuse Treatment 36(3): 278-293, 2009. (67 refs.)

The effect of mothers' participation in substance abuse treatment on reunification with their children who are in out-of-home care is an important policy issue. This article examines the predictors of child reunification among mothers who participated in a statewide treatment outcome study. Data were integrated from multiple sources to determine the contributions of characteristics of mothers (n = 1, 115), their children (n = 2,299), and treatment programs (n = 43) on reunification outcomes. Hierarchical linear modeling was used to determine the fixed and random effects of mother, child, and program characteristics. Mothers with more employment and psychiatric problems were less likely to be reunified with their children; completion of 90 or more days in treatment approximately doubled their likelihood of reunification. Mothers who were treated in programs providing a "high" level of family-related or education/employment services were approximately twice as likely to reunify with their children as those who were treated in programs with "low" levels of these services.

Gunne L. Swedish use and misuse of the Dole & Nyswander treatment. Heroin Addiction and Related Clinical Problems 11(2): 5-8, 2009. (8 refs.)

For 23 years (1966-1989) Sweden had a National Methadone Maintenance treatment of opioid addicts, delivering 70-80 % vocationally rehabilitated patients, taxpaying citizens, with no drug abuse and a great reduction in mortality rates. This treatment was changed in 1990 into a short-term methadone program, resulting in numerous discharges for disciplinary reasons, a high mortality rate among the newly discharged and poor rehabilitation results. Politically, the short-term treatment is called "restrictive", which is regarded as commendable by the Swedish mass media

Hagarty DE; Clark DJ. Using imagery and storytelling to educate outpatients about 12-Step programs and improve their participation in community-based programs. Journal of Addictions Nursing 20(2): 86-92, 2009. (32 refs.)

The longer a patient remains engaged in recovery activities the greater the success of long-term abstinence. Self-help community programs that use the 12-steps such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are known in the addictions field to contribute to sustained abstinence. Connecting patients to 12-step programs in early stages of recovery increases the chance of prolonged involvement. A nurse working in an outpatient substance abuse clinic developed a unique method to inform and educate patients about the 12-step process. A story and image metaphorically describe this journey. The cleaning of a vessel and subsequent discovery of tools along the way provide an uncomplicated look at the 12-steps. Nurses can use the image and story to develop the necessary tools of honesty, open-mindedness, and willingness for patients to embrace the 12-step journey.

McMahon RC; Enders C. Personality disorder factors predict recovery of employment functioning among treated cocaine abusers. American Journal of Drug and Alcohol Abuse 35(3): 138-144, 2009. (36 refs.)

Background: Identifying treatments that produce specific benefits in nondrug psychosocial functioning areas such as employment functioning has been illusive. Examination of dimensions of clinical status that moderate such effects may be useful in planning more effective interventions. Objectives: The purpose of this study is to determine if life stress and four dimensions of personality and psychopathology previously found to predict early post-treatment relapse in diverse groups of substance abusers, predict less recovery in employment functioning among 240 cocaine dependent males after completion of residential treatment. Methods: Latent growth curve analysis was used to determine if antisocial, avoidant, dependent, paranoid-delusional personality dimensions, and life event stress predict employment problem severity evident at drug treatment discharge and change in employment problems over three 3-month follow-up intervals. Results: Individuals with higher employment severity at intake and those who spent less time in treatment tended to have greater employment problems at the predischarge. Two covariates were significant predictors of the linear growth component, and the set of covariates explained approximately 18% of the variation in the linear growth rates. Individuals with higher paranoid/delusional scores and lower educational attainment experienced less improvement in their employment status over follow-up. Conclusions: Current findings appear consistent with those of McLellan and colleagues who found that greater psychiatric severity predicts poor response to treatment across multiple psychosocial outcomes including employment status. Clinical Significance: More intensive and long-term psychiatric treatment and vocational-educational rehabilitative services may be required for improvement in employment functioning among those with relatively severe psychopathology.

Polimeni AM; Moore SM; Gruenert S. Mental health improvements of substance-dependent clients after 4 months in a therapeutic community26. Drug and Alcohol Review 29(5): 546-550, 2010. (26 refs.)

Introduction and Aims. Odyssey House Victoria's Therapeutic Community (TC) accepts substance-dependent clients, including those with co-occurring mental health issues. American data suggest that TCs are effective in rehabilitating such clients; however, Australian research is limited. The aim of the study was to examine Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profiles of Odyssey House TC residents early in their residency and again after 4 months, to chart changes in MMPI-2 profiles and compare them with norms for psychological health. Design and Methods. The sample comprised 351 clients who were part of the residential program between 1997 and 2007, and who remained in treatment at the TC for at least 4 months. They were administered the MMPI-2 after 5 weeks in treatment and again after 4 months. Results. At the first assessment, the validity scales of the MMPI-2 plus the clinical scales Depression, Psychopathic Deviate, Paranoia, Psychasthenia and Schizophrenia were in the clinical range. At the second assessment, mean scores on all clinical scales except Mania were significantly or near significantly lower and, except for Psychopathic Deviate, within the normal range. The validity scales also demonstrated improvement, although two of the three remained in the clinical range. Discussion and Conclusions. Results indicated that treatment within the TC over this time span was associated with improved mental health. The present study suggests that residential rehabilitation's holistic approach provides a suitable treatment model for clients with co-occurring mental health and substance use disorders.

Willemsen MC; van der Meer RM; Schippers GM. Smoking cessation Quitlines in Europe: Matching services to callers' characteristics. BMC Public Health 10: e-article 770, 2010. (18 refs.)

Background: Telephone quitlines offer a wide range of services to callers, including advice and counsel, and information on pharmacotherapy for smoking cessation. But, little is known about what specific quitline services are offered to smokers and whether these services are appropriately matched to characteristics of smokers. This study examines how quitline services are matched to callers' level of addiction, educational level, stage-of-change with quitting, and whether they are referred by a doctor or other health professional. Methods: Between February 2005 and April 2006, 3,585 callers to seven European quitlines responded to our survey. During the course of and immediately after the call, quitline counsellors collected descriptive data on callers' characteristics and the services they used. We then conducted four logistic regression analyses to examine the relationship between quitline services and the four caller characteristics. Results: Forty three percent of all callers received information on pharmacotherapy - most often nicotine patches and nicotine gum - from the counsellor. As we predicted, these callers were the heavy smokers. There was a direct correlation between the length of the conversations between the counsellor and the educational level of the smoker: the lower the education of the smoker, the shorter the call. However, we found no significant association between any other type of service and the educational level of caller. We also found a correlation between the smoker's stage of quitting and the type of advice a counsellor gives. Smokers in the action stage of quitting were more likely to receive advice (in two quitlines) or counselling (in two quitlines) than those in the preparation stage, who were less likely to be referred (in three quitlines). Very few of the total number of calls (10.7%) were from referrals by health professionals. Referred callers were more likely to receive counselling, but this was found only in four of seven quitlines. Conclusion: Most of the services quitlines offer to smokers favour heavy smokers and those at a more advanced stage of cessation, but not based on their educational level. Thus, we recommend that European quitlines extend and tailor their services to include less-educated smokers.

Xie HY; Drake RE; McHugo GJ; Xie L; Mohandas A. The 10-year course of remission, abstinence, and recovery in dual diagnosis. Journal of Substance Abuse Treatment 39(2): 132-140, 2010. (26 refs.)

This study examined the frequency, stability, predictors, and long-term outcomes of 6-month remissions of alcohol use disorders among 116 adults with co-occurring severe mental illnesses followed up prospectively for 10 years. Remission was defined as 6 months without meeting syndromal criteria for alcohol abuse or dependence. Most participants (86%) experienced at least one 6-month remission, and these remissions were relatively durable. One third did not relapse during follow-up, and two thirds relapsed on average 3 years after remission. Six-month remissions were preceded by increased participation in substance abuse treatments, reductions in alcohol and drug use, decreases in psychiatric symptoms, increases in competitive employment, and increases in life satisfaction. Following remissions, participants improved in multiple domains of adjustment: reductions of psychiatric symptoms, decreases in alcohol and drug use, increases in work and social contacts with nonabusers, decreases in hospitalizations and incarcerations, increases in independent living, and increases in life satisfaction. Participants with alcohol dependence rather than alcohol abuse were less likely to attain 6-month remissions and more likely to relapse after attaining remissions.

Andreas JB; O'Farrell TJ. Alcoholics Anonymous attendance following 12-step treatment participation as a link between alcohol-dependent fathers' treatment involvement and their children's externalizing problems. Journal of Substance Abuse Treatment 36(1): 87-100, 2009. (55 refs.)

We investigated longitudinal associations between alcohol-dependent fathers' 12-step treatment involvement and their children's internalizing and externalizing problems (N = 125, M-age = 9.8 +/- 3.1), testing the hypotheses that fathers' greater treatment involvement would benefit later child behavior and that this effect would be mediated by fathers' posttreatment behaviors. The initial association was established between fathers' treatment involvement and children's externalizing problems only, whereas Structural Equation Modeling (SEM) results supported mediating hypotheses. Fathers' greater treatment involvement predicted children's lower externalizing problems 12 months later, and fathers' posttreatment behaviors mediated this association. Greater treatment involvement predicted greater posttreatment Alcoholics Anonymous attendance, which in turn predicted greater abstinence. Finally, fathers' abstinence was associated with lower externalizing problems in children. Theoretical and practical implications of these findings are discussed.

Ashley OS; Sverdlov L; Brady TM. Length of Stay among Female Clients in Substance Abuse Treatment. Chapter 6. Council CL, ed. IN: Health Services Utilization by Individuals with Substance Abuse and Mental Disorders. Analytic Series A-25. Rockville, MD: Office of Applied Studies, 2004. pp. 107-132. (75 refs.)

Research suggests that increased length of stay (LOS) in substance abuse treatment is associated with improved postdischarge outcomes. Although research indicates that LOS in treatment is a strong predictor of posttreatment success, studies of LOS in treatment have been problematic. For example, definitions of LOS vary widely, and study samples are typically small and nonrepresentative. Studies examining the predictors of retention in substance abuse treatment programs generally have used samples with few or no women. Research indicates that different factors influence treatment retention for women than men, including income, referral source, age, and payer type. Unique substance abuse treatment needs for women include child care services, women-only treatment, and prenatal care services. This chapter considers predisposing characteristics affecting LOS, includding age, race, education and marital status, as well as organizational characterisitcs. In summary it was found that those with less than a HS education were more likely to leave early, those referred by sources other than the criminal justice system were likely to leave treatment earlier. Women at facilties with child care services stayed longer, than those at facilities without child care. Those at women-only facilities were retained longer in treatment. Age at admission nor race were associated with length of stay, although previous research as linked these. Those with private insurance had shorter lengths of stay, and this may represent caps on benefits. On the other hand, this may mean that those with private coverage are less severely impaired and thus shorter stays were sufficient.

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

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

Brandon TH; Meade CD; Herzog TA; Chirikos TN; Webb MS; Cantor AB. Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: Dismantling the effects of amount of content versus contact. Journal of Consulting and Clinical Psychology 72(5): 797-808, 2004. (48 refs.)

Relapse prevention remains a major challenge to smoking cessation efforts. T. H. Brandon, B. N. Collins, L. M. Juliano, and A. B. Lazev (2000) found that a series of 8 empirically based relapse-prevention booklets mailed to ex-smokers over I year significantly reduced relapse. This study dismantled 2 components of that intervention: the amount of content (number of booklets) and the frequency of contact. Content and contact were crossed in a 2 X 2 factorial design. The criteria of at least 1 week of abstinence at baseline was met by 431 participants, 75%-85% of whom returned 12-, 18-, and 24-month follow-up questionnaires. Eight booklets produced consistently higher point-prevalence abstinence rates than did a single booklet, but frequency of contact did not affect outcome. Moreover, the high-content interventions were highly cost-effective.

Brooner RK; Kidorf MS; King VL; Stoller KB; Peirce JM; Bigelow GE et al. Behavioral contingencies improve counseling attendance in an adaptive treatment model. Journal of Substance Abuse Treatment 27(3): 223-232, 2004. (56 refs.)

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

Burnette ML; Schneider R; Ilgen MA; Timko C. Women's past-year prostitution status and receipt of substance abuse treatment services. Psychiatric Services 59(12): 1458-1461, 2008. (15 refs.)

Objective: The study compared services received in substance abuse treatment programs by women who reported involvement in prostitution and by those who did not. Methods: Women (N=1,604) in a national study of substance abuse programs completed a structured interview assessing substance abuse, demographic characteristics, and past-year prostitution at program entry. At discharge, information was gathered on treatment modality (residential including inpatient, or outpatient), duration, and amounts of medical, mental health, and psychosocial services received during treatment. Analyses compared women involved in prostitution and those not involved. Results: Women involved in prostitution were more likely to enter residential treatment. No differences between involvement groups were found in residential treatment duration, services received in residential treatment, or length of outpatient enrollment. In outpatient programs, women involved in prostitution received more psychosocial services. Conclusions: Substance abuse treatment programs appear responsive to the greater needs of women involved in prostitution. However, more research is needed on outcomes.

Campbell CI; Alexander JA; Lemak CH. Organizational determinants of outpatient substance abuse treatment duration in women. Journal of Substance Abuse Treatment 37(1): 64-72, 2009. (50 refs.)

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored women's programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and women's treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to external influences.

Carls KA; Ruehter VL. An evaluation of phencyclidine (PCP) psychosis: A retrospective analysis at a state facility. American Journal of Drug and Alcohol Abuse 32(4): 673-678, 2006. (13 refs.)

It has been reported in the literature that phencyclidine (PCP) psychosis recovery may take up to 4-6 weeks. This retrospective review sought to determine whether patients with a new onset of PCP psychosis have a longer hospitalization than those patients with new onset functional psychosis. The PCP arm (N = 20) was found to have a significantly shorter hospitalization than those with a new onset functional psychosis (N = 20)-mean 4.8 days (range 1-9) versus 13.6 days (range 3-41), p < .05. In addition, patients with psychosis related to PCP use were treated more aggressively with conventional antipsychotics than patients with a new onset functional psychosis at this facility.

Chen S; Barnett PG; Sempel JM; Timko C. Outcomes and costs of matching the intensity of dual-diagnosis treatment to patients' symptom severity. Journal of Substance Abuse Treatment 31(1): 95-105, 2006. (63 refs.)

This study evaluated a patient-treatment matching strategy intended to improve the effectiveness and cost-effectiveness of acute treatment for dual-diagnosis patients. Matching variables were the severity of the patient's disorders and the program's service intensity. Patients (N = 230) with dual substance use and psychiatric disorders received low or high service-intensity acute care in 1 of 14 residential programs and were followed up for 1 year (80%) using the Addiction Severity Index. Patients' health care utilization was assessed from charts, Department of Veterans Affairs (VA) databases, and health care diaries; costs were assigned using methods established by the VA Health Economics Resource Center. High-severity patients treated in high-intensity programs had better alcohol, drug, and psychiatric outcomes at follow-up, as well as higher health care utilization and costs during the year between intake and follow-up than did those in low-intensity programs. For moderate-severity patients, high service intensity improved the effectiveness of treatment in only a single domain (drug abuse) and increased costs of the index stay but did not increase health care costs accumulated over the study year. Moderate-severity patients generally had similar outcomes and health care costs whether they were matched to low-intensity treatment or not. For high-severity patients, matching to higher service intensity improved the effectiveness of treatment as well as increased health care costs. Research is needed to establish standards by which to judge whether the added benefits of high-intensity acute care justify the extra costs.

Chou CP; Hser YI; Anglin MD. Longitudinal treatment effects among cocaine users: A growth curve modeling approach. Substance Use & Misuse 38(9): 1323-1343, 2003. (30 refs.)

This study examined longitudinal treatment effects among cocaine users. The study examined a sample of 371 cocaine users screened from arrestees in jails and from patients in sexually transmitted disease clinics and emergency rooms-all in Los Angeles County during 1992-1994. Of the 371 subjects, 121 had never been in treatment and 250 reported a history of participation in drug user treatment (145 subjects' first treatment was for cocaine use and 105 were in treatment for a drug other than cocaine). Data were collected during face-to-face interviews using a natural history interview instrument. We applied a series of growth curve models to investigate treatment effects on cocaine use. For those who had been in treatment for cocaine use, use of cocaine decreased from approximately 70% before treatment to 12% after treatment entry, while no such changes were observed among those who had never been in treatment or those in treatment for other drugs. Relative to nontreated users, cocaine-treated participants showed a greater likelihood of pretreatment use for both initial status (OR = 3.58) and growth rate (OR = 1.05). After treatment entry, cocaine-treated participants as compared to nontreated participants had a lower likelihood of use (OR = 0.27), although their cocaine use after the initial status increased at a greater rate (OR = 1.03). Treated users were five times less likely to use when they were in treatment than when they were out of treatment. Longer treatment retention was related to initially reduced use but not to later rates of change in cocaine use. The study findings support that treatment for cocaine use is effective in reducing cocaine use. Longitudinal models provide opportunities to demonstrate the dynamic relationships between treatment and outcome.

Christenhusz L; Marcel P; Erwin S; van der Palen J. Prospective determinants of smoking cessation in COPD patients within a high intensity or a brief counseling intervention. Patient Education and Counseling 66(2): 162-166, 2007. (16 refs.)

Objectives: The aims of this study were to identify prospective determinants of smoking cessation in COPD patients, and to assess whether prospective determinants vary between two different cessation interventions. Methods: Two hundred and twenty-five moderate to severe COPD patients were randomly allocated to two smoking cessation interventions. One-year cotinine-validated continuous abstinence rates were 9% for the minimal intervention strategy for lung patients (LMIS) and 19% for the SmokeStopTherapy (SST). The baseline characteristics that showed a significant univariate relationship with 1-year continuous abstinence (p < .20) were included in the logistic regression model. This procedure was performed for each intervention separately. Variables that did not remain independent predictors were removed. Results: For the SST separately, no independent significant predictor remained. For the LMIS, attitude towards smoking cessation (OR: 11.8; 95% CI: 1.7-81.5; p = .013) and cotinine level (OR: 2.1; 95% CI: 1.08-3.93; p = .028) remained significant predictors. Within the LMIS, 31% of the variance in continuous abstinence was explained by these variables (p = .003). Conclusion: This study suggests that a moderately intensive intervention (LMIS) is primarily suitable for COPI) patients with a positive attitude regarding smoking cessation. The more intensive SST can be an alternative for patients without such baseline characteristic. Practice implications: This stepped-care approach in smoking cessation counseling may be useful in clinical practice and will enable health care providers to match interventions to individual needs and increase efficiency.

Conners CA; Grant A; Crone CC; Whiteside-Mansell L. Substance abuse treatment for mothers: Treatment outcomes and the impact of length of stay. Journal of Substance Abuse Treatment 31(4): 447-456, 2006. (45 refs.)

This article examines the treatment outcomes of 305 women enrolled in a comprehensive, residential substance abuse treatment program for pregnant and parenting women and their children. The women were assessed at intake and three times in the year after discharge. Analyses focused on change in client functioning over time, and investigating the impact of length of stay in treatment on client outcomes. Comparisons of clients' functioning before and after treatment suggest significant improvements in a number of domains, including substance use, employment, legal involvement, mental health, parenting attitudes, and risky behaviors. For most outcome domains, results suggest that longer treatment stays are associated with more positive outcomes.

Corrigan JD; Bogner J; Lamb-Hart G; Heinemann AW; Moore D. Increasing substance abuse treatment compliance for persons with traumatic brain injury. Psychology of Addictive Behaviors 19(2): 131-139, 2005. (51 refs.)

This study compared 3 methods of increasing participation in substance abuse treatment for clients with traumatic brain injury. Participants (N = 195) were randomly assigned to 4 conditions: (a) motivational interview, (b) reduction of logistical barriers to attendance, (c) financial incentive, and (d) attention control. Four interviewers conducted structured, brief telephone interventions targeting the timeliness of signing an individualized service plan. Participants assigned to the barrier reduction (74%) and financial incentive (83%) groups were more likely to sign within 30 days compared with the motivational interview (45%) and attention control (45%) groups. Similar results were observed for time to signing, perfect attendance at appointments, and premature termination during the following 6 months. Extent of psychiatric symptoms was the only significant covariate.

Davis MI; Jason LA. Sex differences in social support and self-efficacy within a recovery community. American Journal of Community Psychology 36(3-4): 259-274, 2005. (62 refs.)

This study examined similarities and differences in social support and self-efficacy for abstinence between women and men recovering from substance addiction. The sample consisted of 87 residents of Oxford House (OH) self-run, community-based recovery homes. Analyses revealed similarities between women and men in terms of the composition and utilization of support networks and abstinence self-efficacy. Also, for both sexes, length of residency in OH was significantly related to decreased social support for alcohol and drug use and increased self-efficacy for abstinence. However, multiple-group SEM analyses demonstrated that social support for alcohol/drug use fully mediated the link between length of residency and abstinence self-efficacy for women, but not for men. Findings suggest that the process of gaining self-efficacy to remain abstinent is distinct for women and men, and that social support plays a different role in women's recovery than it does in men's.

De Leon G; Melnick G; Cleland CM. Matching to sufficient treatment: Some characteristics of undertreated (Mismatched) clients. Journal of Addictive Diseases 29(1): 59-67, 2010. (24 refs.)

Deck D; Wiitala W; McFarland B; Campbell K; Mullooly J; Krupski A et al. Medicaid coverage, methadone maintenance, and felony arrests: Outcomes of opiate treatment in two states. Journal of Addictive Diseases 28(2): 89-102, 2009. (52 refs.)

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.

Dundon WD; Pettinati HM; Lynch KG; Xie H; Varillo KM; Makadon C et al. The therapeutic alliance in medical-based interventions impacts outcome in treating alcohol dependence. Drug and Alcohol Dependence 95(3): 230-236, 2008. (18 refs.)

This study examined the relationship of the therapeutic alliance and treatment outcomes for alcohol-dependent patients receiving naltrexone or placebo and one of three different types of clinical interventions, including two medical-based (non-specialty) treatments. This is a secondary analysis of a 24-week randomized, placebo-controlled, clinical trial of 100 mg/day of naltrexone or placebo for patients with DSM-IV alcohol dependence. Patients were also randomized to one of three interventions: (1) medication clinic only, (2) medication clinic plus BRENDA (an intervention promoting pharmacotherapy), or (3) medication clinic plus cognitive behavioral therapy (CBT). Early in treatment, patients and clinicians completed the working alliance inventory (WAI). Regression analyses were conducted to determine the predictive validity of the WAI on percent days abstinent and percent of sessions attended over the clinical trial. In the medication clinic only condition, the clinicians' WAI total score was marginally correlated to percent of visits attended (p=.057) but not percent days abstinent. In the medication clinic plus BRENDA condition, clinicians' WAI total score was positively correlated with percent days abstinent (p=.013) but not percent visits attended. No significant relationships were found between the WAI scores and either outcome measure in the CBT condition or for any of the patient rated assessments. To our knowledge, this is the first published report providing some support for the importance of the therapeutic alliance in medical interventions for alcohol dependence but only in the context of the clinicians' ratings. The absence of other effects underscores the need for further research.

Fiorentine R; Hillhouse MP. Why extensive participation in treatment and twelve-step programs is associated with the cessation of addictive behaviors: An application of the addicted-self model of recovery. Journal of Addictive Diseases 22(1): 35-55, 2003. (85 refs.)

Applying the Addicted-Self Model of recovery to explain why extensive participation in recovery activities predicts abstinence, it was hypothesized that high levels of participation in treatment and Twelve-step programs promote abstinence because these activities reinforce the notion that controlled use is not possible for dependent alcohol and drug users. Findings from a prospective treatment outcomes study (n = 356) indicate general support for this hypothesis. Yet the cognitive transformation described by the Addicted-Self Model involving acknowledgement of loss of control over alcohol and other drugs is only a partial explanation of why extensive participation in recovery activities promotes recovery. Reiterating the conclusion that "more is better", frequent counseling participation, treatment completion, and weekly or more frequent participation in Twelve-Step programs promote abstinence independently from their influence on controlled use self-efficacy. Theoretical and clinical implications, and directions for future research are discussed.

Fosados R; Evans E; Hser YI. Ethnic differences in utilization of drug treatment services and outcomes among proposition 36 offenders in California. Journal of Substance Abuse Treatment 33(4): 391-399, 2007. (71 refs.)

This study examined whether ethnic differences exist in access to care, receipt of services, and associated outcomes of 1,057 offenders participating in California's Proposition 36. Data are based on intake and 3-month follow-up interviews conducted as part of a multisite prospective treatment outcome study. Logistic regressions were conducted to examine ethnicity and other predictors of treatment placement and services intensity. Across ethnic groups, services intensity in several domains was inadequately matched to need, and few services besides substance abuse treatment were provided. Blacks and Hispanics received alcohol and employment services that were not commensurate with their greater need. Although Blacks were more likely to be placed in residential programs, their employment status worsened from intake to follow-up. There were few other ethnic differences in outcomes. Assessing and eliminating ethnic-associated differences in health service delivery, even as moderate as our findings revealed, may improve program processes and outcomes.

Friedmann PD; Alexander JA; Yey Y; Nahra T; Soliman S; Pollack HA. Duration of nonmethadone outpatient treatment: Results from a national survey. Substance Abuse 27(3): 47-53, 2006

OBJECTIVES: This study examined organizational trends from 1990 to 2000 and unit characteristics associated with the duration of nonmethadone outpatient addiction treatment. METHODS: Program directors and clinical supervisors from a nationally representative panel of nonmethadone outpatient units in the United States were surveyed in 1990, 1995, and 2000. Treatment duration was measured from clinical supervisors' reports of the average length of stay. Negative binominal regression models controlled for multivariate effects. RESULTS: Treatment duration modestly declined between 1990 and 2000 while addiction severity increased. Affiliation with a mental health center, older program age, JCAHO accreditation-ostensibly a marker for structural quality-and serving more clients with prior authorization requirements- a measure of managed care stringency-were associated with shorter treatment durations. CONCLUSIONS: These findings suggest that treatment duration did not increase between 1990 and 2000 despite clients' worsening addiction severity and growing evidence that longer duration of formal treatment improves treatment outcome. In addition, programs with JCAHO accreditation and stronger managed care oversight appeared to seek efficiencies through reductions in treatment duration.

Friedmann PD; Alexander JA; Yey Y; Nahra T; Soliman S; Pollack HA. Duration of nonmethadone outpatient treatment: Results from a national survey. Substance Abuse 27(3): 47-53, 2007

Objectives. This study examined organizational trends from 1990 to 2000 and unit characteristics associated with the duration of nonmethadone outpatient addiction treatment. Methods. Program directors and clinical supervisors from a nationally representative panel of nonmethadone outpatient units in the United States were surveyed in 1990, 1995, and 2000. Treatment duration was measured from clinical supervisors' reports of the average length of stay. Negative binominal regression models controlled for multivariate effects. Results. Treatment duration modestly declined between 1990 and 2000 while addiction severity increased. Affiliation with a mental health center, older program age, JCAHO accreditation-ostensibly a marker for structural quality-and serving more clients with prior authorization requirementsa measure of managed care stringency -- were associated with shorter treatment durations. Conclusions. These findings suggest that treatment duration did not increase between 1990 and 2000 despite clients' worsening addiction severity and growing evidence that longer duration of formal treatment improves treatment outcome. In addition, programs with JCAHO accreditation and stronger managed care oversight appeared to seek efficiencies through reductions in treatment duration.

Gariti P; Lynch K; Alterman A; Kampman K; Xie H; Varillo K. Comparing smoking treatment programs for lighter smokers with and without a history of heavier smoking. Journal of Substance Abuse Treatment 37(3): 247-255, 2009. (33 refs.)

The study examined the impact of counseling intensity (high vs. low) combined with either bupropion or the nicotine patch. Two hundred sixty participants smoking 6 to 15 cigarettes per day (cpd) were enrolled in a yearlong study to examine the effects of treatment. Four groups of smokers under medication-blinded conditions were compared for treatment completion and abstinence at three follow-up points from the initiation of treatment (Weeks 12, 26, and 52). Both counseling groups had similar treatment completion rates (i.e., defined by a combination of counseling attendance and medication adherence levels). There was a main treatment effect for abstinence favoring the high counseling condition in early follow-up (Week 12) and for continuous abstinence. Participants with a history of heavier smoking ( >= 20 cpd) and African American smokers were least likely to be smoke free at the end of the study. The study has implications for identifying the treatment needs of lighter smokers.

Gossop M; Stewart D; Marsden J. Effectiveness of drug and alcohol counselling during methadone treatment: Content, frequency, and duration of counselling and association with substance use outcomes. Addiction 101(3): 404-412, 2006. (51 refs.)

The study investigates the relationship between the type and severity of drug and alcohol use problems, and the provision of drug- and alcohol-counselling in methadone programmes. The study also specifically investigates the relationship between content, frequency and duration of counselling provided during the first month of treatment, and heroin, cocaine, and alcohol use outcomes at 6 months. The sample comprised 276 patients receiving outpatient methadone treatment who were followed-up 6 months after treatment entry. Data on client characteristics, drug and alcohol problems and on counselling received were collected by structured face-to-face interviews. Drug-focused counselling was associated with less frequent heroin and cocaine use at follow-up, but was not related to pre-treatment drug use. Alcohol-focused counselling was provided for those with higher levels of drinking at admission but was not significantly associated with drinking outcome at 6 months. Results indicate that there are complex interactions between presenting substance use problems, provision of counselling and treatment outcomes. These interactions differ by substance type.

Greenfield L; Burgdorf K; Chen XW; Porowski A; Roberts T; Herrell J. Effectiveness of long-term residential substance abuse treatment for women: Findings from three national studies. American Journal of Drug and Alcohol Abuse 30(3): 537-550, 2004. (15 refs.)

The effectiveness of residential substance abuse treatment for women was examined using data from the Center for Substance Abuse Treatment's Residential Women and Children/Pregnant and Postpartum Women (RWC/PPW) Cross-Site Study and two other recent national studies. Treatment success was defined as posttreatment abstinence from further drug or alcohol use, measured through in-person follow-up interviews conducted 6-12 months after each client's discharge. Despite differences in treatment programs, client profiles, follow-up intervals, data collection methods, and other factors, all three studies found high treatment success rates-ranging narrowly from 68% to 71% abstinent-among women who spent six months or more in treatment. Success rates were lower, and between-study differences were larger, for clients with shorter stays in treatment. Controlling for salient client and treatment project characteristics, strong associations between length of stay in treatment and posttreatment abstinence rate were found in all three studies, suggesting that women's length of stay in residential treatment is a major determinant of treatment effectiveness. In further analysis of RWC/PPW data, treatment completion was also found to be an important outcome factor. Among clients who remained in treatment for at least three months, those who achieved their treatment goals in three to five months abstinence outcomes were as good as those for clients who took more than six months to complete their treatment (76%-78% abstinent) and substantially better than those for clients who did not complete treatment (51%-52% abstinent). Notably, however, most of the RWC/PPW clients who successfully completed treatment (71%) required six months or more to do so.

Grella CE; Needell B; Shi YF; Hser YI. Do drug treatment services predict reunification outcomes of mothers and their children in child welfare? Journal of Substance Abuse Treatment 36(3): 278-293, 2009. (67 refs.)

Grohman K; Fals-Stewart W. Cognitive rehabilitation in substance abuse treatment: Effects on length of stay and posttreatment abstinence. (meeting abstract). Alcoholism: Clinical and Experimental Research 28(5 Supplement): 77A-77A, 2004. (0 refs.)

Gunne L. Swedish use and misuse of the Dole & Nyswander treatment. Heroin Addiction and Related Clinical Problems 11(2): 5-8, 2009. (8 refs.)

Hagarty DE; Clark DJ. Using imagery and storytelling to educate outpatients about 12-Step programs and improve their participation in community-based programs. Journal of Addictions Nursing 20(2): 86-92, 2009. (32 refs.)

Hammarberg A; Wennberg P; Beck O; Franck J. A comparison of two intensities of psychosocial intervention for alcohol dependent patients treated with acamprosate. Alcohol and Alcoholism 39(3): 251-255, 2004. (27 refs.)

Aims: To compare two levels of psychosocial intervention in combination with acamprosate medication for the treatment of alcohol dependence. Methods: Patients (n = 70) were prescribed acamprosate and randomized to Minimal Psychosocial Intervention (MPI) or Extended Psychosocial Intervention (EPI). MPI patients met a psychiatrist for 20-30 min sessions on four occasions during a 6 month period. EPI patients were offered 10-15 sessions with a psychiatric nurse in addition to the visits to the psychiatrist. EPI patients were trained to use behavioural and cognitive coping skills to deal with high-risk situations in line with a manual developed for relapse prevention. Patients were assessed four times during the 24-week study by self-report and laboratory tests. Results: Patients on average reported a decline in days with heavy drinking and in cumulative number of drinking days. No significant differences between patients in MPI and EPI were found with respect to heavy drinking, cumulative number of drinking days, number of days to first drink, or biomarkers of alcohol consumption. Higher age and lower level of education were significant predictors of treatment success. Conclusions: Adding more intensive individual treatments appears to add no extra improvement beyond that obtained by prescribing acamprosate and offering an infrequent consultation with a physician.

Hser YI; Evans E; Huang D; Anglin DM. Relationship between drug treatment services, retention, and outcomes. Psychiatric Services 55(7): 767-774, 2004. (36 refs.)

Objective: This longitudinal study conducted path analyses to examine the relationships between treatment processes and outcomes among patients in community-based drug treatment programs. Methods: A total of 1,939 patients from 36 outpatient drug-free and residential treatment programs in 13 California counties were assessed at intake, discharge, three months after admission, and nine months after admission. Path analyses were conducted to relate the quantity and quality of services that were received in the first three months of treatment to treatment retention and outcomes at the nine-month follow-up. Patients were determined to have a favorable outcome if for at least 30 days before the follow-up assessment they did not use drugs, were not involved in criminal activity, and lived in the community. The path analyses controlled for patients' baseline characteristics. Results: Greater service intensity and satisfaction were positively related to either treatment completion or longer treatment retention, which in turn was related to favorable treatment outcomes. Patients with greater problem severity received more services and were more likely to be satisfied with treatment. These patterns were similar for patients regardless of whether they were treated in outpatient drug-free programs or residential programs. Conclusions: The positive association between process measures -- that is, greater levels of service intensity, satisfaction, and either treatment completion or retention -- and treatment outcome strongly suggests that improvements in these key elements of the treatment process will improve treatment outcomes.

Ilgen M; Moos R. Deterioration following alcohol-use disorder treatment in Project MATCH. Journal of Studies on Alcohol 66(4): 517-525, 2005. (35 refs.)

Objective: This study examines the prevalence and predictors of deterioration during the three months following treatment in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a multisite clinical trial of three different treatments for alcohol use disorders. Method: The outpatient and aftercare samples of Project MATCH were examined to identify the prevalence of deterioration, as reflected by a decline in percent days abstinent between the 3 months prior to baseline and the 3 months immediately following treatment. Analyses of predictors of deterioration were based on baseline sociodemographic and psychological factors, including substance-related and psychiatric symptoms and treatment-related factors, including treatment type, treatment duration and therapeutic alliance. Results: Approximately 10% (91/927) of patients in the outpatient sample and 7% (50/ 738) of patients in the aftercare sample deteriorated in the 3 months following treatment. Primary predictors of deterioration in the outpatient sample were lower baseline severity of alcohol dependence, higher baseline depression, fewer sessions of treatment and lower ratings of therapeutic alliance. The only factor associated with deterioration in the aftercare sample was fewer sessions of treatment. Conclusions: Despite the general positive response of patients to alcohol-use disorder treatment, researchers and treatment providers need to be aware of the potential for deterioration in a sizable minority of patients. Potential methods for identifying patients at risk for deterioration early in treatment are discussed.

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.

Jansson LM; Svikis DS; Beilenson P. Effectiveness of child case management services for offspring of drug-dependent women. Substance Use & Misuse 38(14): 1933-1952, 2003. (34 refs.)

Female drug users and their children have many medical and psychosocial problems, yet they often fail to follow through with prescribed treatments. The present study describes a specialized, case management program for children, birth through age 2, exposed to drugs in utero. Evaluation of program efficacy was examined by comparing 2-year outcomes for women who received different intensities of these child case management services. Mothers who received higher intensity care were more likely to be abstinent from illicit drugs and to have retained custody of their child(ren) at 2-year follow-up than those with lower intensity services. Study findings support clinical and economic efficacy of this model of care.

John U; Veltrup C; Driessen M; Wetterling T; Dilling H. Motivational intervention: An individual counselling vs a group treatment approach for alcohol-dependent in-patients. Alcohol and Alcoholism 38(3): 263-269, 2003. (22 refs.)

Aims: The present study aimed to evaluate whether individual counselling for alcohol-dependent patients in three sessions is as effective as a 2-week group treatment programme as part of an in-patient stay in a psychiatric hospital which was to foster motivation to seek further help and to strengthen the motivation to stay sober. Of particular importance was the external validity of the results, i.e. a 'normal' intake load of in-patients in detoxification and a wide variety of motivation to stop drinking were to be investigated. Methods: Subjects eligible for the study were all patients with alcohol problems admitted to a psychiatric hospital, but without psychosis, as the main diagnosis, and with a maximum of 10 detoxification treatments in the past. A randomized-controlled trial was conducted with 161 alcohol-dependent in-patients who received three individual counselling sessions on their ward in addition to detoxification treatment and 161 in-patients who received 2 weeks of in-patient treatment and four out-patient group sessions in addition to detoxification. Both interventions followed the principles and strategies of motivational interviewing. Results: Six months after intervention, group-treatment patients showed a higher rate of participation in self-help groups; however, this difference had disappeared 12 months after treatment. The abstinence rate among the former patients did not differ between the two intervention groups. Conclusion: Group treatment may lead to a higher rate of participation in self-help groups, but does not increase the abstinence rate 6 months after treatment.

Jungerman FS; Andreoni S; Laranjeira R. Short term impact of same intensity but different duration interventions for cannabis users. Drug and Alcohol Dependence 90(2/3): 120-127, 2007. (33 refs.)

The present study evaluates the efficacy of a brief intervention for cannabis users. A randomized controlled trial compared 3 conditions: 4 weekly individual sessions of motivational interviewing and relapse prevention over 1 month (1MIRP); the same 4 sessions over 3 months (3MIRP), and delayed treatment control (DTC). The short term impact of each intervention was followed up 4 months after randomization. Participants were 160 highly educated adults with a long history of frequent cannabis use. Both treatments showed better results than the DTC, and for primary outcomes (i.e., cannabis consumption) there was no difference between treatments, while the 3MIRP scheme showed greater efficacy in reducing dependence. symptoms and other drug use according to the ASI drug subscale. There was a tendency for the longer treatment to have better outcomes, regardless of intensity, although the waiting list did have some positive effect. The cohort needs to be followed up for a longer period in order to ascertain whether changes are maintained over time.

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

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

Kim S; Crutchfield C. An evaluation of substance abuse aftercare program for homeless women with children using confounding variable-control design. Journal of Drug Education 34(3): 213-233, 2004. (31 refs.)

An outcome evaluation of a substance abuse aftercare program for homeless women with children was conducted using confounding variable-control evaluation design. The confounding variables are chosen from pre-treatment and other contextual variables of the clients that are known to have significant influence on the program outcome, but those that could not have been influenced a priori by the client involvement in in-treatment program activity at Transition House (TH). The latter is the independent variable of this evaluation design. The pre-treatment variables are measured by severity of alcohol and other drug (ACID) problems of the clients, their mental health status, age, and their job status before enrollment in the program. The contextual confounding variables are composed of family and social support available to the clients before and during recovery. While applying multiple regression analysis, we were able to explain 50.8% of the total variance in program outcome by four pre-treatment variables. By adding two contextual variables of family and social support, the total variance in program outcome explained is increased to 64.1%. Finally, by adding the degree of client involvement in in-treatment program activity, we were able to augment the total variance of the program outcome to 69.7%. By estimating the changed variance of program outcome by the in-treatment program activity during the final step, controlling for all other variables previously entered, we were able to establish that client involvement in in-treatment program had unique and positive impact on the program outcome distinct from those explained by the confounding variables. The additional variance uniquely added by in-treatment program activity is 5.6% (p < .001). It has been determined that the degree of client involvement in in-treatment program had positive and systematic impact on the program outcome.

Kletter E. Counseling as an intervention for the cocaine-abusing methadone maintenance patient. Journal of Psychoactive Drugs 35(2): 271-277, 2003. (24 refs.)

Using archival data from Bay Area Addiction Research and Treatment (BAART), a methadone treatment provider, this study examined the efficacy of the clinical intervention of counseling on cocaine use by BAART patients. California State Assembly Bill 2071 mandated that patients at methadone clinics be required to undergo a minimum of 50 minutes of counseling per month. Records of 179 patients continuously active in treatment beginning 12 months prior to (i.e., the baseline) and two years after AB 2071's implementation were reviewed. These patients were also identified as cocaine abusers. A pretest-intervention-posttest design was employed, with the increased counseling mandated by AB 2071 as the intervention. Cocaine abusers' urinalysis results during the one-year baseline were compared to the time period following AB 2071's implementation. The independent variable was the amount of counseling received and the dependent variable was cocaine use. The prediction was that cocaine-abusing methadone maintenance patients would have fewer cocaine positive urine analyses following AB 2071's implementation than in the 12-month baseline period preceding AB 2071. Results supported the main hypothesis that cocaine-abusing patients would show better improvement following AB 2071. Additionally, the actual amount of time in counseling was shown to lead to greater improvement in treatment for cocaine abusers. An important secondary finding was that heroin use was also negatively correlated to time in counseling. There were no gender differences in the response to the counseling treatment.

Knight DK; Broome KM; Simpson DD; Flynn PM. Program structure and counselor-client contact in outpatient substance abuse treatment. Health Services Research 43(2): 616-634, 2008. (27 refs.)

Objectives. To examine organizational structural attributes associated with counselor-client contact. Data Sources. Data were collected in 2004 and 2005 for a federally funded project, which simultaneously examines organizational structure, functioning, and resources among outpatient substance abuse treatment programs. Study Design. The study uses a naturalistic design to investigate organizational structure measures-ownership, accreditation, and supplemental services-as predictors of time in counseling and case management, and caseload size, controlling for geographic differences. Data Collection. Directors at 116 outpatient drug-free treatment programs located in four regions across the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) voluntarily completed a survey about program structure. Primary Finding. Clients received more counseling hours in programs that were "intensive," publicly owned, accredited, and had a lower proportion of recently hired counselors. More case management hours were offered in "intensive," private-for-profit or publicly owned (versus private-nonprofit) programs, serving a lower proportion of dual-diagnosis clients, and providing more on-site supplemental services. Smaller caseloads were found in programs that were accredited and had a smaller average client census and a lower proportion of criminal justice referred clients. Conclusions. Organizational attributes are related to counselor-client contact and may have implications for staff turnover and service quality.

Lo Sasso AT; Lyons JS. The sensitivity of substance abuse treatment intensity to co-payment levels. Journal of Behavioral Health Services & Research 31(1): 50-65, 2004. (48 refs.)

This study exploits variation in co-payment levels among different contractual arrangements within a regional managed behavioral health care organization to estimate the relationship between copayment levels for substance use treatment services and the intensity of substance use treatment. The substance use treatment benefits involved a range of co-payment levels across nearly 400 employers during the years 1993 through 1998. Multiple regression techniques were used to estimate the effect of co-payment levels on treatment intensity. The results indicate that co-payment levels had a significant negative effect on outpatient and inpatient substance use treatment. For outpatient treatment the effect on intensity implied a co-payment elasticity of -0.18, implying that moving from a $10 co-payment to a $20 co-payment would result in, for example, a reduction from 5 to 4 outpatient visits per episode. However, the effect was larger for persons with combined alcohol and drug use disorders, as they exhibited a co-payment elasticity of -0.27. For inpatient days, the co-payment elasticity was considerably smaller at -0.017

Luchansky B; He LJ; Longhi D; Krupski A; Stark KD. Treatment readmissions and criminal recidivism in youth following participation in chemical dependency treatment. Journal of Addictive Diseases 25(1): 87-94, 2006. (30 refs.)

The purpose of this study was to use administrative records of admissions to substance abuse treatment to construct episodes of care for publicly funded adolescent clients in Washington State, and then to analyze two important outcomes after an index episode: re-admissions to treatment and criminal convictions (including felony convictions and any conviction). The Study population was youth, ages 1.4 to 17, who began and ended an index episode in 1997 and 1998 (n = 5903). The youth were followed for 18 months after the end of their episode, and survival analysis techniques were used to determine the treatment correlates of the outcomes. Clients who completed treatment, compared to those who did not, had significantly lower risks of each outcome, while those with treatment episodes longer than 90 days had lower risks of readmission and felony convictions.

Lundgren LM; Sullivan LM; Maina AW; Schilling RF. Client factors associated with length of stay in methadone treatment among heroin users who inject drugs: Quantitative analysis of state-level substance abuse treatment utilization data. Journal of Addiction Medicine 1(1): 26-32, 2007. (34 refs.)

The objective of this study was to examine, for a population of 8,258 adult injection drug users (IDUs) who all had entered a Massachusetts licensed methadone maintenance treatment program (MMT) between 1996 and 2002, client factors associated with remaining in MMT for a minimum of 1 year after program entry. Two binomial logistic regression models were developed. The first model examined the association between age, sex, race/ethnicity, parental status, employment status, educational status, health insurance status, homelessness status, having injected drugs in the past month, residential treatment use, number of overall treatment admissions, and whether a client's longest consecutive stay in MMT had lasted for 1 year or more. Second, to examine the stability of the statistical relationships identified in the first logistic regression model, a second logistic regression model examined whether there were significant differences in client level characteristics between those who used MMT for 6 months or less compared with their counterparts. Those who were older, women, those who were not homeless, those who resided with their children, those who had public health insurance, and those who had not used residential treatment were significantly more likely to have stayed in MMT for at least 1 year or more. In contrast, those who were younger, males, homeless, did not live with children, had no insurance, and had used residential treatment were significantly more likely to have stayed in MMT for 6 months or less compared with their counterparts. Those who stayed in MMT for 1 year or more were more likely to have stable lives compared with those who dropped out of MMT before a year. Providing services to improve MMT clients' employment, housing, and family stability may help improve MMT retention rates. Second, clients with a history of having used residential substance abuse treatment were more likely to stay in MMT for a shorter time period compared with their counterparts. The extent to which treatment bifurcation is a matter of choice or related to other factors needs to be further explored.

Marsh JC; Cao D; D'Aunno T. Gender differences in the impact of comprehensive services in substance abuse treatment. Journal of Substance Abuse Treatment 27(4): 289-300, 2004. (40 refs.)

This study examines the impact of comprehensive services on treatment outcomes for women and men. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective, cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3,142 clients (1,123 women and 2,019 men) from 59 treatment facilities. The results show that substance abuse treatment benefits both women and men. Further, both women and men benefit from comprehensive services provided as part of substance abuse treatment: specifically, the receipt of educational, housing and income support services is related to reduced post-treatment substance abuse for both women and men. Gender differences are revealed by the fact that, overall, greater proportions of women receive services and, when individual, service, and treatment organizational characteristics are controlled, women show greater reductions in post-treatment substance use. Further, women and men differ in their responsiveness to organizational characteristics: the availability of on-site services and the frequency of counseling significantly predict reduced post-treatment substance use for men but not for women.

Marsh JC; Cao DC. Parents in substance abuse treatment: Implications for child welfare practice. Children and Youth Services Review 27(12): 1259-1278, 2005. (44 refs.)

Substance abuse treatment in parents of young children is an important element of child welfare services. This study compares the predictive factors of post-treatment drug use in organizational, service and individual characteristics between parents and non-parents, mothers and fathers. The analysis sample is derived from the National Treatment Improvement Evaluation Study (NTIES), a longitudinal study designed to evaluate the implementation and effectiveness of the specialty substance abuse service system. The results show that treatment duration and the frequency of counseling available in treatment facilities are the most predictive factors for parents when other factors are controlled. Further, treatment duration, onsite service availability, and frequency of counseling available are significant factors in predicting post-treatment drug use for fathers, but not for mothers. These findings have implications for improving substance abuse treatment services for parents in child welfare settings.

McKay JR. Is there a case for extended interventions for alcohol and drug use disorders? (review). Addiction 100(11): 1594-1610, 2005. (125 refs.)

To determine whether there is evidence to support the implementation of extended interventions (i.e. longer than 6 months) for individuals with alcohol or other drug use disorders. Literature on extended behavioral and pharmacotherapy interventions was reviewed, along with findings from studies of extended monitoring and monitoring paired with adjunctive counseling. Studies were identified through database searches, citations in prior reviews and examinations of recent volumes of relevant journals. Key terms were defined, and a theoretical rationale was presented for extended treatment. Several adaptive treatment studies that made use of stepped care or continuation protocols were also described. The primary outcomes that were considered were alcohol and drug use during the intervention and post-intervention follow-ups. Other outcomes were examined when they were included in the articles reviewed. Most of the studies in the review provided support for the effectiveness of extended interventions for alcohol and drug abusers, whether the extended care was delivered through face-to-face contact or via the telephone. These findings held across all types of interventions that were examined (e.g. behavioral treatment, pharmacotherapy and monitoring). However, only a few studies directly compared extended and standard length version of the same intervention. New developments in addiction treatment with implications for extended care models were also described and discussed. The findings of the review indicate that maintaining therapeutic contact for extended periods of time with individuals with alcohol and other drug disorders appears to promote better long-term outcomes than 'treatment as usual', although more studies are needed that compare extended and standard versions of interventions. Achieving good compliance and successful disease management with extended interventions will probably require adaptive protocols in which the intensity of treatment can be adjusted up or down in response to changes in symptoms and functioning over time. Future directions in research on extended interventions were discussed.

McMahon RC; Enders C. Personality disorder factors predict recovery of employment functioning among treated cocaine abusers. American Journal of Drug and Alcohol Abuse 35(3): 138-144, 2009. (36 refs.)

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; Heller RF. Counselling provision in specialist drug treatment services. Journal of Substance Use 9(1): 44-51, 2004. (12 refs.)

Background: Counselling is one of the most common treatment options in drug services, and recent research has convincingly demonstrated its effectiveness if certain quality parameters regarding intensity and qualifications of those providing it are observed. However, there is a remarkable paucity of literature on the nature of counselling provision in UK drug treatment. Aims: To describe the extent and nature of counselling provision in UK drug treatment services. Method: A national survey of specialist drug services in England and Wales was carried out, and information was obtained from 326 services. Results: Levels of counselling provision were very similar in nonstatutory, community-based, residential day care and statutory, community-based services (around 90%), with slightly lower levels in inpatient services (78%, difference not significant). In the majority of services (74%), individual sessions were provided by drug workers without counselling accreditation. In 32% of agencies, counselling was provided only by drug workers, whereas 36% of agencies employed both drug workers and accredited counsellors. In 17% of agencies, sessions were run by accredited counsellors only. Volunteers without formal training provided one-to-one sessions in 27% of agencies, mostly in agencies also employing counsellors and drug workers. Most agencies (66%) operated a schedule of weekly sessions; 12% of agencies offered fortnightly or less frequent sessions, whereas 15% of agencies offered several sessions a week. More than three-quarters of all sessions were scheduled to last between 50 and 60 minutes. Conclusion: Typically, counselling is provided on a weekly to fortnightly basis by drug workers without formal counselling qualifications. In-depth research is needed to examine whether and how sessions provided by drug workers differ from sessions provided by counsellors, as past research has only demonstrated the effectiveness of counselling in studies using highly trained counselling staff.

Moggi F; Giovanoli A; Strik W; Moos BS; Moos RH. Substance use disorder treatment programs in Switzerland and the USA: Program characteristics and 1-year outcomes. Drug and Alcohol Dependence 86(1): 75-83, 2007. (42 refs.)

Aim: This study compared matched samples of substance use disorder (SUD) patients in Swiss and United States (US) residential treatment programs and examined the relationship of program characteristics to patients' substance use and psychosocial functioning at a 1-year follow-up. Design and Setting: The study used a prospective, naturalistic design and a sample of 10 public programs in the German-speaking part of Switzerland and 15 US public treatment programs. Participants: A total of 358 male patients in Swiss programs were matched on age, marital status and education with 358 male patients in US programs. A total of 160 Swiss and 329 US patient care staff members also participated. Measurement: Patients completed comparable inventories at admission, discharge and 1-year follow-up to assess their substance use and psychological functioning and receipt of continuing care. Staff members reported on program characteristics and their beliefs about substance use. Findings: Compared to Swiss patients, US patients had more severe substance use and psychological problems at intake and although they did not differ on abstinence and remission at follow-up, had somewhat poorer outcomes in other areas of functioning. Swiss programs were longer and included more individual treatment sessions; US programs included more group sessions and were more oriented toward a disease model of treatment. Overall, length of program, treatment intensity and 12-step orientation were associated with better 1-year outcomes for patients in both Swiss and US programs. Conclusions: The sample of Swiss and US programs studied here differed in patient and treatment characteristics; however, in general; there were comparable associations between program characteristics and patients' 1-year outcomes. These findings suggest that associations between treatment processes and patients' outcomes may generalize from one cultural context to another.

Moos RH; Moos BS. Long-term influence of duration and intensity of treatment on previously untreated individuals with alcohol use disorders. Addiction 98(3): 325-337, 2003. (98 refs.)

Aims: This study examined the influence of the duration and intensity of the first episode of treatment for previously untreated individuals with alcohol use disorders on short-term and long-term outcomes, and the effect of additional treatment and delayed treatment on outcomes. Design, setting, participants: A sample of alcoholic individuals (n = 473) was recruited at alcoholism information and referral centers and detoxification units and was surveyed at baseline and 1 year, 3 years and 8 years later. Measurements: At each contact point, participants completed an inventory that assessed their treatment utilization since the last assessment and their current alcohol-related, psychological and social problems. Findings: Compared with individuals who remained untreated, individuals who entered treatment relatively quickly and who obtained a longer duration of treatment had better short-and long-term alcohol-related outcomes and better short-term social functioning. Individuals who obtained a longer duration of additional treatment had better alcohol-related outcomes than individuals who obtained no additional treatment but, among individuals who delayed treatment entry. the duration of treatment was not associated with treatment outcomes. In general, the intensity of treatment was not related to better outcomes. Conclusions: Rapid entry into treatment and the duration of treatment for alcohol use disorders may be more important than the intensity of treatment. Treatment providers should consider structuring their programs to emphasize continuity, rather than intensity of care.

Moos RH; Moos BS. Risk factors for nonremission among initially untreated individuals with alcohol use disorders. Journal of Studies on Alcohol 64(4): 555-563, 2003. (61 refs.)

Objective: This study identified risk factors for I-year and 8-year nonremission among initially untreated individuals with alcohol use disorders and examined whether a longer duration of professional treatment or Alcoholics Anonymous (AA) increased the likelihood of remission, moderated the influence of risk factors on remission status and reduced modifiable risk factors. Method: A sample of individuals with alcohol use disorders (N = 473) was recruited at alcoholism information and referral centers and detoxification units and was surveyed at baseline and 1 year, 3 years and 8 years later. At each contact, participants completed an inventory that assessed their alcohol-related problems and personal characteristics and their participation in treatment and AA since the last assessment. Results: An 11-item baseline risk index was associated with 1-year nonremission. Longer duration of treatment and AA in the first year predicted remission and a decline in modifiable risk factors. In addition, longer duration of AA increased the likelihood of remission more among high-risk than among low-risk individuals. The risk factors at 1 year were associated with 8-year nonremission; longer duration of additional treatment or AA was associated with a higher likelihood of 8-year remission and further reductions in modifiable risk factors. Conclusions: Referral counselors and treatment providers can identify high-risk individuals early in their help-seeking career and intervene to reduce the likelihood of a chronic course of their alcohol use disorder.

Moos RH; Moos BS. The interplay between help-seeking and alcohol-related outcomes: Divergent processes for professional treatment and self-help groups. Drug and Alcohol Dependence 75(2): 155-164, 2004. (45 refs.)

This study examined the influence of self-selection, as reflected in alcohol-related functioning, on the duration of professional treatment and Alcoholics Anonymous (AA), and the influence of social causation, as reflected in the duration of treatment and AA, on alcohol-related outcomes. A sample of alcoholic individuals was surveyed at baseline and 1, 3, and 8 years later. At each point, participants completed an inventory that assessed participation in treatment and AA since the last assessment and alcohol-related functioning. There were divergent processes of self-selection and social causation with respect to the duration of participation in professional treatment and AA. Individuals with more severe alcohol-related problems obtained longer episodes of professional treatment, but this self-selection process was much less evident for AA. Longer participation in professional treatment in the first year predicted better alcohol-related outcomes; however, the duration of subsequent treatment was not associated with better subsequent outcomes. In contrast, longer participation in AA consistently predicted better subsequent alcohol-related outcomes. These findings are consistent with a need-based model of professional treatment, in which more treatment is selected by and allocated to individuals with more severe problems, and an egalitarian model of self-help, in which need factors play little or no role in continued participation.

Morris ZS; McKeganey N. Retention in drug treatment in Scotland: Accounting for retention and its implication for policy and practice. IN: Pederson MU; Segraeus V; Hellman M, eds. Evidence Based Practice? Challenges in Substance Abuse Treatment. NAD Monograph No. 47. Helsinki Finland: Nordic Council for Alcohol and Drug Research, 2005. pp. 207-225. (38 refs.)

Retention in treatment is significant for treatment outcome. Numerous studies have attempted to isolate variables that predict retention. The study reported here followed a cohort of clients at the point of entering treatment. There were follow-up interviews to ascertain continuing treatment involvement and the reasons if not involved, intensity of treatment, types of treatment, days using heroin (the dominant drug of choice in the preceding three months, and severity of dependence. Satisfaction with treatment was a predictor or retention as was the intensity of treatment. Of note, is that those who were no longer in contact with the initial agency, many had had contact/involvement with other treatment programs. In terms of what was associated with retention in treatment, background variables seem to have had little impact, e.g. age, gender. There were differences between agencies in the levels of retention, suggesting that agency variables played a role. Some agencies had no outreach for clients who missed an appointment.

Mullins SM; Bard DE; Ondersma SJ. Comprehensive services for mothers of drug-exposed infants: Relations between program participation and subsequent Child Protective Services reports. Child Maltreatment 10(1): 72-81, 2005. (22 refs.)

It is unclear whether intensive services for women using drugs during pregnancy can reduce child maltreatment. Within-subjects, dose-response analyses can be conducted using Child Protective Services (CPS) reports. Dose of services received can indicate either engagement or higher need for services. Using data from an intensive intervention program for mothers of drug-exposed infants, the authors examined associations between CPS reports and (a) dose of services received and (b) a termination status variable combining dose of services received with duration of service involvement and progress on treatment plan goals. Cox regression revealed no association between dose of services and follow-up CPS reports. The termination status variable was strongly related to follow-up CPS reports, such that higher ratings were associated with significantly lower risk of re-report, even after controlling for baseline motivation. Findings suggest that program effects may be detectable using a treatment process based index that combines dose, duration, and quality of program involvement.

Nalpas B; Matelak F; Martin S; Boulze O; Balmes JL; Crouzet C. Clinical management methods for out-patients with alcohol dependence. Substance Abuse Treatment, Prevention, and Policy 1: article 5, 2006. (9 refs.)

Background: In France outpatient centres for the care of alcoholics are healthcare establishments providing medical, psychological and social support. Although they meet the practical needs of these patients, their degree of use in each of these domains and the respective mobilisation of different skills by the care team are not well understood. Our aim was therefore to determine in detail the management involved as a function of the severity of alcohol dependence. For this purpose, all the procedures involved were compiled in a thesaurus describing its type (psychological, medical, social, reception), its scheduled or unscheduled nature, its method (face-to-face, telephone, letter) and its duration. The severity of dependence was evaluated using the Addiction Severity Index (ASI). Results: 45 patients were included and followed-up during 291 � 114 days. The mean initial ASI scores (� SD) were: medical (M) = 0.39 � 0.3, working-income (ER) = 0.5 � 0.3, alcohol (A) = 0.51 � 0.2, illicit drugs (D) = 0.07 � 0.08, legal (L) = 0.06 � 0.13, familial and social environment (FS) = 0.34 � 0.26, psychological (P) = 0.39 � 0.22. The total number of procedures was 1341 (29.8 per patient) corresponding to 754.4 hours (16.7 per patient). The intensity of management peaked during the first month of treatment, and then declined rapidly; the maximum incidence of abstinence was observed during the 3rd month of management. Interviews with patients, group therapy and staff meetings represented 68.7%, 9.9% and 13.9% of all procedures, respectively. In patients with severe dependence, as compared to moderate, management was twice as intense in the psychological and social domains, but not in the medical domain. The ASI questionnaire was completed a second time by 24 patients, after an average of 3.2 months. The improvement was significant in the M, A, D and P domains only. Conclusion: This study provided an overview of the methods employed in managing a sample of patients consulting an alcoholism centre in line with standards for medical, psychological and social establishments. The predominance of the social and psychological domains over the medical domain was clearly established. Relapses were common after the third month of treatment, but a remobilisation of teams made it possible to contain them. These results provide a framework for discussions on the organisation of healthcare systems and highly suggest that staff need to maintain a constant level of care throughout the treatment process.

Niaura R. Nonpharmacologic therapy for smoking cessation: Characteristics and efficacy of current approaches. American Journal of Medicine 121(4, Supplement 1): S11-S19, 2008. (61 refs.)

This article reviews the most common nonpharmacologic approaches used to support smoking cessation and, where possible, provides estimates of their efficacy in controlled clinical trials. Virtually all of the approaches that have been systematically evaluated to date have demonstrated modest efficacy in increasing quit rates. A cornerstone of effective treatment is tobacco dependence counseling, for which there is a dose-response relation between the intensity of counseling (total minutes of contact) and its effectiveness. New approaches in which treatment is tailored to individual patient characteristics appear promising for the future but require further study. Also, new technologies that permit delivery of smoking interventions to a wider range of patients could have a significant impact on reducing smoking prevalence worldwide in the future. Overall, the clinical literature strongly endorses combining nonpharmacologic interventions with pharmacotherapy to optimize support for smokers who are trying to quit.

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

Oliver P; Keen J; Rowse G; Ewins E; Griffiths L; Mathers N. The effect of time spent in treatment and dropout status on rates of convictions, cautions and imprisonment over 5 years in a primary care-led methadone maintenance service. Addiction 105(4): 732-739, 2010. (21 refs.)

Background: Methadone maintenance treatment (MMT) in primary care settings is used increasingly as a standard method of delivering treatment for heroin users. It has been shown to reduce criminal activity and incarceration over periods of periods of 12 months or less; however, little is known about the effect of this treatment over longer durations. Aims To examine the association between treatment status and rates of convictions and cautions (judicial disposals) over a 5-year period in a cohort of heroin users treated in a general practitioner (GP)-led MMT service. Design: Cohort study. Setting: The primary care clinic for drug dependence, Sheffield, 1999-2005. Participants: The cohort comprised 108 consecutive patients who were eligible and entered treatment. Ninety were followed-up for the full 5 years. Intervention The intervention consisted of MMT provided by GPs in a primary care clinic setting. Measurements: Criminal conviction and caution rates and time spent in prison, derived from Police National Computer (PNC) criminal records. Findings: The overall reduction in the number of convictions and cautions expected for patients entering MMT in similar primary care settings is 10% for each 6 months retained in treatment. Patients in continuous treatment had the greatest reduction in judicial disposal rates, similar to those who were discharged for positive reasons (e.g. drug free). Patients who had more than one treatment episode over the observation period did no better than those who dropped out of treatment. Conclusions: MMT delivered in a primary care clinic setting is effective in reducing convictions and cautions and incarceration over an extended period. Continuous treatment is associated with the greatest reductions.

Pray ME; Watson LM. Effectiveness of day treatment for dual diagnosis patients with severe chronic mental illness. Journal of Addictions Nursing 19(3): 141-149, 2008. (40 refs.)

This study examined the clinical outcomes of dual diagnosis patients with severe chronic mental illness and a secondary diagnosis of an addictive substance (N = 48) who attended a daily Day Treatment Center (DTC). Clinical interventions included the DTC program plus weekly dual diagnosis groups. Outcome measures included urine toxicology screens, Global Assessment of Functioning (GAF) scores, relapses, and hospitalizations. Results revealed that the length of stay (LOS) in the DTC program was the only statistically significant predictor of both pre and post study GAF scores for all three groups. Patients with one year of remission were less likely to relapse. The longer the patient's stay in the DTC program, the better the treatment outcome.

Roll JM; Saules KK; Chudzynski JE; Sodano R. Relationship between Tridimensional Personality Questionnaire scores and clinic attendance among cocaine abusing, buprenorphine maintained outpatients. Substance Use & Misuse 39(6): 1025-1040, 2004. (31 refs.)

With the recent approval of buprenorphine for the treatment of opiate dependence in the United States it has become important to develop an understanding of the factors that influence the likelihood of successful treatment outcomes when using buprenorphine. This study examined, in a convenience sample, the relationship between novelty-seeking behaviors, as determined by Cloninger's Tridimensional Personality Questionnaire (TPQ), and attendance variables during participation in a buprenorphine-based treatment program for 21 heroin-dependent cocaine users that took place in the late 1990s. Approximately two-thirds of the participants were male and primarily African-American. About half of them were employed and had Lit least a high school education. Approximately one-third of them were married or cohabitating and they all resided in the greater Detroit, Michigan area of the United States. The Tridimensional Personality Questionnaire (TPQ) was administered to the participants prior to entering the treatment program. Demographic variables, psychiatric distress, and substance use severity were also evaluated. Variables with significant bivariate relationships with poor attendance measures were entered into a regression analysis predicting attendance measures. Participants who scored high on the TPQ Novelty Seeking Scale attended significantly fewer regularly scheduled visits, had a greater overall number of missed visits, and shorter treatment retention times. Demographics, substance use severity, and psychiatric distress did not have significant relationships with these attendance measures.

Romelsjo A; Palmstierna T; Hansagi H; Leifman A. Length of outpatient addiction treatment and risk of rehospitalization. (rapid communication). Journal of Substance Abuse Treatment 28(3): 291-296, 2005. (21 refs.)

Several studies, mainly from the U.S. and usually with selected male samples, show that aftercare is positively related to lower risk of re-addiction or re-treatment. The present study extends this line of research in a report from public health health care addiction treatment services in Stockholm County. The study sample comprises all 196 men and 100 women alcohol-dependent patients from 10 districts hospitalized for at least 2 days during 1997-99 and who received outpatient care within 5 days. These patients were followed up until 2000, without attrition for renewed rehospitalization. Greater length of outpatient treatment was significantly related to reduced rehospitalization, but only in men. The intensity (average number of visits) of outpatient treatment was not significantly related to rehospitalization. The different effect of length of outpatient treatment between the genders may be due to differences in severity of alcohol dependence, social situation, psychiatric co-morbidity, and/or the extent to which treatment met patients' needs.

Ross J; Teesson M; Darke S; Lynskey M; Ali R; Ritter A et al. Short-term outcomes for the treatment of heroin dependence: Findings from the Australian Treatment Outcome Study (ATOS). Addictive Disorders and Their Treatment 5(3): 133-143, 2006. (26 refs.)

AIMS: To examine drug use, crime, physical and mental health at 3 months postentry to treatment for heroin dependence. DESIGN: Longitudinal cohort study. SETTING: Sydney, Melbourne, and Adelaide, Australia. PARTICIPANTS: Seven hundred forty-five individuals recruited on entry to treatment for heroin dependence in the 3 main treatment modalities (methadone/buprenorphine maintenance therapy; detoxification; residential rehabilitation), and 80 heroin users who were not seeking treatment at baseline. MEASUREMENTS: Structured questionnaires were used to measure drug use, crime, psychopathology, and physical health. At 3 months 10% of the cohort were randomly selected and provided a hair sample as a biologic measure of heroin use for the month preceding interview. FINDINGS: A 3-month follow-up rate of 88% (n=728) was achieved. There were substantial reductions in heroin use, polydrug use, injection-related risk-taking, heroin overdose, and criminal activity, as well as improvements in physical and mental health. Improvements were less marked among the nontreatment group. There was strong concordance between the cohort's self-reported heroin use and hair analysis results. Positive outcomes tended to be associated with a greater cumulative number of treatment days, and fewer treatment episodes. CONCLUSIONS: Treatment works in the short term. Greater treatment exposure was related to improvements across a range of outcomes.

Satre DD; Blow FC; Chi FW; Weisner C. Gender differences in seven-year alcohol and drug treatment outcomes among older adults. American Journal on Addictions 16(3): 216-221, 2007. (24 refs.)

This study examined participants at seven-year followup to assess long-term outcomes of older women (n = 25) and men ( n 59) ages 55 and over in an outpatient addiction program. It measured demographic characteristics, alcohol and drug use, psychiatric symptoms, Addiction Severity Index, treatment length, and outcomes. At seven years, 76.0% of women reported abstinence in the prior 30 days versus 54.2% of men, p = .05. Logistic regression analysis found that longer treatment stay predicted abstinence. Findings indicate that older women have better long-term addiction outcome than older men, but treatment length is more significant than gender in predicting outcome.

Schaefer JA; Harris AHS; Turner RC; Turrubiartes P. Treatment staff's continuity of care practices, patients' engagement in continuing care, and abstinence following outpatient substance-use disorder treatment. Journal of Studies on Alcohol and Drugs 69(5): 747-756, 2008. (30 refs.)

Objective: Although speculation suggests that continuity of care predicts abstinence following substance-use disorder (SUD) treatment, models examining staff's continuity of care practices and engagement in continuing care and whether they mediate or moderate the association between patient and treatment factors and abstinence are lacking. In this study, we aimed to model abstinence using combinations of independent pretreatment and treatment factors, discharge continuity of care practices, and posttreatment engagement and to identify mediators or moderators of relationships between these factors and abstinence. Method: Staff in 18 Department of Veterans Affairs (VA) outpatient SUD programs used the Addiction Severity Index to assess 429 nonabstinent patients' alcohol and drug problems at treatment entry. Staff supplied discharge data on patients' motivation, treatment intensity and completion, and continuity of care practices. Administrative data assessed patients' continuing care engagement. A 6-month follow-up, the Addiction Severity Index assessed abstinence. Mixed-effects logistic regression models were used to examine predictors of abstinence. Results: Abstinence occurred more when discharge plans specified at least one continuing care appointment per week, patients received continuing care appointments before discharge, and staff provided patients drug-free/sober living arrangements and with longer engagement in continuing care. SUD/psychiatric clinic use before treatment entry, treatment completion, access to transportation for continuing care appointments, and more patient motivation for continuing care also predicted abstinence. Engagement in continuing care mediated the relationship between continuity of care and abstinence and between SUD/psychiatric clinic use and abstinence. Conclusion: Findings suggest that continuity of care practices influence abstinence mostly through their effect on patients' engagement in continuing care.

Secades-Villa R; Alonso-Perez F; Garcia-Rodriguez O; Fernandez-Hermida JR. Effectiveness of three intensities of smoking cessation treatment in primary care. Psychological Reports 105(3): 747-758, 2009. (26 refs.)

The purpose of this study was to compare the effectiveness of three smoking cessation programs of varying intensity applied in a primary care setting. Participants were 89 individuals randomly assigned to one of three treatment groups: brief counseling plus information pamphlet, self-help program with telephone follow-up, and intensive behavioral treatment. At the 12-mo. follow-up, intensive behavioral treatment (42.8% abstinence) was more effective than the self-help program (27.5%), which was in turn more effective than Counseling (12.9%). Continued abstinence was also higher in the intensive treatment group (37.9%) than in the self-help (17.2%) and the counseling groups (9.7%), although these differences only reached statistical significance in the first and third of these groups. Treatment adherence was higher in the intensive behavioral group (82.8% of participants attended all the sessions) than in the self-help group (61.8% completed the program). The results appear to confirm a dose-response effect in the treatment of smokers and indicate satisfactory acceptability of intensive behavioral programs applied in primary care.

Sigmon SC; Stitzer ML. Use of a low-cost incentive intervention to improve counseling attendance among methadone-maintained patients. Journal of Substance Abuse Treatment 29(4): 253-258, 2005. (14 refs.)

Despite the importance of counseling in methadone maintenance treatment, many patients do not take advantage of these services. Incentives for attending group counseling were offered to methadone-maintained patients during an orientation phase of treatment or during required attendance at a relapse group later in treatment. Upon attending each counseling session, patients could draw for prizes under an escalating draw system with a 50% probability that draws would result in a prize. Incentives included small ($1), moderate ($5), and large ($20) prizes, with chances of winning inversely related to prize costs, and a maximum possible total of $160 per patient. It was anticipated that this policy would provide a relatively low-cost approach to improving counseling attendance in our methadone clinic. The incentive policy significantly increased the percent of counseling sessions attended (52% vs. 76%) and promoted periods of continuous attendance. These data further support the effectiveness of low-cost incentive programs in enhancing counseling attendance among methadone patients.

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.

Stephenson GM; Zygouris N. Effects of self reflection on engagement in a 12-step addiction treatment programme: A linguistic analysis of diary entries. Addictive Behaviors 32(2): 416-424, 2007. (11 refs.)

Thirty clients receiving Twelve-Step Facilitation Therapy in a rehabilitation setting formed the intervention group. They were asked to complete in third person a weekly evaluation of progress based on reading personal "Feelings" diaries they had written on a daily basis over a period of one week, starting 3 weeks previously. The diaries of the clients and of a further 60 clients in two matched control groups were compared. One control group consisted of clients receiving treatment before the intervention was introduced, and clients in the second control group received treatment after the intervention was terminated. Clients in the control groups were matched to the intervention group according to presenting disorder (alcohol, drugs or food), gender and age. Analysis of the number of words written and diaries produced suggested that the experimental group's productivity was enhanced. Linguistic and cluster analyses indicated that the clients in the Intervention group referred more frequently to key elements of the programme (steps and spirituality) and responded in a more integrated way to the major aspects of their treatment regime. The study supported the expectation that by promoting self-reflection on progress in therapeutic settings, an increase in programme engagement can be expected.

Teesson N; Ross J; Darke S; Lynskey M; Ali R; Ritter A; Cooke R. One year outcomes for heroin dependence: Findings from the Australian Treatment Outcome Study (ATOS). Drug and Alcohol Dependence 83(2): 174-180, 2006. (34 refs.)

Aim: To determine 1 year outcomes for drug use, criminality, psychopathology and injection-related health problems in those entering treatment for heroin dependence in Australia. Design: Longitudinal prospective cohort study. Participants: Seven hundred and forty five individuals entering treatment (methadone/buprenorphine maintenance therapy; detoxification; residential rehabilitation) and 80 heroin users not seeking treatment. Setting: Sydney, Melbourne and Adelaide, Australia. Findings: A total of 657 individuals were re-interviewed at 1 year, 80% of the original sample. There were substantial reductions in heroin and other drug use across all three treatment modalities. The majority of those who had entered treatment were heroin abstinent at 1 year (maintenance therapy 65%, detoxification 52%, residential rehabilitation 63%) compared to 25% of the non-treatment sample. The reduction in heroin use among the treatment samples was paralleled by reductions in poly drug use. There were also substantial reductions in risk-taking, crime and injection-related health problems across all treatment groups, and less marked reductions among the non-treatment group. Psychopathology was dramatically reduced among the treatment modalities, while remaining stable among the non-treatment group. Positive outcomes at 1 year were associated with a greater number of cumulative treatment days experienced over the 1 year follow-up period ('treatment dose') and fewer treatment episodes undertaken in that time ('treatment stability'). Conclusions: At 1 year, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure. The positive findings were associated with a greater "dose" of treatment, and with more treatment stability over the follow-up period.

Timko C; Sempel JM. Short-term outcomes of matching dual diagnosis patients' symptom severity to treatment intensity. Journal of Substance Abuse Treatment 26(3): 209-218, 2004. (58 refs.)

This study evaluated a patient-treatment matching strategy intended to improve the effectiveness of hospital-inpatient and community-residential treatment for dual diagnosis patients. Matching variables were the severity of patient disorders and the program's service intensity. Each of three high-intensity hospital programs was paired with a nearby high-intensity community program; there were also four low-intensity pairs. Patients (N=230) were randomly assigned to hospital or community care at intake, and followed at discharge (96%) and at 4 months (90%). Support was found for the matching strategy at discharge in that severely ill patients treated in high-intensity programs improved more on substance abuse outcomes, and moderately ill patients treated in low-intensity programs improved more on psychiatric outcomes. The benefits of matching held at 4 months in that high-severity patients had better alcohol outcomes when they were treated in high-rather than low-intensity programs. High-and moderate-severity patients did not show differential outcomes in hospital-based or community-based programs. Dual diagnosis patients should be matched by symptom severity with program service intensity, but matching with hospital or community care may not enhance treatment outcomes.

Trafton JA; Tracy SW; Oliva EM; Humphreys K. Different components of opioid-substitution treatment predict outcomes of patients with and without a parent with substance-use problems. Journal of Studies on Alcohol and Drugs 68(2): 165-172, 2007. (28 refs.)

Objective: The aim of this study was to determine how the treatment needs and outcomes of polysubstance-using patients entering opioid-substitution treatment (OST) may be affected if the patient had a parent with substance-use problems. Method: This prospective observational study examined outcomes of 255 patients (97% male) entering OST at eight clinics in the Veterans Health Administration. Self-reported substance-use outcomes in the first year of treatment were compared between patients with (n = 121) and without (n = 134) a parent with substance-use problems. The association between receipt of practice guideline-recommended elements of care and treatment outcome was examined. Results: Parent history-positive patients had greater drug use at 6 months, but by 12 months they had reduced their drug use to the same extent as parent history-negative patients. Ongoing methadone (Dolophine, Methadose) maintenance was associated with improved outcomes of drug use in parent history-negative patients; however, parent history-positive patients who ended methadone maintenance reduced drug use as much as those who continued treatment. The association between treatment received and outcome differed in these populations. In parent history-negative patients, reduced severity of substance use at 1 year was predicted solely by receiving methadone for a greater number of days. In parent history-positive patients, reduced severity of substance use was predicted by receiving methadone for fewer days, by greater satisfaction with and receipt of counseling services, and by lesser tendency for providers to encourage a reduction in methadone use. Conclusions: The importance of counseling and medication components of OST may differ depending on family history. For parent history-negative patients, medication maintenance may be more therapeutically necessary.

Williams GC; McGregor H; Borrelli B; Jordan PJ; Strecher VJ. Measuring tobacco dependence treatment outcomes: A perspective from the behavior change consortium. Annals of Behavioral Medicine 29(Suppl. S): 11-19, 2005. (43 refs.)

The Behavior Change Consortium (BCC) served as a consortium of 15 National Institutes of Health-funded trials intended to link theories of health behavior change to outcomes related to improved diet, exercise, and/or tobacco cessation. Five sites developed and tested interventions aimed at changing tobacco use behaviors, and the remaining 10 focused on changing diet and/or physical activity. The BCC's tobacco dependence workgroup functioned to identify measures of tobacco use and dependence for use across the 15 BCC trials. The BCC tobacco intervention trials described herein were categorized by type of trial; theory(ies) on which each was based: and the "thickness," or intensity, of the intervention. Between-site differences across these parameters posed conceptual and analytic challenges for combining data for cross-site analyses, which were integral to the BCC mission of identifying mechanisms of health behavior change. The lessons learned by the BCC tobacco dependence workgroup regarding the measurement and analysis of tobacco outcomes among BCC trials are discussed, including the challenges and the opportunities regarding the preparation for cross-site analyses. The work-group concludes that trials should report both assessment of a prolonged period of abstinence of 6 months or longer, in addition to the traditional 7-day point prevalence outcome.

Worley M; Gallop R; Gibbons MBC; Ring-Kurtz S; Present J; Weiss RD et al. Additional treatment services in a cocaine treatment study: Level of services obtained and impact on outcome. American Journal on Addictions 17(3): 209-217, 2008. (22 refs.)

The objective of this study was to examine the level of additional treatment services obtained by patients enrolled in the NIDA Cocaine Collaborative Study, a multi-center efficacy trial of four treatments for cocaine dependence, and to determine whether these set-vices impact treatment outcome. Cocaine-dependent patients (N = 487) were recruited at five sites and randomly assigned to six months of one of four psychosocial treatments. Assessments were made at baseline, monthly during treatment, and at follow-ups at 9, 12, 15, and 18 months post-randomization. On average, patients received little or no additional treatment services during active treatment (first six months), but the rate of obtaining most services increased during the follow-up phase (month 7 to 18). In general, the treatment groups did not differ in the rates of obtaining non-protocol services. For all treatment groups, patients with greater psychiatric severity received more medical and psychiatric services during active treatment and follow-up. Use of treatment services was unrelated to drug use outcomes during active treatment. However, during the follow-up period, increased use of psychiatric medication, twelve-step attendance, and twelve-step participation was related to less drug use. The results suggest that during uncontrolled follow-up phases, additional non-protocol services may potentially confound the interpretation of treatment group comparisons in drug use outcomes.

Wu E; El-Bassel N; Gilbert L; Piff J; Sanders G. Sociodemographic disparities in supplemental service utilization among male methadone patients. Journal of Substance Abuse Treatment 26(3): 197-202, 2004. (40 refs.)

The high prevalence of health and psychosocial needs among methadone treatment patients has prompted efforts to supplement methadone treatment with additional services. Research has generally focused on linking supplemental service utilization to drug treatment outcomes, with fewer studies aimed at understanding supplemental service utilization itself. This study with randomly selected male methadone maintenance treatment program (MMTP) patients examined associations between sociodemographic factors and supplemental service utilization while controlling for need for services and treatment duration. Findings indicate that MMTP patients who are African American, Latino, uninsured, or have less education were less likely to report any supplemental service utilization. Hypotheses positing sociodemographic differences in regular vs. occasional service utilization were not supported. There is a need to improve access to supplemental services for minority and disadvantaged MMTP patients, and MMTPs may represent an important venue to address health disparities in general.

Zhang ZW; Friedmann PD; Gerstein DR. Does retention matter? Treatment duration and improvement in drug use. Addiction 98(5): 673-684, 2003. (48 refs.)

Aim: This study examines whether there is a minimum threshold, continuous or non-linear relationship between the duration of addiction treatment and improvements in drug use. Design Longitudinal cohort study of 62 drug treatment units and 4005 clients in the US National Treatment Improvement Evaluation Study, fielded from 1993 to 1995. Subjects: Baseline and I-year follow-up interviews with clients in methadone maintenance, out-patient non-methadone, short-term residential and long-term residential treatment programs. Measures Improvement in drug use is the difference between the client-reported peak frequency of drug use (in days per month) in the year prior to the baseline interview minus the peak frequency in the year after discharge. Primary drug, and overall use of the major illicit drugs (heroin, cocaine powder, crack cocaine, and marijuana) are considered separately. Results: Controlling for multiple factors, treatment duration had a positive linear relationship with primary drug use improvement among methadone clients and an inverted-U-shaped relationship with overall and primary drug use improvements among out-patient and long-term residential clients. Improvement with longer duration is greatest for long-term residential clients. Conclusions: Contrary to previous arguments for a sharp retention threshold for onset of treatment effects, we find smooth curves relating treatment duration to drug use improvements in methadone maintenance, out-patient non-methadone and long-term residential modalities. These relationships are effectively linear for durations typically observed in single treatment episodes, but unusually long retention in out-patient non-methadone and long-term residential units appear steadily less predictive of improvement.