Serving Substance Abuse Professionals Since 1993

Last Update: 15.06.12

C O R K O N L I N E

powerpoint presentations
CORK database search
resource materials
bibliographies
clinical tools
user services
newsletters
about cork
home

CORK Bibliography: Treatment Intensity

31 citations. 2009 to present

Prepared: June 2012

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.

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.

Birath CS; Demarinis V; Stenbacka M; Klinteberg B. Women with alcohol problems: The possible significance of personality clustering for treatment planning. Drug and Alcohol Review 30(2): 207-215, 2011. (51 refs.)

Introduction and Aims. Establishing subgroups in clinical practice is important for treatment planning. The aim of the study was to cluster the study group subjects according to personality traits and psychological health variables and to establish possible differences in treatment outcome in terms of: (i) drinking outcomes (gram and number of drinking days); (ii) perceived physiological health; and (iii) use of treatment resources (length of time in treatment and number of visits) among 134 treatment-seeking women with alcohol problems in a clinical context, between the two clusters obtained. Design and Methods. Data were collected from 134 consecutive women at a Swedish clinic specialised in treating women with alcohol problems. A hierarchical cluster analysis was performed on the basis of self-rated personality scale scores and psychological health variables. Results. Two clusters were identified: one in which the women displayed personality and psychological health scores indicating problems (Cluster 1); and another where the women showed personality and psychological health scores within the norm range (Cluster 2). Alcohol consumption rates at the start of treatment were the same in both clusters. The consumption rates were also the same at the end of treatment for the cluster, showing a significant decrease in alcohol consumption in each. The Cluster 1 women, however, had a significantly higher number of visits at the clinic, and rated the consequences of their alcohol drinking as being significantly worse than Cluster 2 women. Discussion and Conclusions. The importance of individual differences according to personality traits for treatment planning is discussed in terms of the need for variation in treatment time and methods.

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.

Carlin-Menter S; Cummings KM; Celestino P; Hyland A; Mahoney MC; Willett J et al. Does offering more support calls to smokers influence quit success? Journal of Public Health Management and Practice 17(3): E9-E15, 2011. (13 refs.)

Background: Previous studies have found that offering additional callback counseling support to smokers calling a telephone quit line increases quit rates. However, what is less certain is the most cost-efficient protocol for offering such a service. Objective: This study compares the efficacy of offering 2 versus 4 counseling callbacks after an initial call from Medicaid/uninsured adult smokers contacting the New York State Smokers' Quit Line (NYSSQL). Outcomes compared are the 7-and 30-day nonsmoker prevalence rates measured at 3-month follow-up and the cost per quit. Design: A 2-group randomized trial was conducted. Setting and Participants: The study population included 1923 adult (18+ years) Medicaid/uninsured current smokers (10+ cigarettes per day) who called the NYSSQL between February and March 2009 seeking help to stop smoking. At the time of the study, the NYSSQL provided Medicaid/uninsured callers with up to 6 weeks of free nicotine medications and up to 4 counseling callbacks. Half the subjects were randomized to standard care with up to 4 counseling callbacks with the remaining subjects offered only 2 counseling callbacks. All participants were sent a minimum of a 2-week supply of nicotine replacement therapy, with some receiving up to 6 weeks. Participants: were recontacted 3 months after enrollment in the study to assess smoking status. Main Outcome Measures: Quit rates, total counseling callbacks completed, reductions in cigarette consumption, and cost per quit measures. Results: There was not a significant difference between study groups in the number of callbacks completed. There was also no difference in 7-or 30-day nonsmoker prevalence rates measured after 3 months' follow-up or reported use of the free nicotine replacement therapy between those assigned to either the 2-or 4-callback protocols. The cost per quit was essentially the same in both groups (2 callbacks-442 per quit vs 4 callbacks-$445 per quit). Conclusion: There was no advantage in terms of quit success or cost to offering up to 4 callbacks instead of 2 callbacks.

Carmody TP; Delucchi K; Duncan CL; Banys P; Simon JA; Solkowitz SN et al. Intensive intervention for alcohol-dependent smokers in early recovery: A randomized trial. Drug and Alcohol Dependence 122(3): 186-194, 2012. (66 refs.)

Introduction: The purpose of this study was to investigate the efficacy of an intensive tobacco cessation intervention for alcohol-dependent smokers in early recovery. Methods: A total of 162 alcohol-dependent smokers were randomized to either intensive intervention for smoking cessation or usual care. The intensive intervention consisted of 16 sessions of individual cognitive behavior therapy (CBT) and combination nicotine replacement therapy that lasted 26 weeks. Usual care involved referral to a free-standing smoking cessation program that provided smoking cessation counseling of varying duration and guideline-concordant medications. The primary cessation outcome was verified 7-day point prevalence abstinence (PPA) at 12, 26, 38, and 52 weeks. Results: At 12 and 26 weeks, the verified 7-day point-prevalence quit rate was significantly higher for the intensive intervention group than for the usual care group (both p = 0.03). However, the quit rates for the two treatment groups were not significantly different at 38 or 52 weeks. Verified 30-day alcohol abstinence rates were not significantly different for the two treatment groups at any of the follow-up assessments. Conclusions: The intensive smoking cessation intervention yielded a higher short-term smoking quit rate without jeopardizing sobriety. A chronic care model might facilitate maintenance of smoking cessation during the first year of alcohol treatment and perhaps for longer periods of time. It is hoped that studies such as this will inform the development of more effective interventions for concurrent alcohol and tobacco use disorders.

Chi FW; Parthasarathy S; Mertens JR; Weisner CM. Continuing care and long-term substance use outcomes in managed care: Early evidence for a primary care-based model. Psychiatric Services 62(10): 1194-1200, 2011. (44 refs.)

Objectives: How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry. Methods: In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure. Results: A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without. Conclusions: Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

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.

Dale V; Coulton S; Godfrey C; Copello A; Hodgson R; Heather N et al. Exploring treatment attendance and its relationship to outcome in a randomized controlled trial of treatment for alcohol problems: Secondary analysis of the UK Alcohol Treatment Trial (UKATT). Alcohol and Alcoholism 46(5): 592-599, 2011. (36 refs.)

Aims: To identify client characteristics that predict attendance at treatment sessions and to investigate the effect of attendance on outcomes using data from the UK Alcohol Treatment Trial. Methods: Logistic regression was used to determine whether there were characteristics that could predict attendance and then continuation in treatment. Linear regression was used to explore the effects of treatment attendance on outcomes. Results: There were significant positive relationships between treatment attendance and outcomes at Month 3. At Month 12, these relationships were only significant for dependence and alcohol problems for those randomized to motivational enhancement therapy (MET). There were significant differences between groups in attendance, with MET clients more likely to attend than clients allocated to social behaviour and network therapy (SBNT). MET clients were also more likely to attend all sessions (three sessions) compared with SBNT (eight sessions). MET clients with larger social networks and those with confidence in their ability not to drink excessively were more likely to attend. SBNT clients with greater motivation to change and those with more negative short-term alcohol outcome expectancies were more likely to attend. No significant predictors were found for retention in treatment for MET. For those receiving SBNT, fewer alcohol problems were associated with continuation in treatment. Conclusion: Attending more sessions was associated with better outcomes. An interpretation of these findings is that, to improve outcomes, methods should be developed and used to increase attendance rates. Different characteristics were identified that predicted attendance and continuation in treatment for MET and SBNT.

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.

Dennis ML; Scott CK. Four-year outcomes from the Early Re-Intervention (ERI) experiment using Recovery Management Checkups (RMCs). Drug and Alcohol Dependence 121(1-2): 10-17, 2012. (41 refs.)

Background: While drug abuse is the 10th leading cause of mortality in the US, the public health care system has been slow to adopt a chronic disease approach with aggressively timed monitoring and interventions. Drug abuse remains isolated from adoption into the "chronic condition" model of care. This paper evaluates the efficacy of quarterly Recovery Management Checkups (RMCs) on treatment reentry and long-term substance use in the context of chronic substance use disorders. Methods: 446 adult substance users were randomly assigned to RMC or a control group and assessed quarterly for 4 years (94% completion). The main outcome measures were: time from need of treatment to treatment reentry, frequency of treatment reentry, days of treatment, number of substance use related problems per month, and total days abstinent. Results: Participants in the RMC condition were significantly more likely than participants in the control group to return to treatment sooner, to return at all, to return more times, and to receive more total days of treatment. They subsequently had significantly fewer quarters in need of treatment, fewer substance related problems per month, and more total days of abstinence. Effects were larger for those with earlier onset and higher crime/violence scores. Conclusions: RMC is an effective method of monitoring and re-intervening with chronic substance users and is associated with improved long-term outcomes. A subgroup of people for whom RMC did not appear to be "enough," signals a need to explore more intensive models to address chronicity.

Dunlop A. Counselling during substitution treatment: Not enough is too much? (editorial). Addiction 107(5): 954-956, 2012. (7 refs.)

Evans E; Huang D; Hser YI. High-risk offenders participating in court-supervised substance abuse treatment: Characteristics, treatment received, and factors associated with recidivism. Journal of Behavioral Health Services & Research 38(4): 510-525, 2011. (51 refs.)

High-risk offenders treated by California's Proposition 36 court-supervised drug treatment initiative account for a disproportionate number of re-arrests (Hawken 2008) undermining the many successes of the program, yet little is known about their characteristics, treatment experiences, or factors that influence re-arrest. To better understand this group, self-reported and administrative data were analyzed on 78 high-risk (five or more convictions in the previous 5 years) and 1,009 low-risk offenders enrolled during 2004. At intake, high-risk offenders were younger, more were male, and more had prior contact with psychiatric and criminal justice systems. Treatment received and the proportion recidivated during the 30-months after treatment assessment were similar across groups, but high-risk offenders had a greater number of re-arrests. The number of re-arrests was increased by high-risk classification, but decreased by receipt of more treatment services and longer treatment length. Moreover, the number of re-arrests was highest among high-risk offenders with shorter treatment lengths, whereas it was similar to that among low-risk offenders if treatment length was longer. To reduce recidivism among high-risk offenders in court-supervised drug treatment, consideration of psychiatric problems and criminal history is needed, as is receipt of sufficient treatment.

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.

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.

Gryczynski J; Mitchell SG; Peterson TR; Gonzales A; Moseley A; Schwartz RP. The relationship between services delivered and substance use outcomes in New Mexico's Screening, Brief Intervention, Referral and Treatment (SBIRT) Initiative. Drug and Alcohol Dependence 118(2-3): 152-157, 2011. (32 refs.)

Background: Recent years have seen increased diffusion of Screening, Brief Intervention, Referral and Treatment (SBIRT) in healthcare environments. This study examined the relationship between substance use outcomes and service variables within the SBIRT model. Methods: Over 55,000 adult patients were screened for substance misuse at rural health clinics throughout New Mexico during the SBIRT Initiative. This naturalistic pre-post services study used administrative baseline, 6 month follow-up, and services data for adult participants in the New Mexico SBIRT evaluation (n = 1208). Changes in self-reported frequency of illicit drug use, alcohol use, and alcohol intoxication were examined as a function of service level (brief intervention - BI vs. brief treatment/referral - BT/RT) and number of service sessions. Results: Participants reported decreased frequency of illicit drug use, alcohol use, and alcohol intoxication 6 months after receipt of SBIRT services (p < .001 for each). Compared to those who received BI, participants who received BT/RT had sharper reductions in frequency of drinking (IRR = .78; p < .05) and alcohol intoxication (IRR = .75; p < .05). Number of service sessions was associated with reduced frequency of alcohol use (IRR = .84; p < .01) and intoxication (IRR = .82; p < .05), but only among those who received BI. Conclusions: Substance-using patients with disparate levels of use may benefit from SBIRT. In a real-world, multi-site rural SBIRT program, services of higher intensity and (within the BI modality) frequency were associated with greater magnitude of change in drinking behaviors. Reductions in illicit drug use, while substantial, did not differ significantly based on service variables. Future studies should identify the preferred service mix in the SBIRT model as it continues to expand.

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.

Harris AHS; Kivlahan D; Barnett PG; Finney JW. Longer length of stay is not associated with better outcomes in VHA's substance abuse residential rehabilitation treatment programs. Journal of Behavioral Health Services & Research 39(1): 68-79, 2012. (27 refs.)

Are longer stays in Veterans Health Administration (VHA) substance abuse residential rehabilitation treatment programs (SARRTPs) associated with better substance-related outcomes? To investigate, up to 50 new patients were randomly selected from each of 28 randomly selected programs (1,307 patients). The goal was to examine if patient and program average length of stay (ALOS) were associated with improvement on Addiction Severity Index (ASI) Alcohol and Drug composite scores in covariate-adjusted, multi-level regression models. Patients in programs with ALOS greater than 90 days tended to have more mental health treatment prior to the index episode and less severe substance-related symptoms, but more homelessness. At follow-up, programs longer than 90 days had the least improvement in the ASI Alcohol composite and significantly less improvement than programs with ALOSs of 15 to 30 and 31 to 45 days (both p<0.05). Therefore, in VHA SARRTPs, ALOS greater than 90 days cannot be justified by the substance use disorder severity of the patients served or the magnitude of the clinical improvement observed.

Kidorf M; King VL; Pierce J; Kolodner K; Brooner RK. Benefits of concurrent syringe exchange and substance abuse treatment participation. Journal of Substance Abuse Treatment 40(3): 265-271, 2011. (45 refs.)

Participation in syringe exchange programs (SEPs) is associated with many individual and public health benefits but may have little impact on reducing drug use without concurrent treatment engagement. This study evaluated rates of drug use, other risk behaviors, and illegal activities in newly registered SEP participants (N = 240) enrolled versus not enrolled in substance abuse treatment over a 4-month observation window and examined the effect of days in treatment on these outcomes. After controlling for baseline differences, SEP registrants enrolled in treatment (n = 113) reported less days of opioid and cocaine use, injection drug use, illegal activities, and incarceration than those not enrolled in treatment (n = 127). For those enrolled in treatment, days of treatment was strongly correlated with each of these outcomes. These findings provide good evidence for a dose response effect of treatment in syringe exchangers and suggest that substance abuse treatment significantly expands the harm reduction benefits of SEP participation.

Knudsen HK. Adolescent-only substance abuse treatment: Availability and adoption of components of quality. Journal of Substance Abuse Treatment 36(2): 195-204, 2009. (44 refs.)

There are few studies of the availability and quality of adolescent-only treatment programs. Drawing upon existing samples of publicly and privately funded treatment programs, this research considers whether organizational characteristics are associated with the availability of adolescent-only programming and measures components of quality within these programs. Significant organizational correlates of adolescent-only services included organizational size, location within a hospital setting, center accreditation, adherence to a 12-step treatment model, and reliance on public sources of funding. In-depth interviews were then conducted with 154 managers of adolescent-only treatment programs regarding levels of care offered and service quality. The most prevalent levels of care were standard outpatient and intensive outpatient. Analysis of nine domains of treatment quality revealed a medium level of quality. Treatment quality was significantly greater in programs offering more intensive levels of care. These results are largely consistent with other recent research and Suggest a need for continued quality improvement efforts in this treatment sector.

Kroner DG; Takahashi M. Every session counts: The differential impact of previous programmes and current programme dosage on offender recidivism. Legal and Criminological Psychology 17(1): 136-150, 2012. (51 refs.)

Purpose. The present study examined the impact of current treatment dosage on recidivism among offenders. Methods. Using a sample of dropouts from a community treatment programme, current treatment dosage and past completed programmes were used to predict criminal recidivism. Results. After statistically controlling for risk levels, only current dosage was predictive of recidivism. Conclusions. Offenders' current direction, indicated by current dosage, is central to reducing recidivism. Strategies for offenders completing treatment sessions are 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.)

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.

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.

Polimeni AM; Moore SM; Gruenert S. Mental health improvements of substance-dependent clients after 4 months in a therapeutic community. 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.

Schwartz RP; Kelly SM; O'Grady KE; Gandhi D; Jaffe JH. Randomized trial of standard methadone treatment compared to initiating methadone without counseling: 12-month findings. Addiction 107(5): 943-952, 2012. (29 refs.)

Aims: This study aimed to determine the relative effectiveness of 12 months of interim methadone (IM; supervised methadone with emergency counseling only for the first 4 months of treatment), standard methadone treatment (SM; with routine counseling) and restored methadone treatment (RM: routine counseling with smaller case-loads). Design: A randomized controlled trial was conducted comparing IM, SM and RM treatment. IM lasted for 4 months, after which participants were transferred to SM. Setting The study was conducted in two methadone treatment programs in Baltimore, MD, USA. Participants: The study included 230 adult methadone patients newly admitted through waiting- lists. Measurements We administered the Addiction Severity Index and a supplemental questionnaire at baseline, 4 and 12 months post- baseline. Measurements included retention in treatment, self- reported days of heroin and cocaine use, criminal behavior and arrests and urine tests for heroin and cocaine metabolites. Findings: At 12 months, on an intent- to- treat basis, there were no significant differences in retention in treatment among the IM, SM and RM groups ( 60.6%, 54.8% and 37.0%, respectively). Positive urine tests for the three groups declined significantly from baseline ( Ps < 0.001 and 0.003, for heroin and cocaine metabolites, respectively) but there were no significant group x time interactions for these measures. At least one arrest was reported by 30.6% of the sample during the year, but there were no significant between- group effects. Conclusions: Limited availability of drug counseling services should not be a barrier to providing supervised methadone to adults dependent on heroin- at least for the first 4 months of treatment.

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.

Selby P; Voci SC; Zawertailo LA; George TP; Brands B. Individualized smoking cessation treatment in an outpatient setting: Predictors of outcome in a sample with psychiatric and addictions co-morbidity. Addictive Behaviors 35(9): 811-817, 2010. (21 refs.)

Objective: Patients with psychiatric disorders have higher rates of smoking and greater difficulty quitting smoking. However, few studies have compared patients with schizophrenia or schizoaffective disorders to patients with other psychiatric diagnoses without psychosis, addressing ability to quit and differences in treatment characteristics. Method: A retrospective chart review was conducted on a sample of 165 cigarette smokers admitted to an outpatient smoking cessation clinic located in a large inner-city psychiatric hospital. Patients with schizophrenia and schizoaffective disorder (n = 55) were matched for age and sex at a ratio of 1:2 with a comparison group without psychosis (n = 110) from the same clinic. Primary outcomes of interest were quit status (7-day point prevalence) and significant reduction in cigarettes per day (>= 50% but not quit) at final treatment session. Results: There were no significant differences between groups for end-of-treatment quit rate or significant reduction (50%) in cigarettes per day. Patients with schizophrenia made significantly more visits to the clinic and were in treatment for a longer period of time. A greater number of individual treatment sessions and being male were the most significant predictors of cessation. Conclusion: Patients with schizophrenia were as likely to quit smoking as a comparison group of patients with a high rate of other psychiatric comorbidities without psychosis. Findings suggest treatment success in this population requires an extended number of clinic visits, group therapy, and possibly higher doses of nicotine replacement.

Stein JA; Zane JI; Grella CE. Impact of abstinence self-efficacy and treatment services on physical health-related behaviors and problems among dually diagnosed patients. Journal of Dual Diagnosis 8(1): 64-73, 2012. (50 refs.)

Objective: Physical health problems are pervasive among patients with co-occurring substance use and mental disorders. Yet, drug treatment programs often ignore tobacco use and its association with health. Abstinence self-efficacy has been associated with improved outcomes for co-occurring disorders, which in turn may also impact physical health. This study had the goal of assessing whether abstinence self-efficacy for drugs and alcohol and availability and use of services would influence tobacco use and other health-related outcomes among 351 individuals with co-occurring disorders in residential drug treatment. Methods: Structural models tested the impact of baseline abstinence self-efficacy and treatment service characteristics on 6-month outcomes of health problems, functional limitations, health perceptions, and cigarette and heavy alcohol use. Demographics and baseline values for outcome variables were included as covariates. Results: Correlations within time for poor health, cigarette use, and heavy alcohol use were substantial. A longer time in drug treatment was associated with less cigarette and heavy alcohol use at a 6-month follow-up. Baseline health problems were associated with more cigarette use and functional limitations at 6-months. Abstinence self-efficacy did not predict less cigarette use but predicted less heavy alcohol use and fewer functional limitations. Availability of specialized dual diagnosis groups and more on-site psychological services were not directly associated with outcomes but had an impact through indirect effects on more psychological service utilization which predicted better subjective health. Conclusions: Improving overall treatment retention and services utilization among patients with co-occurring disorders may generalize to improved health perceptions, but specific health promotion and smoking-cessation interventions are warranted to improve health outcomes.

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.