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CORK Bibliography: Treatment Programs

79 citations. Jauary 2008 to present

Prepared: June 2009

Alexander JA; Wells R. How do resource dependencies affect treatment practices? The case of outpatient substance abuse treatment programs. Medical Care Research and Review 65(6): 729-747, 2008. (37 refs.)

This study uses resource dependence theory to examine how the concentration of client referrals into outpatient substance abuse treatment may affect treatment comprehensiveness. Data were from the 1995, 1999/2000, and 2005 waves of a national longitudinal survey. Results from generalized estimating equation models (sample sizes from 1,350 to 1,375) indicate that more concentrated referral sources were negatively associated with three of the four indicators of treatment comprehensiveness: the percentages of clients receiving routine medical care, mental health care, and financial counseling. Substance abuse treatment programs may be focusing their treatment practices to meet the demands of key referral sources. Given the importance of comprehensive treatment for substance abusing clients, however, these findings raise concerns about the potential implications of continued industry consolidation. The authors suggest strategies for organizations as well as policy makers to mitigate possible negative effects of very high reliance on one or two referral sources.

Angelucci M. Love on the rocks: Domestic violence and alcohol abuse in rural Mexico. B E Journal of Economic Analysis & Policy 8(1): e-article 43, 2008. (43 refs.)

I use experimental data for the evaluation of Oportunidades to study the determinants of domestic violence and alcohol abuse. The program, a combination of cash transfers to women and human capital investments, decreases husbands' alcohol abuse by 15% and changes their aggressive behavior depending on transfer size, husbands' education, and spousal age gap. While small transfers decrease violence by 37% for all households, large transfers increase the aggressive behavior of husbands with traditional views of gender roles, probably because their wife's entitlement to a large transfer threatens their identity. This evidence rejects standard unitary, collective, and bargaining models for this latter group of households. It also shows that, while targeting women as recipients of micro-credit or other welfare programs may have additional beneficial effects by reducing alcoholism and domestic violence in most households, the risk of violence may increase for some.

Baca CT; Yahne CE. Smoking cessation during substance abuse treatment: What you need to know. (review). Journal of Substance Abuse Treatment 36(2): 205-219, 2009. (195 refs.)

Patients in substance abuse treatment frequently smoke cigarettes and often die of tobacco-related causes. Substance abuse treatment programs too often ignore tobacco use. Many patients have expressed interest in stopping smoking, although they may be ambivalent about smoking cessation during substance abuse treatment. This article provides a review of tobacco cessation literature and successful methods of intervention. Research supports two key findings: (a) smoking cessation during substance abuse treatment does not impair outcome of the presenting substance abuse problem and (b) smoking cessation may actually enhance outcome success. We will discuss how to incorporate smoking cessation.

Bobrova N; Rughnikov U; Neifeld E; Rhodes T; Alcorn R; Kirichenko S et al. Challenges in providing drug user treatment services in Russia: Providers' views. Substance Use & Misuse 43(12-13): 1770-1784, 2008. (40 refs.)

The estimated number of opiate users in Russia is 2,000,000 and heroin consumption is continuing to increase. The Russian government is discussing the initiation of compulsory treatment to bring illegal drug users to the treatment services. At the same time, there is no access to the evidence-based treatment for opiate addiction such as methadone and buprenorphine maintenance programs. Qualitative interviews were conducted with drug user treatment service providers (N = 35) in Barnaul, Volgograd, and Yekaterinburg, Russia, in 2003-2004 to examine their views on drug user treatment services in Russia. The framework approach was used in data collection and analysis. Study participants identified major challenges in service provision for drug using population, including lack of resources, rehabilitation programs, and social support. It also depicted ambivalent attitudes toward compulsory treatment and clients' registration. The Russian drug user treatment system desperately needs resources allocation to provide quality care and diversify in its services in order to achieve long-term recovery. At this stage, it seems unreasonable to initiate compulsory treatment as is advocated by some government officials.

Bohman TM; Kulkarni S; Waters V; Spence RT; Murphy-Smith M; McQueen K. Assessing health care organizations' ability to implement screening, brief intervention, and referral to treatment. Journal of Addiction Medicine 2(3): 151-157, 2008. (18 refs.)

Objectives: To determine if a new measure of organizational readiness for change reflects site and staff role differences when implementing a screening, brief intervention, and referral to treatment (SBIRT) program) for alcohol and drug misuse in a healthcare organization. Sample: One hundred forty-one Community Health Program (CHP) and 45 Emergency Center (FC) respondents completed the survey. Methods: Medical and ancillary staff from a Level 1 trauma hospital EEC and 3 CHP clinics within a large, urban, publicly funded health-care system were asked to complete the 45-item Medical Organizational Readiness for Change (MORC) survey 5 to 7 months after the start of implementation planning. One-way ANOVAs compared the 4 sites' responses and independent t tests compared the clinical versus administrative staff responses on MORC scales. Results: There were statistically significant differences between the EC and CHP sites on Need for External Guidance, Pressure to Change, Organizational Readiness to Change, Workgroup Functioning, Work Environment, and Autonomy Support. Clinical and administrative staff differed significantly on Need for External Guidance, Pressure to Change, and Organizational Readiness to Change. When change agents used the MORC data to inform their implementation process, the results were positive. Conclusions: Among CHP sites, there were differences in organizational functioning, which were consistent with CHP implementation Outcomes. The MORC scales can help planners and change agents understand their organization's current readiness to integrate screening, brief intervention, and referral to treatment services into their medical setting.

Booth BM; Shields JJ; Chandler RK. Recent achievements in alcohol and drug abuse health services research. (editorial). Journal of Behavioral Health Services & Research 36(1): 5-10, 2009. (12 refs.)

Bride BE. Adoption of effective interventions for substance-misusing women. (editorial). Substance Use & Misuse 43(8/9): 1260-1261, 2008. (9 refs.)

Brunette MF; Asher D; Whitley R; Lutz WJ; Wieder BL; Jones AM et al. Implementation of integrated dual disorders treatment: A qualitative analysis of facilitators and barriers. Psychiatric Services 59(9): 989-995, 2008. (23 refs.)

Objective: Approximately half of the people who have serious mental illnesses experience a co-occurring substance use disorder at some point in their lifetime. Integrated dual disorders treatment, a program to treat persons with co-occurring disorders, improves outcomes but is not widely available in public mental health settings. This report describes the extent to which this intervention was implemented by 11 community mental health centers participating in a large study of practice implementation. Facilitators and barriers to implementation are described. Methods: Trained implementation monitors conducted regular site visits over two years. During visits, monitors interviewed key informants, conducted ethnographic observations of implementation efforts, and assessed fidelity to the practice model. These data were coded and used as a basis for detailed site reports summarizing implementation processes. The authors reviewed the reports and distilled the three top facilitators and barriers for each site. The most prominent cross-site facilitators and barriers were identified. Results: Two sites reached high fidelity, six sites reached moderate fidelity, and three sites remained at low fidelity over the two years. Prominent facilitators and barriers to implementation with moderate to high fidelity were administrative leadership, consultation and training, supervisor mastery and supervision, chronic staff turnover, and finances. Conclusions: Common facilitators and barriers to implementation of integrated dual disorders treatment emerged across sites. The results confirmed the importance of the use of the consultant-trainer in the model of implementation, as well as the need for intensive activities at multiple levels to facilitate implementation. Further research on service implementation is needed, including but not limited to clarifying strategies to overcome barriers.

Cacciola JS; Alterman AI; Lynch KG; Martin JM; Beauchamp ML; McLellan AT. Initial reliability and validity studies of the revised Treatment Services Review (TSR-6). Drug and Alcohol Dependence 92(1/3): 37-47, 2008. (20 refs.)

Objective: Report the results of initial reliability and validity analyses for a revised Treatment Services Review (TSR-6) instrument which measures a broader range of services than the original TSR. Method: First, the number of services for a 28-day period was compared for three versions of the instrument varying in their reporting timeframes. Accordingly, four successive 7-day TSR-6s, two 14-day TSR-6s, or one 28-day TSR-6 were administered to more than 300 clients (30% women) in substance abuse treatment (SAT). Second, short-term (2-5 days) test-retest reliabilities were compared for an initial 7-, 14-, or 28-day version of the TSR-6. Third, test-retest reliabilities were compared when an initial in-person (IP) administration was followed by either IP or telephone (TEL) TSR-6 administration. Finally, preliminary discriminative validity analyses were conducted. Results: Few differences in the quantity of services reported for a 4-week period were found with versions of the TSR-6 that used different timeframes. Also, comparisons of test-retest reliabilities for the different version of the TSR-6 revealed few differences. Test-retest reliabilities were generally comparable for the IP-TEL and IP-IP conditions. Finally, analyses demonstrated preliminary discriminative validity for the instrument when services for three distinctive forms of treatment: intensive outpatient, methadone and residential were compared. Conclusions: The findings of this study support the reliability and validity of the TSR-6 and suggest that a version with a 28-day reporting period can provide information comparable to that obtained with versions using shorter reporting periods.

Cartwright WS. A critical review of accounting and economic methods for estimating the costs of addiction treatment. Journal of Substance Abuse Treatment 34(2): 224-233, 2008. (27 refs.)

Researchers have been at the forefront of applying new costing methods to drug abuse treatment programs and innovations. The motivation for such work has been to improve costing accuracy. Recent work has seen applications initiated in establishing charts of account and cost accounting for service delivery. As a result, researchers now have available five methods to apply to the costing of drug abuse treatment programs. In all areas of costing, there is room for more research on costing concepts and measurement applications. Additional work would be useful in establishing studies with activity-based costing for both research and managerial purposes. Studies of economies of scope are particularly relevant because of the integration of social services and criminal justice in drug abuse treatment. In the long run, managerial initiatives to improve the administration and quality of drug abuse treatment will benefit directly from research with new information on costing techniques.

Chassin L. Juvenile justice and substance use. Future of Children 18(2): 165-183, 2008. (63 refs.)

This paper focuses on the elevated prevalence of substance use disorders among young offenders in the juvenile justice system and on efforts by the justice system to provide treatment for these disorders. She emphasizes the importance of diagnosing and treating these disorders, which are linked both with continued offending and with a broad range of negative effects, such as smoking, risky sexual behavior, violence, and poor educational, occupational, and psychological outcomes. The high rates of substance use problems among young offenders suggests a large need for treatment. Although young offenders are usually screened for substance use disorders, the author notes the need to improve screening methods and to ensure that screening takes place early enough to allow youths to be diverted out of the justice system into community-based programs when appropriate. Cautioning that no single treatment approach has been proven most effective, Chassin describes current standards of "best practices" in treating substance use disorders, examines the extent to which they are implemented in the juvenile justice system, and describes some promising models of care. The author highlights several treatment challenges, including the need for better methods of engaging adolescents and their families in treatment and the need to better address environmental risk factors, such as family substance use and deviant peer networks, and co-occurring conditions, such as learning disabilities and other mental health disorders. The author advocates policies that encourage wider use of empirically validated therapies and of documented best practices for treating substance use disorders. High relapse rates among youths successfully treated for substance use disorders also point to a greater need for aftercare services and for managing these disorders as chronic illnesses characterized by relapse and remission. A shortage of aftercare services and a lack of service coordination in the juvenile justice system suggests the need to develop treatment models that integrate and coordinate multiple services for adolescent offenders, particularly community-based approaches, both during and after their justice system involvement.

Chen T; Masson CL; Sorensen JL; Greenberg B. Residential treatment modifications: Adjunctive services to accommodate clients on methadone. American Journal of Drug and Alcohol Abuse 35(2): 91-94, 2009. (20 refs.)

Background/Objectives: This article describes therapeutic community (TC) services modified to support methadone residents and their service utilization in a study of TC patients (N = 231) receiving versus not receiving methadone. Methods: Service utilization data are reported from providers (i.e., methadone support group counselor, acupuncturist, and consulting psychiatrist) for 12 months after admission. Descriptive statistics are used to report methadone residents use of methadone support group and acupuncture services. Pearson chi-square tests are used to compare methadone and non-methadone participants use of psychiatrist services. Additionally, such tests were used to compare both groups DSM-IV diagnoses. Results: Ninety-seven percent of methadone patients attended at least one methadone support group; 52% used acupuncture services. Proportionally more non-methadone residents used psychiatric services (p .05). Conclusion and Scientific Significance: Services tailored to methadone residents were accessed by this group. However, while 32% of all participants met diagnostic criteria for a current psychiatric disorder, only 22% received onsite psychiatric care, which questions whether integrated care is being provided adequately for participants with co-occurring disorders.

Chriqui JF; Terry-McElrath Y; McBnde DC; Eidson SS. State policies matter: The case of outpatient drug treatment program practices. Journal of Substance Abuse Treatment 35(1): 13-21, 2008. (50 refs.)

This study examined relationships between state policy requirements governing outpatient substance abuse treatment services and reported outpatient treatment program practices. State policies effective as of February 1, 2003, and February 1, 2004, were collected and analyzed via primary legal research; data were validated by state officials (88% response rate; > 90% validation rate). Treatment practice data were obtained from the National Survey of Substance Abuse Treatment Services for the years 2003 and 2004. Multivariate analyses clustered by state were conducted, controlling for state, program, and state-aggregated client admission characteristics. Results indicated that treatment programs located in states with requirements for comprehensive substance abuse assessment, family counseling, substance abuse and infectious disease/sexually transmitted disease testing services, HIV/AIDS education, and aftercare services had significantly higher odds of offering such services (p values ranging from <.05 to <.001). This study presents new information regarding the potential role that state policy context may play in understanding treatment program practices.

Clark HW; Power AK; Le Fauve CE; Lopez EI. Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders. Journal of Substance Abuse Treatment 34(1): 3-13, 2008. (39 refs.)

This article describes factors that influence national policy and practice, with particular focus on the implications of epidemiological survey research. Examples of areas of concern to policymakers include treatment-seeking patterns, access to care at points of service in public health and social service systems, evidence-based practices, workforce development, and the complexities of reimbursement. In responding to data on systemic barriers to care, the Substance Abuse and Mental Health Services Administration (SAMHSA) has sought to promote a no wrong door strategy to address the needs of persons with co-occurring disorders (CODs) involving their mental health and substance use. Examples of SAMHSA programs and policies addressing CODs discussed in this article include targeted partnerships with the states, mechanisms to enhance system infrastructure, technical assistance, and initiatives with special populations.

Cleary M; Hunt GE; Matheson S; Walter G. Views of Australian mental health stakeholders on clients' problematic drug and alcohol use. Drug and Alcohol Review 28(2): 122-128, 2009. (33 refs.)

Introduction and Aims. Substance misuse by people with a serious mental illness may exacerbate psychiatric symptoms and contribute to relapse. The aim of the study was to ascertain the views of a wide range of Australian mental health service providers on staff education and training, client contact and management, assessment, and treatment effectiveness and service delivery. Design and Methods. A survey was sent to a sample of 171 mental health stakeholders in Australia identified through internet searches, state and territory mental health departments and professional organisations. Results. Of the 66 respondents (39% response rate), the substances identified to be most problematic were alcohol and cannabis. Integrated service models of treatment were identified as the most preferable and effective. Barriers to treatment included client motivation to reduce substance use, poor communication and coordination between treatment services, and lack of specific services for dual diagnosis clients. Almost all indicated a need for further training in the area of dual diagnosis. Discussion and Conclusions. Dual diagnosis is common and the reality is that this vulnerable clientele will continue to challenge service providers and treatment approaches into the foreseeable future. Issues include the organization and delivery of treatment services, education and training, resource allocation, collaboration between treatment agencies and clinically relevant research evaluating the effectiveness of practice. It is thus surprising that with so much investment in this area the majority of stakeholders are still dissatisfied with access to and the level of care for dual diagnosis clients.

Compton P. Should opioid abusers be discharged from opioid-analgesic therapy? (editorial). Pain Medicine 9(4): 383-390, 2008. (29 refs.)

Cristofalo M; Boutain D; Schraufnagel TJ; Bumgardner K; Zatzick D; Roy-Byrne PP. Unmet need for mental health and addictions care in urban community health clinics: Frontline provider accounts. Psychiatric Services 60(4): 505-511, 2009. (32 refs.)

Objective: To facilitate planning to improve care delivery in community health clinics, this study provides an in-depth description of the social, cultural, and organizational factors that create the context for mental health and addictions treatment delivery in this setting. Methods: Seventeen community health clinic providers and personnel were interviewed for 45-90 minutes with open-ended questions to elicit the context of their frontline provider experiences. Major themes and sub-themes of responses were identified with content analysis. Results: Issues that create significant barriers to care included complex patient comorbidity and demographic characteristics; clinic organization, resources, and funding shortfalls; communication barriers with specialty mental health and addictions agencies; and stigmatizing aspects of mental health, addictions, and disadvantaged status. Conclusions: The unique barriers to care in the community health care setting, as well as the unique characteristics of patients served, are likely to require context-specific solutions. These solutions will determine the viability of existing chronic disease management models, such as collaborative care, when applied to this setting.

Dennis ML; Ives ML; White MK; Muck RD. The Strengthening Communities for Youth (SCY) initiative: A cluster analysis of the services received, their, correlates and how they are associated with outcomes. Journal of Psychoactive Drugs 40(1): 3-16, 2008. (35 refs.)

This article describes the Strengthening Communities for Youth (SCY) initiative using data from 1,297 adolescents in eight U.S. cities (Oakland, CA; Tucson, AZ; Iowa City, IA; Bloomington, IL; St. Louis, MO; Cleveland, OH; Louisville, KY, New York, NY) to better understand the pattern of services they received, how these services varied by need, and how services were associated with initial treatment outcomes. Data include adolescent reports collected with the Global Assessment of Individual Needs (GAIN) at treatment intake and 90 days post-intake, information on early therapeutic alliance using a modified Working Alliance Inventory (WAI), and staff reports from service logs. Cluster analysis identified four patterns of treatment received: (1) substance abuse and mental health treatment, (2) primarily residential treatment, (3) interrupted treatment, and (4) primarily outpatient treatment. Outcomes examined included changes in substance use, substance abuse/dependence problems, recovery environment risk, as well as risk from social peers, illegal activity and emotional problems. Overall and for most groups, treatment was associated with reduced or unchanged problems in each of these areas. The exception was for cluster 1, for whom emotional problems actually increased. Implications for placement, treatment planning and future research are discussed.

Fischer J; Neale J; Bloor M; Jenkins N. Conflict and user involvement in drug misuse treatment decision-making: A qualitative study. Substance Abuse Treatment, Prevention and Policy 3: e-article 21, 2008. (37 refs.)

Background: This paper examines client/staff conflict and user involvement in drug misuse treatment decision-making. Methods: Seventy-nine in-depth interviews were conducted with new treatment clients in two residential and two community drug treatment agencies. Fifty-nine of these clients were interviewed again after twelve weeks. Twenty-seven interviews were also conducted with staff, who were the keyworkers for the interviewed clients. Results: Drug users did not expect, desire or prepare for conflict at treatment entry. They reported few actual conflicts within the treatment setting, but routinely discussed latent conflicts - that is, negative experiences and problematic aspects of current or previous treatment that could potentially escalate into overt disputes. Conflict resulted in a number of possible outcomes, including the premature termination of treatment; staff deciding on the appropriate outcome; the client appealing to the governance structure of the agency; brokered compromise; and staff skilfully eliciting client consent for staff decisions. Conclusion: Although the implementation of user involvement in drug treatment decision-making has the potential to trigger high levels of staff-client conflict, latent conflict is more common than overt conflict and not all conflict is negative. Drug users generally want to be co-operative at treatment entry and often adopt non-confrontational forms of covert resistance to decisions about which they disagree. Staff sometimes deploy user involvement as a strategy for managing conflict and soliciting client compliance to treatment protocols. Suggestions for minimising and avoiding harmful conflict in treatment settings are given.

Fishbain DA; Cole B; Lewis J; Rosomoff HL; Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. (review). Pain Medicine 9(4): 444-459, 2008. (106 refs.)

Design. This is a structured evidence-based review of all available studies on the development of abuse/addiction and aberrant drug-related behaviors (ADRBs) in chronic pain patients (CPPs) with nonmalignant pain on exposure to chronic opioid analgesic therapy (COAT). Objectives. To determine what percentage of CPPs develop abuse/addiction and/or ADRBs on COAT exposure. Method. Computer and manual literature searches yielded 79 references that addressed this area of study. Twelve of the studies were excluded from detailed review based on exclusion criteria important to this area. Sixty-seven studies were reviewed in detail and sorted according to whether they reported percentages of CPPs developing abuse/addiction or developing ADRBs, or percentages diagnosed with alcohol/illicit drug use as determined by urine toxicology. Study characteristics were abstracted into tabular form, and each report was characterized according to the type of study it represented based on the Agency for Health Care Policy and Research Guidelines. Each study was independently evaluated by two raters according to 12 quality criteria and a quality score calculated. Studies were not utilized in the calculations unless their quality score (utilizing both raters) was greater than 65%. Within each of the above study groupings, the total number of CPPs exposed to opioids on COAT treatment was calculated. Similarly, the total number of CPPs in each grouping demonstrating abuse/addiction, ADRBs, or alcohol/illicit drug use was also calculated. Finally, a percentage for each of these behaviors was calculated in each grouping, utilizing the total number of CPPs exposed to opioids in each grouping. Results. All 67 reports had quality scores greater than 65%. For the abuse/addiction grouping there were 24 studies with 2,507 CPPs exposed for a calculated abuse/addiction rate of 3.27%. Within this grouping for those studies that had preselected CPPs for COAT exposure for no previous or current history of abuse/addiction, the percentage of abuse/addiction was calculated at 0.19%. For the ADRB grouping, there were 17 studies with 2,466 CPPs exposed and a calculated ADRB rate of 11.5%. Within this grouping for preselected CPPs (as above), the percentage of ADRBs was calculated at 0.59%. In the urine toxicology grouping, there were five studies (15,442 CPPs exposed). Here, 20.4% of the CPPs had no prescribed opioid in urine and/or a nonprescribed opioid in urine. For five studies (1,965 CPPs exposed), illicit drugs were found in 14.5%. Conclusion. The results of this evidence-based structured review indicate that COAT exposure will lead to abuse/addiction in a small percentage of CPPs, but a larger percentage will demonstrate ADRBs and illicit drug use. These percentages appear to be much less if CPPs are preselected for the absence of a current or past history of alcohol/illicit drug use or abuse/addiction.

Flynn PM; Brown BS. Co-occurring disorders in substance abuse treatment: Issues and prospects. (review). Journal of Substance Abuse Treatment 34(1): 36-47, 2008. (105 refs.)

This article explores the epidemiology of co-occurring disorders (CODs) with an emphasis on the implications of study findings for the functioning and potential of substance abuse treatment. Severity of disorder is discussed as an issue that may have particular significance for the selection of specialized as opposed to traditional substance abuse treatment forms. Exploration is made, as well, of the resources currently available to substance abuse treatment, especially the human resources available, and the implications of resource availability for undertaking initiatives specific to COD. Findings from standard and enhanced treatment for comorbid individuals are examined in an effort to clarify areas of need for specialized and typical treatment personnel. Issues are raised for consideration by the clinical research and treatment provider communities in terms of assessment and diagnosis, manpower and training, and response to the challenge of relapse in this population.

Fornili K. Integrated treatment for women with co-occurring disorders and an explanatory model for policy analysis and evaluation. (editorial). Journal of Addictions Nursing 19(2): 109-118, 2008. (41 refs.)

In this column, addiction nurses are introduced to basic, brief methods of policy analysis and evaluation that can be used to quickly determine whether policies and programs are achieving, or are likely to achieve, their intended outcomes. A particular focus is on whether the outcomes are likely to be attributed to the policy(ies) of interest, or rather to some other exogenous factors that may somehow influence those outcomes. Since the theme of this issue of the Journal of Addictions Nursing is women and co-occurring disorders (COD), and a growing body of research evidence supports the provision of integrated services for individuals with co-occurring psychiatric and substance use disorders, treatment integration was selected as an example for policy analysis and evaluation. The Geelhoed-Schouwstra framework (GSF) (Schouwstra Ellman, 2006) was utilized to demonstrate how numerous influences can potentially affect policy outcomes. These include conceptual-level influences, such as perception of unmet need for mental health care, personal histories of trauma, and the role of intimate partners. Institutional-level influences include funding trends and involvement in domestic violence or child welfare programs. The influences associated with integrated treatment policies are addressed, but actual performance indicator data (input, process, throughput and output data) are not presented. The aim of this column is to demonstrate how nurses and policy-makers can utilize systematic models of policy analysis and evaluation to evaluate how health policies affect service delivery, patient outcomes and nursing practice.

Garnick DW; Lee MT; Horgan CM; Acevedo A. Adapting Washington Circle performance measures for public sector substance abuse treatment systems. Journal of Substance Abuse Treatment 36(3): 265-277, 2009. (52 refs.)

The Washington Circle, a group focused on developing and disseminating performance measures for substance abuse services. developed three such measures for private health plans. In this article, we explore whether these measures are appropriate for meeting measurement goals in the public sector and feasible to calculate in the public sector using data collected for administrative purposes by state and local substance abuse and/or mental health agencies. Working collaboratively, 12 states specified revised measures and 6 states pilot tested them. Two measures were retained from the original specifications: initiation of treatment and treatment engagement. Additional measures were focused on continuity of care after assessment, detoxification, residential or inpatient care. These data demonstrate that state agencies can calculate performance measures from routinely available information and that there is wide variability in these indicators. Ongoing research is needed to examine the reasons for these results, which might include lack of patient interest or commitment, need for quality improvement efforts, or financial issues.

Gossop M. The clinical fallacy and treatment outcomes (editorial). Addiction 103(1): 89-90, 2008. (8 refs.)

Gotham HJ; White MK; Bergethon HS; Feeney T; Cho DW; Keehn B. An implementation story: Moving the GAIN from pilot project to statewide use. Journal of Psychoactive Drugs 40(1): 97-107, 2008. (25 refs.)

Similar to implementing an evidence-based practice (EPB), implementing an evidence-based assessment (EBA) is a long, complex process that can take several years to complete. Between 2002 and 2007, the state of Missouri first piloted the Global Appraisal of Individual Needs-Initial (GAIN-I; Dennis et al. 2006) assessment at one state-contracted adolescent substance abuse treatment program and then implemented the GAIN statewide. This case study documents the implementation process through Fixsen and colleagues' (2005) six stages of implementation, from exploration and adoption through sustainability, and outlines challenges and solutions encountered at the external, organizational, and individual staff level. Strengths of this project included recognition that implementation is an ongoing multistep process, strong support by state-level staff, contracting with an external purveyor for ongoing technical assistance at the agency level as well as training of front-line clinicians, and an implementation team comprised of stakeholders at multiple levels.

Greaves L; Poole N. Bringing sex and gender into women's substance use treatment programs. (editorial). Substance Use & Misuse 43(8/9): 1271-1273, 2008. (21 refs.)

Greenwood P. Prevention and intervention programs for juvenile offenders. Future of Children 18(2): 185-210, 2008. (50 refs.)

Over the past decade researchers have identified intervention strategies and program models that reduce delinquency and promote pro-social development. Preventing delinquency, says Peter Greenwood, not only saves young lives from being wasted, but also prevents the onset of adult criminal careers and thus reduces the burden of crime on its victims and on society. It costs states billions of dollars a year to arrest, prosecute, incarcerate, and treat juvenile offenders. Investing in successful delinquency-prevention programs can save taxpayers seven to ten dollars for every dollar invested, primarily in the form of reduced spending on prisons. According to Greenwood, researchers have identified a dozen "proven" delinquency-prevention programs. Another twenty to thirty "promising" programs are still being tested. In his article, Greenwood reviews the methods used to identify the best programs, explains how program success is measured, provides an overview of programs that work, and offers guidance on how jurisdictions can shift toward more evidence-based practices The most successful programs are those that prevent youth from engaging in delinquent behaviors in the first place. Greenwood specifically cites home-visiting programs that target pregnant teens and their at-risk infants and preschool education for at-risk children that includes home visits or work with parents. Successful school-based programs can prevent drug use, delinquency, anti-social behavior, and early school drop-out. Greenwood also discusses community-based programs that can divert first-time offenders from further encounters with the justice system. The most successful community programs emphasize family interactions and provide skills to the adults who supervise and train the child. Progress in implementing effective programs, says Greenwood, is slow. Although more than ten years of solid evidence is now available on evidence-based programs, only about 5 percent of youth who should be eligible participate in these programs. A few states such as Florida, Pennsylvania, and Washington have begun implementing evidence-based programs. The challenge is to push these reforms into the mainstream of juvenile justice.

Haberstroh S; Gee R; Arredondo R. Community-based interventions for addressing alcohol and tobacco dependence in Latino communities: Adapting consensually derived guidelines. Alcoholism Treatment Quarterly 26(4): 464-479, 2008

Background: This article describes the development of culturally sensitive guidelines for an alcohol and tobacco use intervention model for Latino communities. Extensive research supports the fact that people who use alcohol also use tobacco. In fact, 80% to 95% of alcoholics smoke, with the heaviest alcohol consumers being the heaviest consumers of tobacco. Concurrent use of these substances poses numerous public health threats. The goals of this project are to increase the consistency of culturally appropriate treatment strategies for this population. Method: A consensus conference composed of nationally recognized experts in nicotine dependence, multiculturalism, treatment, research, and consumer advocacy were identified and convened. Results: The panel recommended and developed a community intervention model as a best practice for use in Latino communities. This consensually derived model incorporated promotores, or community health workers, as frontline interventionists. Following the consensus recommendations, the authors of this article describe how these models can be modified to address concomitant dependencies to alcohol and tobacco. Conclusion: The model presented is a promising and replicable approach to improve the health of nicotine and alcohol-dependent Latino adults. Alcohol treatment providers need to be aware of these promising intervention approaches. This community-based model has the potential for reaching countless individuals who may not otherwise be exposed to alcohol and tobacco-related interventions.

Harris AHS; Humphreys K; Bowe T; Kivlahan DR; Finney JW. Measuring the quality of substance use disorder treatment: Evaluating the validity of the Department of Veterans Affairs continuity of care performance measure. Journal of Substance Abuse Treatment 36(3): 294-305, 2009. (47 refs.)

This study examined the patient- and facility-level associations between the continuity of care performance measure adopted by the Department of Veterans Affairs (VA) and improvements in self-administered Addiction Severity Index (ASI) composites and other indicators of problematic substance use. Up to 50 patients from each of a nationally representative sample of 109 VA substance use disorder (SUD) treatment programs at 73 VA facilities were assessed at intake and posttreatment. The continuity of care performance measure specifies that patients should receive at least two SUD outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. In analyses adjusting for baseline characteristics, meeting the continuity of care performance measure was not associated with patient-level improvements in the ASI alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Facility-level rates of continuity of care were negatively associated with improvements in ASI alcohol and drug composites. The continuity of care performance measure derived from prior patient-level evidence did not discriminate facility-level performance as predicted. Translating research into process-of-care quality measures requires postconstruction validation.

Henderson CE; Taxman FS; Young D. A Rasch model analysis of evidence-based treatment practices used in the criminal justice system. Drug and Alcohol Dependence 93(1/2): 163-175, 2008. (73 refs.)

This study used item response theory (IRT) to examine the extent to which criminal justice facilities and community-based agencies are using evidence-based substance abuse treatment practices (EBPs), which EBPs are most commonly used, and how EBPs cluster together. The study used data collected from wardens, justice administrators, and treatment directors as part of the National Criminal Justice Treatment Practices survey (NCJTP; Taxman et al., 2007a), and includes both adult criminal and juvenile justice samples. Results of Rasch modeling demonstrated that a reliable measure can be formed reflecting the extent to which juvenile and adult correctional facilities, and community treatment agencies serving offenders, have adopted various treatment practices supported by research. We also demonstrated the concurrent validity of the measure by showing that features of the facilities' organizational contexts were associated with the extent to which facilities were using EBPs, and which EBPs they were using. Researchers, clinicians, and program administrators may find these results interesting not only because they show the program factors most strongly related to EBP use, but the results also suggest that certain treatment practices cluster together, which may help stakeholders plan and prioritize the adoption of new EBPs in their facilities. The study has implications for future research focused on understanding the adoption and implementation of EBPs in correctional environments.

Henskens R; Garretsen H; Bongers I; Van Dijk A; Sturmans F. Effectiveness of an outreach treatment program for inner city crack abusers: Compliance, outcome, and client satisfaction. Substance Use & Misuse 43(10): 1464-1475, 2008. (9 refs.)

In a randomized controlled trial the effectiveness of an outreach treatment program (OTP) was compared with standard addiction care services for hard-drug addicts in Rotterdam (The Netherlands). The study aimed at chronic, high-risk crack abusers who were insufficiently engaged in standard addiction treatment services. Data were collected from February 2000 to December 2001. A total of 124 subjects participated in the study at baseline. Follow-up data were available for 94 subjects. Outcome measures included treatment compliance, outcome, and satisfaction. Data were collected by means of monthly registrations, EuropAsi interviews and an evaluation form. There was a high compliance with OTP in the treatment group; the average length-of-stay was 6 months, with visits three times a week. Although both groups were well represented in standard care, participation was mainly based on methadone maintenance. Subjects treated in OTP showed significant improvements in physical health, general living conditions, and psychiatric status, but no change in employment, substance abuse, and legal status. The control group remained almost unchanged. Clients of OTP reported feeling very satisfied with their treatment. On-the-spot incentives and a positive relationship with the care provider were directly associated with treatment retention. An outreach treatment program, as conducted in this study, is associated with high compliance, general improvement, and treatment satisfaction. Characteristics of this treatment modality are (1) assertive outreach, (2) a mixed program with incentives, and (3) a strong focus on individual-bound therapy. Further research is needed with larger groups and similar conditions at baseline assessment.

Jessup MA; Song YS. Tobacco-related practices and policies in residential perinatal drug treatment programs. Journal of Psychoactive Drugs Supplement 5: 357-364, 2008. (59 refs.)

Despite serious health consequences from high rates of smoking among perinatal women, smoking cessation and/or nicotine treatment practices have yet to be broadly adopted into perinatal substance abuse treatment settings. This correlational cross-sectional survey examined tobacco-related policies, practices, knowledge, and attitudes of 31 directors of perinatal residential substance abuse treatment programs in California. We found that the directors' programs had limited on-site adoption of evidence-based practices for smoking cessation, and that directors had gaps in their knowledge of perinatal tobacco effects. Implications for tobacco policy initiatives in perinatal substance abuse treatment are discussed.

Kang SY; Deren S; Colon H. Gender comparisons of factors associated with drug treatment utilization among Puerto Rican drug users. American Journal of Drug and Alcohol Abuse 35(2): 73-79, 2009. (35 refs.)

Objective: This study examined gender-specific effects of social bonds, network characteristics, and other factors on drug treatment enrollment among Puerto Rican drug users. Method: Participants (425 women; 1,374 men) were recruited in New York and Puerto Rico in 1998-2003. Results: Gender differences were found: education ( high school/GED) and having a sex partner who is an injection drug user (IDU) were significantly related to current enrollment in drug treatment (EDT) for women; for men, having an IDU friend (negatively) had a main effect on EDT, and having an IDU friend also had a significant interaction effect with their own injection drug use on EDT. For both women and men, recruitment site (New York), having health insurance, and prior methadone treatment were significant predictors of EDT. Conclusion: The findings may be useful in developing gender-differentiated drug counseling and treatment efforts that engage women's sex partners and men's friendship networks to build support for drug treatment.

Katz A; Goldberg D; Smith J; Trick WE. Tobacco, alcohol, and drug use among hospital patients: Concurrent use and willingness to change. Journal of Hospital Medicine 3(5): 369-375, 2008. (40 refs.)

BACKGROUND: Data are limited on concurrent smoking and substance use among hospital patients. To better inform hospital-based intervention strategies, we evaluated the prevalence and concurrent use of these behaviors. This study evaluated the association between tobacco, alcohol, and other drug use, compared willingness to quit smoking among patients with and without substance use, and evaluated the relationship between willingness to quit smoking and readiness to change substance use. METHODS: This study was a cross-sectional survey of non-Intensive Care Unit hospital patients at 2 public hospitals (a 464-bed tertiary-care hospital and a 100-bed community hospital) by bedside interview. Severity of use and willingness to change behavior was determined. We evaluated the association between smoking and substance use by multivariable methods. RESULTS: Of 7,391 patients with known smoking status, 2,684 (36%) were current smokers. Among them, 1,376 hospitalized smokers (51%) had concurrent substance use. Among the 1,972 patients with at-risk alcohol or drug use, the prevalence of smoking was 70% compared to 24% for non-substance users (P < .01). Compared to other patients who smoked, substance-dependent patients were more likely (Prevalence Rate Ratio = 1.4, 95% Confidence Interval = 1.1-1.9) to be moderate to heavy smokers. Regardless Of Substance use pattern, most patients (60%) expressed a desire to immediately quit smoking. CONCLUSION: Hospital patients who describe at-risk substance use are likely to smoke and express willingness to quit smoking. Given the prevalence of concurrent smoking and substance use and patients' desire to change both behaviors, there is a need for coordination of substance use and smoking cessation interventions.

Kay-Lambkin FJ. Technology and innovation in the psychosocial treatment of methamphetamine use, risk and dependence. Drug and Alcohol Review 27(3): 318-325, 2008. (60 refs.)

Issues. The dramatic increase in methamphetamine use has led to the urgent need for high-quality, effective treatments and management strategies for methamphetamine use problems to be developed and disseminated. Although some evidence exists for the use of psychological, pharmacological and other approaches to treatment for problematic methamphetamine use, other evidence suggests that many methamphetamine users do not access these treatment options due to a range of individual and service-level barriers. Approach. A review of available research literature was undertaken to identify treatment strategies for methamphetamine users, which overcome the problems associated with treatment access for this important target group and involve technological and other innovative approaches. Key Findings. Several approaches to addressing problematic methamphetamine use have been suggested, including assertive engagement strategies, flexibility in the provision of treatment and retention strategies and use of a multi-focused intervention package, such as stepped care, perhaps including new technologies as alternatives or supplements to face-to-face-delivered treatments. No research currently exists to examine the possible benefit of these strategies for people with methamphetamine use problems. Implications. The use of stepped-care intervention packages has the potential to address many of the current challenges faced by both clinicians and clients in treating methamphetamine use problems. Conclusions. Although promising, these approaches require further attention and research effort, particularly among the specific group of methamphetamine users.

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.

Knott AM; Corredoira R; Kimberly J. Improving consistency and quality of service delivery: Implications for the addiction treatment field. Journal of Substance Abuse Treatment 35(2): 99-108, 2008. (11 refs.)

Addiction treatment providers face serious problems in delivering consistent, high-quality services over time. Among those providers with multiple treatment sites, there is also intersite variability. This is a serious problem in the addiction field, likely to be made worse as new technologies are introduced and/or as there is industry consolidation (Corredoira, R., Kimberly, J. (2006) Industry evolution through consolidation: Implications for addiction treatment. Journal of Substance Abuse Treatment 31, 255-265.). Although serious, these problems in managing and monitoring to assure consistent service quality have been faced by many other industries. Here, we review evidence from research in other industries regarding three different forms of management (vertical integration, franchising, and licensing) across a chain of individual service providers. We show how each management form affects the level, consistency, and improvement of service delivery over time. In addition, we discuss how such performance advantages affect customer demand as well as regulatory endorsement of the consolidated firm and its approach.

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.

Kubiak SP; Arfken CL. Comparing credentialing requirements of substance abuse treatment staff by funding source. Journal of Substance Abuse Treatment 35(1): 93-98, 2008. (20 refs.)

Studies have found that clinicians with higher education and/or attainment of national certification have a more favorable outlook regarding the adoption of evidence-based practices. However, staff hiring decisions may be based on a multitude of factors, including available resources and demands stemming from different funders. Using a mixed-methods case study approach with 34 agencies within one state, we assessed administrators' perspectives of the most important funding source, views on clinical hiring practices, and current staffing. We found that funding source predicted views and actual staff level of credentialing and education. Those agencies citing a criminal justice entity as the most important funder had the lowest requirements for credentialing and education. As the substance abuse treatment delivery system evolves and expands, we must ensure that vulnerable groups have access to more highly-rather than less-skilled workers to assess and facilitate recovery.

Lubman D; Hides L; Elkins K. Developing integrated models of care within the youth alcohol and other drug sector. Australian Psychiatry 16(5): 363-366, 2008. (18 refs.)

Objective: The aim of this paper is to describe an initiative in Victoria, Australia, aimed at improving the detection and management of co-occurring mental health issues within the youth Alcohol and Other Drug (AOD) sector. Conclusions: Over the past 4 years, in partnership with local youth AOD services, we have developed a successful service model that addresses co-occurring mental health issues within the youth AOD sector. However, such capacity-building requires the full support of workers and senior management, and a cultural shift whereby the assessment and management of mental health issues are seen as a priority and core service issue. The capacity-building process was facilitated by embedding experienced mental health clinicians within each service to support and implement the initiative. This model offered learning opportunities through the modelling of relevant skills and the provision of 'on-the-job' training. Such approaches demonstrate that integrated models of care can be delivered within youth AOD services, although further research is needed to determine their effectiveness.

Magura S. Effectiveness of dual focus mutual aid for co-occurring substance use and mental health disorders: A review and synthesis of the Double Trouble in Recovery Evaluation. Substance Use & Misuse 43(12-13): 1904-1926, 2008. (94 refs.)

Over 5 million adults in the United States have a co-occurring substance use disorder and serious psychological distress. Mutual aid (self-help) can usefully complement treatment, but people with co-occurring substance use and psychiatric disorders often encounter a lack of empathy and acceptance in traditional mutual aid groups. Double Trouble in Recovery (DTR) is a dual focus fellowship whose mission is to bring the benefits of mutual aid to persons recovering from co-occurring disorders. An evaluation of DTR was conducted by interviewing 310 persons attending 24 DTR meetings in New York City (NYC) in 1998 and following them up for 2 years, in 1999 and 2000. The evaluation produced 13 articles in 12 peer-reviewed journals, the main results of which are summarized here. The sample's characteristics were as follows: mean age, 40 years; women, 28%; black, 59%; white, 25%; Hispanic, 14%; never married, 63%; live in supported community residence, 53%; high school graduate or GED, 60%; arrested as adult, 63%; diagnoses of: schizophrenia, 39%; major depression, 21%; or bipolar disorder, 20%; currently prescribed psychiatric medication, 92%; primary substance used, current or past: cocaine/crack, 42%; alcohol 34%; or heroin, 11%. Overall, the findings indicate that DTR participation has both direct and indirect effects on several important components of recovery: drug/alcohol abstinence, psychiatric medication adherence, self-efficacy for recovery, and quality of life. The study also identified several common therapeutic factors (e.g., internal motivation and social support) and unique mutual aid processes (helper-therapy and reciprocal learning) that mediate the influence of DTR participation on recovery. For clinicians, these results underline the importance of fostering stable affiliation with specialized dual focus 12-step groups for their patients with co-occurring disorders, as part of a comprehensive recovery-oriented treatment approach.

Marsh JC; Cao DC; Guerrero E; Shin HC. Need-service matching in substance abuse treatment: Racial/ethnic differences. Evaluation and Program Planning 32(1): 43-51, 2009. (61 refs.)

This study examines the impact of ancillary health and social services matched to client needs in substance abuse treatment for African Americans, Latinos and Whites. 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 3142 clients (1812 African Americans, 486 Latinos, 844 Whites) from 59 treatment facilities. Results show that racial/ethnic minorities are underserved compared to Whites in the substance abuse service system. Different racial/ethnic groups come into treatment with distinct needs and receive distinct services. Although groups respond differentially to service types, substance abuse counseling and matching services to needs is an effective strategy both for retaining clients in treatment and for reducing post-treatment substance use for African Americans and Whites. Receipt of access services was related to reduced post-treatment substance use for Latinos. Study findings are relevant to planning special services for African Americans and Latinos.

May PA; Miller JH; Goodhart KA; Maestas OR; Buckley D; Trujillo PM et al. Enhanced case management to prevent fetal alcohol spectrum disorders in northern Plains communities. Maternal and Child Health Journal 12(6): 747-759, 2008. (52 refs.)

Women proven to be extremely high risk for drinking during pregnancy were provided case management (CM) enhanced with strategies derived from motivational interviewing (MI) as a part of a comprehensive Fetal Alcohol Syndrome (FAS) epidemiology and prevention program in four American Indian communities in Northern Plains states. Data on the first women enrolled (n = 131) revealed that they have extreme issues with alcohol abuse to overcome. Sixty-five percent of these women have experienced extensive alcohol use within their immediate family. At intake, 24% of CM clients reported binge drinking one or more days in the preceding week. Heavy drinking resulted in estimated blood alcohol concentrations (BAC) as high as .576 using the BACCUS methodology. Project staff has attempted to actively engage each of these women in CM. Clients have been in CM an average of 17.2 months (SD = 16.6). The mean number of significant contacts (face-to-face or telephone MI sessions) was 19. Thirty-one percent of the women entered some type of formal alcohol or drug treatment while in CM. Data were collected at 6 month intervals from 6 to 72 months after enrollment. Consumption of alcohol, as measured by both quantity and frequency measures, was reduced at 6 months. Thirty-eight percent of enrolled women reported complete abstinence from alcohol use at 6 months, and the number of binges while drinking in CM declined significantly from 15 at baseline to 4.3 at 6 months. However, mean peak BACs for the heavy drinking sessions were still problematic for those who continued to drink. They ranged from .234 to .275 from baseline to 12 month follow-up, but the total number of binges was reduced substantially at 12 months as well. Furthermore, the most important outcomes are the status of the children born while in CM. One hundred and forty nine pregnancies have occurred among these women, and 76% of those pregnancies have resulted in normal deliveries, and only two children born in CM are suspected of having some form of severe FASD. At 6, 12, 18, and 24 month follow-up milestones, 70% of the women who were not currently pregnant were protected from having a child with FAS by not drinking, using birth control, or both. Other measures of CM success include enrolling in school, regaining custody of children, completing substance abuse treatment, probation from the criminal justice system, substantial periods of abstinence, enrolling in programs to improve life skills, and employment.

Mayet S; Groshkova T; Morgan L; MacCormack T; Strang J. Drugs and pregnancy: Outcomes of women engaged with a specialist perinatal outreach addictions service. Drug and Alcohol Review 27(5): 497-503, 2008. (23 refs.)

Substance misuse during pregnancy may result in harm to both mother and child. The aims of this study were to assess changes in outcomes of women seen by a specialist perinatal addictions outreach service (1989-1991 versus 2002-2005) and compare outcomes to the local hospital maternity population (2004-2005). A cross-sectional audit of health-care records was conducted comparing the outcomes of women in 2002-2005 with earlier data from 1989-1991 and the local maternity population (2004-2005). The service was attended by 126 women, of whom 83% of opioid-dependent women started/continued opioid maintenance treatment. Of 118 babies delivered, there were two stillbirths and one early neonatal death, 20% were premature, 28% were low birth weight, 21% required the Special Care Baby Unit and 21% of babies born to opioid-dependent mothers were treated for neonatal abstinence syndrome (NAS). Fewer babies required treatment for NAS in 2002-2005 compared to 1989-1991 (21% versus 44%). There were higher rates of miscarriage (3% versus < 1%), low birth weight (28% versus 9%) and premature babies (20% versus 9%) compared to the local maternity population (2004-2005). Integrated perinatal addictions treatment may deliver benefits; however, engaging women into treatment earlier and reducing substance use before conception remains the objective.

Mayet S; Groshkova T; Morgan L; MacCormack T; Strang J. Drugs and pregnancy: Outcomes of women engaged with a specialist perinatal outreach addictions service. Drug and Alcohol Review 27(5): 497-503, 2008. (23 refs.)

Mayet S; Groshkova T; Morgan L; MacCormack T; Strang J. Drugs, alcohol and pregnant women: Changing characteristics of women engaging with a specialist perinatal outreach addictions service. Drug and Alcohol Review 27(5): 490-496, 2008. (25 refs.)

Pregnant substance misusers present an increased risk to themselves and the unborn child. The aim of this study was to investigate changes in the characteristics of women referred to a specialist perinatal addictions outreach service (1989-1991 versus 2002-2005). A cross-sectional audit of health records was conducted. Information was gathered for each woman who contacted the service (2002-2005). Data were compared to an earlier study in the same locality (1989-1991). A total of 167 pregnant substance-using women were referred between 2002 and 2005, of whom 126 made contact. The mean age was 30.2 years at 20.8 weeks' fetal gestation, with 76% not in addictions treatment, 32% from black or minority ethnic (BME) communities, 49% polysubstance users and 29% homeless. The primary substance used was illicit heroin (38%), followed by cocaine (24%). Compared to 1989-1991, there were significantly more pregnant women presenting at an older age, later gestation, with increased polysubstance use and a higher percentage of women from BME communities. This service was able to access vulnerable substance-abusing women with an altered pattern of substance use compared to over 10 years previously. However, improvements are needed for engaging all referred women and accessing women at an earlier gestation.

McWhirter PT. Enhancing adolescent substance abuse treatment engagement. Journal of Psychoactive Drugs 40(2): 173-182, 2008. (27 refs.)

Trends in adolescent drug use are encouraging and suggest the importance of preventative programs for youth. Yet, among those who become involved with illicit substances and seek treatment, only a fraction report positive outcomes. This article describes an approach to enhance adolescent participation in substance abuse treatment. Aspects of the transtheoretical model are integrated into a treatment program designed to meet the unique developmental needs of adolescent alcohol and marijuana abusers. The result is a treatment that better engages adolescents in participation, thereby increasing the likelihood for treatment success.

Melnick G; Coen C; Taxman FS; Sacks S; Zinsser KM. Community-based co-occurring disorder (COD) intermediate and advanced treatment for offenders. Behavioral Sciences and the Law 26(4): 457-473, 2008. (31 refs.)

Against a backdrop of increasing concern about the adequacy of treatment for co-occurring substance use and mental disorders (typically known as "co-occurring disorders," or COD) in the criminal justice system, this article attempts to provide empirical evidence for a typology of levels of COD treatment for offenders in both prison and community settings. The paper investigates two levels of treatment programs for COD; "intermediate" programs, in which treatment programming has been designed primarily for offenders with a single disorder, and "advanced" programs, in which programming has been designed to provide integrated substance abuse treatment and mental health services. Findings from a national survey of program directors indicated that both intermediate and advanced COD treatment programs were similar in their general approach to substance abuse treatment, but differed considerably in their treatment of mental disorders, where the advanced programs employed significantly more evidence- and consensus-based practices. Results provide support for the distinction between intermediate- and advanced-level services for offenders with COD and support a typology that defines advanced programs as integrating a range of evidence- and consensus-based practices so as to modify treatment sufficiently to address both diseases.

Melnick G; Wexler HK; Cleland CM. Client consensus on beliefs about abstinence: Effects on substance abuse treatment outcomes. Drug and Alcohol Dependence 93(1/2): 30-37, 2008. (45 refs.)

Organizational culture, as evinced by consensus regarding staff and client beliefs and values, has been shown to affect client engagement in residential substance abuse treatment. The present paper extends this work to treatment outcomes. Secondary analysis of data from a "Beliefs About Abstinence Scale," used in the Drug Abuse Treatment Outcomes Study (DATOS), was conducted for 76 programs, including outpatient methadone treatment, outpatient drug-free, short-term inpatient, and long-term residential programs. Findings show that higher levels of client consensus after 1 month of treatment were associated with less use of drugs and alcohol at 1-year follow-up, after controlling for the mean of the scale score, gender, age, client substance use at baseline and treatment modality. The implications of the results for substance abuse treatment are discussed.

Melnick G; Wexler HK; Chaple M; Cleland CM. Constructive conflict and staff consensus in substance abuse treatment. Journal of Substance Abuse Treatment 36(2): 174-182, 2009. (58 refs.)

Previous studies demonstrated the relationship between consensus among both staff and clients with client engagement in treatment and between client consensus and 1-year treatment outcomes. The present article explores the correlates of staff consensus, defined as the level of agreement among staff as to the importance of treatment activities in their program, using a national sample of 80 residential substance abuse treatment programs. Constructive conflict resolution had the largest effect on consensus. Low client-to-staff ratios, staff education, and staff experience in substance abuse treatment were also significantly related to consensus. Frequency of training, an expected correlate of consensus, was negatively associated with consensus, whereas frequency of supervision was not a significant correlate. The implications of the findings for future research and program improvement are discussed.

Mold A; Berridge V. 'The rise of the user'? Voluntary organizations, the state and illegal drugs in England since the 1960s. Drugs: Education, Prevention and Policy 15(5): 451-461, 2008. (39 refs.)

This article examines the place of the drug user in drug policy and practice in England since the 1960s. It argues that though the drug user has 'risen' in the sense that users now play a key role in contemporary policy and practice, this was not a neat, linear process. Moreover, the current position of the drug user is constrained by a range of wider forces.

Nabitz U; Jansen P; van der Voet S; van den Brink W. Psychosocial work conditions and work stress in an innovating addiction treatment centre. Consequences for the EFQM Excellence Model. Total Quality Management & Business Excellence 20(3): 267-281, 2009. (30 refs.)

In the Job Demand Control Model (JDCM) and the EFQM Excellence Model, psychosocial work conditions are regarded as critical factors for the functioning of the personnel and the organisation. In order to gain insight into the role of work conditions for the development of work strain and well-being, an empirical study was conducted in an innovating addiction treatment centre in Amsterdam, the Netherlands. The Work Stress Monitor on Mental Health (WSMMH) was used as a measure of the JDCM. A cohort of 209 employees of an addiction treatment centre, in which a far-reaching innovation programme was carried out, participated in this study. With the exception of physical demands, job demands, were high, whereas job controls and the organisational supports were low. Seven out of the 18 work condition scales significantly predicted work strain and well-being. Age and educational level were positive related to well-being. Compared with other health care sectors, work in this addiction treatment centre can be characterised as high-demand low-control and thus as a high strain job. Seven important predictors for this undesirable situation were identified. These predictors can be translated into criteria for the EFQM Excellence Model and can be used to enhance the overall quality of addiction treatment services.

Nahra TA; Mendez D; Alexander JA. Employing super-efficiency analysis as an alternative to DEA: An application in outpatient substance abuse treatment. European Journal of Operational Research 196(3): 1097-1106, 2009. (78 refs.)

A common technique for conducting efficiency analyses consists of a two-stage procedure that combines data envelopment analysis (DEA) with Tobit regression. As the DEA scores are censored at one, this method has the drawback of masking important information at the upper tail of the distribution of scores. In this paper, we present a DEA-based methodology for a two-stage efficiency analysis where the upper bound constraint of one for the efficiency scores is relaxed. This method, super-efficiency DEA, is contrasted with the two-stage approach that employs traditional, bounded DEA scores. We use data from the National Drug Abuse Treatment Survey to examine how the relative efficiency of the treatment units is affected by the organizational structures, operating characteristics and treatment modalities of a nationally representative sample of outpatient substance abuse treatment units. Our results show that the super-efficiency DEA approach offers advantages over the traditional methodology. It is easy to implement, and, for the same sample size provides more information.

Norman J; Walsh N; Mugavin J; Stoove M; Kelsall J; Austin K et al. The acceptability and feasibility of peer worker support role in community based HCV treatment for injecting drug users. Harm Reduction Journal 5(1): e-article 8, 2008. (31 refs.)

Hepatitis C is the most common blood borne virus in Australia affecting over 200,000 people. Effective treatment for hepatitis C has only become accessible in Australia since the late 1990's, although active injecting drug use (IDU) remained an exclusion criteria for government-funded treatment until 2001. Treatment uptake has been slow, particularly among injecting drug users, the largest affected group. We developed a peer-based integrated model of hepatitis C care at a community drug and alcohol clinic. Clients interested and eligible for hepatitis C treatment had their substance use, mental health and other psychosocial comorbidities co-managed onsite at the clinic prior to and during treatment. In a qualitative preliminary evaluation of the project, nine current patients of the clinic were interviewed, as was the clinic peer worker. A high level of patient acceptability of the peer-based model and an endorsement the integrated model of care was found. This paper describes the acceptability of a peer-based integrated model of hepatitis C care by the clients using the service.

Pollack HA; D'Aunno T. Dosage patterns in methadone treatment: Results from a National Survey, 1988-2005. Health Services Research 43(6): 2143-2163, 2008. (32 refs.)

To examine the extent to which U.S. methadone maintenance facilities meet established standards for minimum dosages, 1988-2005. Data were collected from a nationally representative sample of outpatient treatment facilities in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), and 2005 (n=146). Random-effects multiple regression analysis was used to examine unit characteristics associated with below recommended doses. Data regarding the proportion of patients who received maintenance dosages of < 40, 60, and 80 mg/day were collected from unit directors and clinical supervisors. Forty-four percent of patients receive doses of at least 80 mg/day-the threshold identified as recommended practice in recent work. Thirty-four percent of patients receive doses below 60 mg/day, while 17 percent receive doses below 40 mg/day. Units that serve a high proportion of African American or Latino clients were more likely to report low-dose care. Units managed by individuals who strongly favor abstinence models (e.g., Narcotics Anonymous) were more likely to provide low-dose care. One-third of methadone facilities provide doses below recommended levels. Managerial attitudes about abstinence and their relationship to low doses underscore the contested role of methadone in treatment of opiate disorders.

Raw M; Regan S; Rigotti NA; McNeill A. A survey of tobacco dependence treatment services in 36 countries. Addiction 104(2): 279-287, 2009. (17 refs.)

This paper reports the results of a survey of national tobacco dependence treatment services in 36 countries. The objective was to describe the services and discuss the results in the context of Article 14 of the Framework Convention on Tobacco Control, which asks countries to promote adequate treatment for tobacco dependence. A questionnaire on tobacco dependence treatment services was e-mailed to a convenience sample of contacts in 2007. Completed questionnaires were received from contacts in 36 countries. The survey instrument was a 10-item questionnaire asking about treatment policy and practice, including medications. According to our informants, fewer than half the countries in our survey had an official written policy on (44%), or a government official responsible for (49%), treatment. Only 19% had a specialized national treatment system and only 24% said help was easily available in general practice. Most countries (94%) allowed the sale of nicotine replacement therapy (NRT), bupropion (75%) and varenicline (69%) but only 40% permitted NRT on 'general sale'. Very few countries responding to the question fully reimbursed any of the medications. Fewer than half (45%) fully reimbursed brief advice and only 29% fully reimbursed intensive specialist support. Only 31% of countries said that their official treatment policy included the mandatory recording of patients' smoking status in medical notes. Taken together, our findings show that few countries have well-developed tobacco dependence treatment services and that, at a national level, treatment is not yet a priority in most countries.

Reid MS; Fallon B; Sonne S; Flammino F; Nunes EV; Jiang H et al. Smoking cessation treatment in community-based substance abuse rehabilitation programs. Journal of Substance Abuse Treatment 35(1): 68-77, 2008. (65 refs.)

Nicotine dependence is highly prevalent among drug- and alcohol-dependent patients. A multisite clinical trial of smoking cessation (SC) treatment was performed at outpatient community-based substance abuse rehabilitation programs affiliated with the National Drug Abuse Treatment, Clinical Trials Network. Cigarette smokers (N = 225) from five methadone maintenance programs and two drug and alcohol dependence treatment programs were randomly assigned in a 2:1 ratio to receive either (1) SC treatment as an adjunct to substance abuse treatment-as-usual (TAU) or (2) substance abuse TAU. Smoking cessation treatment consisted of I week of group counseling before the target quit date and 8 weeks of group counseling plus transdermal nicotine patch treatment (21 mg/day for Weeks 1-6 and 14 mg/day for Weeks 7 and 8) after the target quit date. Smoking abstinence rates in SC, 10%-11% during treatment and 5%-6% at the 13- and 26-week follow-up visits, were significantly better than those in TAU during treatment (p <.01). In addition, SC was associated with significantly greater reductions as compared with TAU in cigarettes smoked per day (75% reduction, p <.001), exhaled carbon monoxide levels (P <.001), cigarette craving (p <.05), and nicotine withdrawal (p <.05). Smoking cessation did not differ from TAU on rates of retention in substance abuse treatment, abstinence from primary substance of abuse, and craving for primary substance of abuse. Compliance with SC treatment, moderate at best, was positively associated with smoking abstinence rates. Smoking cessation treatment resulted in significant reductions in daily smoking and modest smoking abstinence rates without having an adverse impact on substance abuse rehabilitation when given concurrently with outpatient substance abuse treatment. Substance abuse treatment programs should not hesitate to implement SC for established patients.

Robinson LA; Emmons KM; Moolchan ET; Ostroff JS. Developing smoking cessation programs for chronically ill teens: Lessons learned from research with healthy adolescent smokers. Journal of Pediatric Psychology 33(2): 133-144, 2008. (68 refs.)

Objective: Medically fragile teens who smoke need access to smoking cessation programs, because they are at even higher risk than their healthy peers for smoking-related complications. Methods To date, no studies on the outcome of smoking cessation programs for medically ill teens have been conducted. To suggest directions for future research, we turn to the literature on smoking cessation in the general population of teens and occasionally to the literature on adult smokers. Results Four areas are explored: (a) the prevalence of unaided cessation in healthy teens; (b) the outcomes of various treatments for smoking cessation in healthy adolescents; (c) special issues that should be considered when designing programs for medically ill teens; and (d) lessons learned from previous research. Conclusions: Medically ill teens face a number of medical, emotional, social, and developmental challenges that can affect the quitting process. Research is sorely needed to address the unique needs of this population.

Rogers N. From "Treatment" to "Care": Developing youth drug treatment services using a social model of health. Australian Journal of Primary Health 14(1): 52-58, 2008. (22 refs.)

The Youth Substance Abuse Service (YSAS) was conceived and developed as a youth alcohol and other drug (AOD) service when few adolescent treatment models existed. Although initially funded to provide drug support and treatment, our developing practice, training and research findings encouraged us to view our role more broadly. Now with 10 years' experience, YSAS increasingly draws on social health concepts and primary health practices to describe our work with young drug users. Through our growing practice and training experience we have developed services to meet client needs. Evaluation of these services and further research has refined our thinking and provided a theoretical basis for our work. This paper sets out to describe the evolution of a youth AOD service, and demonstrate how social health concepts and primary health practices have helped frame and facilitate our responses to young drug users during YSAS' first 10 years.

Rose D. Quality initiatives in the alcohol and other drug treatment sector. Australian Journal of Primary Care 14(2): 58-63, 2008. (21 refs.)

Quality improvement has recently become a key focus of the alcohol and other drug (AOD) treatment sector through initiatives such as accreditation, workforce development and the adoption of an evidence-based practice approach. While this attention on quality improvement is viewed as a much-needed change, a number of barriers to successful implementation of quality initiatives within the AOD sector exist. This;paper discusses these issues, drawing from the research evidence and a case example examining accreditation and workforce development in the AOD sector in Victoria, Australia. The paper concludes that the recent focus on quality improvement within the AOD sector is a very desirable direction, but quality initiatives must be supported by an appropriate level of funding if they are to lead to improved outcomes for service users.

Sacks S; Chandler R; Gonzales J. Responding to the challenge of co-occurring disorders: Suggestions for future research. Journal of Substance Abuse Treatment 34(1): 139-146, 2008. (32 refs.)

This special issue consolidates some recent research findings and scientific thought on co-occurring disorders from both the substance abuse and mental health fields. This summary article recaps and synthesizes the main findings and themes, then considers additional issues in the field today to arrive at an agenda for future co-occurring disorders research. Plans must: (1) encourage and assist further development of treatment programs that respond to an array of types and severities of co-occurring disorders while taking into account the limited resources typically available; (2) continue the development and testing of continuing care models by exploring strategies that will sustain the recovery of treated individuals who remain vulnerable to relapse; and (3) contribute to our understanding of the mechanisms and processes that enable new interventions and practices to be adopted, implemented, and sustained. '' Co-occurring disorders '' is a relatively new area of research; this special issue illustrates the productivity of work to date and indicates the potential for advances to come.

Schroder R; Sellman D; Frampton C; Deering D. Profile of young people attending alcohol and other drug treatment services in Aotearoa, New Zealand: Clinical file search. Australian and New Zealand Journal of Psychiatry 42(11): 963-968, 2008. (16 refs.)

Objective: The aim of the present study was to provide a profile of young people attending alcohol and other drug (AOD) treatment services in Aotearoa, New Zealand. Method: Data were gathered from a clinical file search of 184 randomly selected young people aged 13-19 years who had attended one of eight youth AOD treatment services in New Zealand during 2003 or 2004. These services represented eight of the 11 youth-specific AOD services available to youth in New Zealand. Results: Young people who attend youth-specific AOD services in New Zealand present with a range of complex needs including substance use and mental health issues, criminality, family conflict and disengagement from school. A total of 62.0% were male, 56.4% had criminal convictions, 40.6% had spent some time in Child, Youth and Family Services care and 53.8% were reported to have a coexisting substance use and mental health disorder. Low rates of reporting of substance use and mental health diagnoses in treatment files suggest that substance use and mental health disorders among this population are likely to be higher than those reported. Conclusions: This paper provides a unique profile of young people attending youth-specific AOD treatments in New Zealand. Such information is useful in informing treatment planning and funding and ensuring that service development occurs to specifically meet the complex needs of this patient group.

Schulte SJ; Meier PS; Stirling J; Berry M. Treatment approaches for dual diagnosis clients in England. Drug and Alcohol Review 27(6): 650-658, 2008. (71 refs.)

Introduction. Dual diagnosis (DD, co-occurrence of substance use and mental health problems) prevalence data in England are limited to specific regions and reported rates vary widely. Reliable information on actual service provision for dual diagnosis clients has not been collated. Thus a national survey was carried out to estimate dual diagnosis prevalence in treatment populations and describe the service provision available for this client population in drug/alcohol (DAS) and mental health services (MHS). Design. A questionnaire was sent to managers of 706 DAS and 2374 MHS. Overall, 249 (39%) DAS and 493 (23%) MHS participated in the survey. Results. In both DAS and MHS, around 32% of clients were estimated to have dual diagnosis problems. However, fewer than 50% of services reported assessing clients for both problem areas. Regarding specific treatment approaches, most services (DAS: 88%, MHS: 87%) indicated working jointly with other agencies. Significantly fewer services used joint protocols (DAS: 55%, MHS: 48%) or shared care arrangements, including access to external drug/alcohol or mental health teams (DAS: 47%, MHS: 54%). Only 25% of DAS and 17% of MHS employed dual diagnosis specialists. Conclusions. Dual diagnosis clients constitute a substantial proportion of clients in both DAS and MHS in England. Despite recent policy initiatives, joint working approaches tend to remain unstructured.

Sheridan J; Goodyear-Smith F; Butler R; Wheeler A; Gohns A. Barriers to, and incentives for, the transfer of opioid-dependent people on methadone maintenance treatment from secondary care to primary health care. Drug and Alcohol Review 27(2): 178-184, 2008. (16 refs.)

Aim. To explore barriers to, and incentives for, clients on methadone-maintenance treatment (MMT) in Auckland, New Zealand to transfer from secondary care to general practitioner (GP) care. Design. Surveys (with free text response sections) of MMT secondary care staff, stabilised clinic clients, authorised GPs and GP patients. Results. High response rates from secondary care staff (77%) and GPs (74%). Barriers to stable clients' transfer included financial cost and attitudes of secondary care staff and clients. Incentives for patient transfer included confidentiality, a holistic approach to their care, continuity of care, increased patient control, convenience and avoidance of contact with other opioid-dependent people. Distrust in the quality of care provided by authorised GPs was a major barrier for some secondary care staff and their clients, despite prerequisite training for authorisation. In contrast, patients rated primary better than secondary care with none stating a likelihood to return to the secondary service within 6 months. Conclusions. Progression from secondary to primary care should be incorporated in MMT planning from the outset, with secondary services staff reassured about the quality of primary care. An integrated transition period and exploration of funding options to assist transfer from largely publicly funded secondary to largely privately funded primary care are also recommended.

Simmons R; Ungemack J; Sussman J; Anderson R; Adomo S; Aguayo J et al. Bringing adolescents into substance abuse treatment through community outreach and engagement: The Hartford Youth Project. Journal of Psychoactive Drugs 40(1): 41-54, 2008. (34 refs.)

While outreach and case management services have been shown to improve retention of at-risk youth in behavioral health treatment, these important support services are challenging to implement. The Hartford Youth Project (HYP), established by the Connecticut Department of Children and Families as a pilot for the state adolescent substance abuse treatment system, made outreach and engagement integral to its system of care. HYP brought together a network of stakeholders: referral sources (juvenile justice, schools, community agencies, child welfare, and families); community-based outreach agencies; treatment providers; and an administrative service organization responsible for project coordination. Culturally competent Engagement Specialists located in community agencies were responsible for: cultivation of referral sources; community outreach; screening and assessment; engagement of youth and families in treatment; case management; service planning; recovery support; and advocacy. This article describes HYP's approach to identifying and engaging youth in treatment, as well as its challenges. Use of family-based treatment models, expectations of referral sources, limited service capacity, youth and family problems, and staff turnover were all factors that affected the outreach and engagement process. Process, baseline assessment and case study data are used to describe the needs and issues specific to Hartford's substance-abusing Latino and African-American youth.

Squires DD; Gumbley SJ; Storti SA. Training substance abuse treatment organizations to adopt evidence-based practices: The Addiction Technology Transfer Center of New England science to service laboratory. Journal of Substance Abuse Treatment 34(3): 293-301, 2008. (20 refs.)

Underutilization of evidence-based treatments for substance abuse represents a longstanding problem for the field and the public health of our nation. Those who would most benefit from research advances (community treatment agencies and the clients they serve) have historically been the least likely to be exposed to innovative evidence-based methods for substance abuse treatment. To help address this gap, the Addiction Technology Transfer Center of New England (ATTC-NE), located at Brown University, has adapted and implemented an organizational change strategy intended to equip substance abuse treatment organizations and their employees with the skills needed to adopt evidence-based treatment practices. Since 2003, the ATTC-NE has worked with 54 community-based substance abuse treatment agencies from across New England using this model, which is called Science to Service Laboratory (SSL). Twenty-eight of 54 agencies completed all of the SSL components, and 26 of these 28 completer agencies (96%) successfully adopted and implemented contingency management as a result. Survey data comparing completer and dropout agencies' satisfaction with the quality, organization, and utility of the SSL indicate that both groups rated the SSL favorably. However, differences emerged with respect to organizational characteristics between completer and dropout agencies. Specifically, dropout agencies were more likely to report turnover in staff positions vital to training effort. Future directions for the model are discussed.

Storbjork J; Room R. The two worlds of alcohol problems: Who is in treatment and who is not? Addiction Research & Theory 16(1): 67-84, 2008. (61 refs.)

In the study "Women and Men in Swedish Alcohol and Drug Treatment," it is possible to compare alcohol consumption and problems among respondents in the general population with those in clients entering alcohol treatment. The differences between these groups have led researchers to talk about the "two worlds" of alcohol problems - in general and in clinical populations. The aim of this article is to study the relative strength of factors in predicting entering and the clinical population. The studied factors are demographics and marginalization; volume and frequency of drinking; alcohol dependence; social response to drinking (suggestions to cut down or seek treatment by informal actors, e.g. family and friends, and formal actors such as employer, the social services or judicial system); and treatment history. The client sample includes 1202 clients (71% men) interviewed face-to-face when entering inpatient and outpatient treatment facilities in Stockholm. In the general population survey, 3557 persons aged 18-75 years were interviewed. The two samples differ significantly. As expected, clients were older, more marginalized and reported more severe alcohol problems, and many reported previous treatment experiences and social responses. Logistic regression analyses show that previous treatment, unemployment/institutionalization and having an unstable living situation are the strongest predictors of who is in treatment, followed by age, alcohol dependence and frequency of drinking. Formal pressures to cut down or seek treatment are also important and males are more likely to be in treatment. The results support a notion of the treatment system as a place for handling marginalized people, beyond and beside their extent of drinking.

Thomas SE; Miller PA; Randall PK; Book SW. Improving acceptance of naltrexone in community addiction treatment centers: A pilot study. Journal of Substance Abuse Treatment 35(3): 260-268, 2008. (29 refs.)

Alcoholism pharmacotherapies are underused in community addiction treatment settings, in part because individuals who practice in these settings-nonmedical addiction counselors and administrators-lack knowledge about and confidence in the value of adjunctive alcohol pharmacotherapies. We developed and tested an intervention to improve knowledge and attitudes about naltrexone. A team of researchers, physicians, addiction treatment counselors, and administrators collaborated to develop a naltrexone educational intervention designed for nonmedical addiction professionals. The intervention was compared with a control condition in a pilot study with 6 addiction treatment agencies (3 agencies per group). Participants (counselors and administrators, N = 84) were assessed before and 6 months after the intervention. Results revealed that the intervention significantly improved naltrexone knowledge, and participants who received the intervention reported greater satisfaction with the education they received, as well as greater use of the information. The effect of the intervention on attitudes about naltrexone was encouraging but did not to reach statistical significance. This study is the first reported attempt to develop and test an intervention specifically to improve acceptance of adjunctive medications for alcoholism among nonmedical addiction professionals.

Tracy K; Brown LS; Kritz S; Alderson D; Robinson J; Bini EJ et al. Substance abuse treatment clinician opinions and infectious disease service delivery. Journal of Addictive Diseases 28(1): 8-12, 2009. (8 refs.)

Substance abuse treatment programs are an important platform for delivery of services for infectious diseases associated with drug and alcohol use. However, important components of infectious disease care are not universally provided. Clinician training often focuses on information about infectious diseases and less attention is paid to provider opinions and attitudes that may be barriers to providing infectious diseases services. In a national multi-site trial conducted by the National Drug Abuse Treatment Clinical Trials Network (CTN), we investigated the relationship between clinician opinions and the delivery of services for human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections in substance abuse treatment settings. Survey data were collected from 1,723 clinicians at 269 CTN treatment programs. Clinician opinion was found to be significantly related to infectious disease service delivery. Implications for training are discussed.

Vahabzadeh M; Lin JL; Mezghanni M; Epstein DH; Preston KL. Automation in an addiction treatment research clinic: Computerised contingency management, ecological momentary assessment and a protocol workflow system. Drug and Alcohol Review 28(1): 3-11, 2009. (26 refs.)

Introduction and Aims. A challenge in treatment research is the necessity of adhering to protocol and regulatory strictures while maintaining flexibility to meet patients' treatment needs and to accommodate variations among protocols. Another challenge is the acquisition of large amounts of data in an occasionally hectic environment, along with the provision of seamless methods for exporting, mining and querying the data. Design and Methods. We have automated several major functions of our outpatient treatment research clinic for studies in drug abuse and dependence. Here we describe three such specialised applications: the Automated Contingency Management (ACM) system for the delivery of behavioural interventions, the transactional electronic diary (TED) system for the management of behavioural assessments and the Protocol Workflow System (PWS) for computerised workflow automation and guidance of each participant's daily clinic activities. These modules are integrated into our larger information system to enable data sharing in real time among authorised staff. Results. ACM and the TED have each permitted us to conduct research that was not previously possible. In addition, the time to data analysis at the end of each study is substantially shorter. With the implementation of the PWS, we have been able to manage a research clinic with an 80 patient capacity, having an annual average of 18 000 patient visits and 7300 urine collections with a research staff of five. Finally, automated data management has considerably enhanced our ability to monitor and summarise participant safety data for research oversight. Discussion and Conclusions. When developed in consultation with end users, automation in treatment research clinics can enable more efficient operations, better communication among staff and expansions in research methods.

Wallander L; Blomqvist J. Modeling ideal treatment recommendations: A factorial survey of Swedish social workers' ideal recommendations of inpatient or outpatient treatment for problem substance users. Journal of Social Service Research 35(1): 47-64, 2009. (43 refs.)

With the aim of examining predictors of social workers' ideal recommendations of inpatient or outpatient treatment for problem substance users, this study applied multilevel logistic regression to factorial survey data collected from a sample of 205 frontline social workers from 36 social services units in Sweden. The results show that social workers' ideal recommendations of inpatient or outpatient treatment are based on evaluations of a number of client characteristics. These include the clients' treatment preferences, their primary drug, levels of social resources, and age. In addition, it was found that professional recommendations are also determined by treatment availability and policy guidelines, and by the decision makers' own ideological convictions regarding alcohol and narcotics problems. This study brings to light the necessity of organizational routines that allow and encourage social workers to reflect on and to articulate their judgements and decisions.

Warner TD; Kramer JH. Closing the revolving door? Substance abuse treatment as an alternative to traditional sentencing for drug-dependent offenders. Criminal Justice and Behavior 36(1): 89-109, 2009. (37 refs.)

The criminal justice system is often viewed as a revolving door for drug-dependent offenders due to its failure to recognize the association between addiction and offending, and repeated incarceration of drug-dependent offenders has contributed to prison overcrowding. The authors evaluated the effectiveness of Pennsylvania's drug and alcohol treatment-based intermediate punishment, Restrictive Intermediate Punishments (RIP/D&A), at reducing the risk of rearrest. Rearrest was compared at 12, 24, and 36 months postrelease. Offenders who successfully completed treatment had a lower risk of rearrest than traditionally sentenced offenders in general and county jail and probation offenders specifically. However, offenders sentenced to RIP/D&A who did not successfully complete treatment were more at risk for rearrest than traditionally sentenced offenders in general. Also, offenders sentenced to state incarceration had a lower risk of rearrest than RIP/D&A participants, regardless of program completion.

Waters E; Thom B. Reforming the Soviet model: Alcohol treatment services in Kazakhstan. Addiction Research & Theory 16(4): 319-330, 2008. (63 refs.)

Based on documentary and interview material this article reviews key aspects of the current alcohol treatment services in Kazakhstan and assesses the extent to which the Soviet model has been superseded. Before 1991, alcohol services in Kazakhstan were typical for the USSR: government providers delivered psychiatry-led treatments free of charge as part of a centralised and hierarchical system in which compulsion and breaches of confidentiality were integral. Since independence, the collapse of the communist state and the introduction of a market economy have altered the context in which the Soviet model of treatment services operates. There is no longer a single centralised provider and treatment is no longer necessarily free at the point of delivery. However, within the statutory sector, which still dominates service provision, the individual components of the Soviet model are relatively unchanged. Reforms in methods and delivery of treatments are likely to take place as economic prosperity increases and professional isolation weakens; the extension of patient rights may depend on wider social and political developments in the republic.

White WL; Sanders M. Recovery management and people of color: Redesigning addiction treatment for historically disempowered communities. Alcoholism Treatment Quarterly 26(3): 365-395, 2008

Communities of color have been ill-served by acute care models of treating severe alcohol and other drug (AOD) problems that define the source of these problems in idiopathic (biopsychological) terms and promote their resolution via crisis-elicited episodes of brief, individual interventions. This article explores how approaches that shift the model of intervention from acute care (AC) of individuals to a sustained recovery management (RM) partnership with individuals, families, and communities may be particularly viable for historically disempowered peoples. The advantages of the RM model for communities of color include: a broadened perspective on the etiological roots of AOD problems (including historical/cultural trauma); a focus on building vibrant cultures of recovery within which individual recoveries can be anchored and nourished; a proactive, hope-based approach to recovery engagement; the inclusion of indigenous healers and institutions with the RM team; an expanded menu of recovery support services; culturally grounded catalytic metaphors and rituals; and a culturally-nuanced approach to research and evaluation.

Winstock A; Molan J; Lea T. Survey of New South Wales Opioid Treatment Program Public Clinics: SWAT Report 3. NDARC Technical Report No. 298. Sydney: National Drug and Alcohol Research Centre

Summary: The State-Wide Advisory Team (SWAT): Drug Health Streamed Shared Care was established in 2005 by NSW Health and Drug Health Services, Sydney South West Area Health Service for the purpose of mapping, consulting and supporting opioid pharmacotherapy services across NSW. The objective was to build capacity within existing specialist and community facilities for the management of those with drug and alcohol problems, with an initial focus on those with opioid dependence. To support this effort a study was conducted to identify the range of work practices, clinical referral pathways and supporting policies currently in place in public clinics providing treatment for opioid dependence across NSW. This report presents the findings of that Survey. Initial consultations with Area Health Services (AHS) revealed wide variation in culture and priorities as well as in staffing levels, resources, and operational practices at public clinics across NSW. Consistently across the state many public clinics had a limited capacity to take on new-to-treatment clients and there appeared to be an under-utilisation of available community pharmacy dosing places. This report reviews the demographics of current clients and clinical characteristics; describes the 35 programs in the state in terms of service provided, and staffing. The findings included the following: In terms of opening hours, generally, the bigger the clinic the longer the opening hours. However, there was wide variation in dosing hours between clinics (two to eight hours/day) and there was generally very limited availability of early and late dosing. All but th`ee clinics were open seven days a week. The majority of clients managed by a public clinic (59%) received their doses at a public clinic. The mean number of FTE clinical staff at each clinic was four. Ninety-four percent of clinics reported having on-site medical officers, with 54% having staff specialist medical cover. Nine clinics reported having a waiting list. These findings should not be interpreted as meaning that the remaining clinics had available capacity. The findings only suggest that the majority of clinics do not keep a formal record of their inability to provide treatment to all those who present for treatment. Two thirds of clinics reported the use of standard assessment tools for identifying stable clients for transfer. Less than half reported the transfer of stable clients to GPs and only two-thirds reported they had contact with any of their local GP divisions. Data is presented in 28 figures and tables.

Wittchen HU; Apelt SM; Soyka M; Gastpar M; Backmund M; Golz J et al. Feasibility and outcome of substitution treatment of heroin-dependent patients in specialized substitution centers and primary care facilities in Germany: A naturalistic study in 2694 patients. Drug and Alcohol Dependence 95(3): 245-257, 2008. (37 refs.)

Background: In many countries, buprenorphine and methadone are licensed for the maintenance treatment (MT) of opioid dependence. Despite many short-term studies, little is known about the long-term (12-month) effects of these treatments in different settings, i.e. primary care-based (PMC) and specialized substitution centers (SSCs). Objectives: To describe over a period of 12 months: (1) mortality, retention and abstinence rates; (2) changes in concomitant drug use, somatic and mental health; and (3) to explore differences between different types of provider settings. Methods: 12-Month prospective-longitudinal naturalistic study with four waves of assessment in a prevalence sample of N=2694 maintenance patients, recruited from a nationally representative sample of N=223 substitution physicians. Results: The 12-month retention rate was 75%; the mortality rate 1.1%. 4.1% of patients became "abstinent" during follow-up. 7% were referred to drug-free addiction treatment. Concomitant drug use decreased and somatic health status improved. No significant improvements were observed for mental health and quality of life. When controlling for initial severity, small PMC settings revealed better retention, abstinence and concomitant drug use rates. Conclusion: The study underlines the overall 12-month effectiveness of various forms of agonist MT. Findings reveal relatively high retention rates, low mortality rates, and improvements in most 12-month outcome domains, except for mental health and quality of life. PMC settings appear to be a good additional option to improve access to MTs.

Woodward AM; Raskin IE; Blacklow B. A profile of the substance abuse treatment industry: Organization, costs, and treatment completion. Substance Use & Misuse 43(5): 647-679, 2008. (52 refs.)

Nationally representative data from the Alcohol and Drug Services Study, conducted between 1996 and 1999, are used to explore the structure and operation of the substance user treatment industry in the United States. The empirical relationship among client (N = 4945) retention and completion, types and use of counseling and medical personnel, diagnostic mix, client demographics, the level of services used, and the cost of treatment in different treatment settings is discussed using tabular presentation and tests of significance. Limitations of the analysis are outlined. This information and analysis are expected to help the research community understand the potential of the ADSS data in addressing many important questions about substance user treatment.

Yannessa JF; Reece M; Basta TB. HIV provider perspectives: The impact of stigma on substance abusers living with HIV in a rural area of the United States. AIDS Patient Care and STDS 22(8): 669-675, 2008. (49 refs.)

Recent literature has documented growing concerns related to access to HIV care services for rural individuals living with both HIV and a dual diagnosis of substance abuse. Previous research has investigated issues from a client perspective, but limited research has investigated provider perspectives of rural issues surrounding HIV and substance abuse. The purpose of this qualitative study was to examine issues that impact the ability of care providers to create sustainable linkages to care for dual diagnosed individuals who live in rural areas. In-depth interviews were conducted in late 2005 with 39 HIV service providers at 11 agencies that provided HIV-related services to individuals in rural areas of a Midwestern state in the United States. Findings suggest multidimensional stigma in the medical referral network as the leading factor that presents challenges to service providers in rural areas. The service providers reported verbal stigma in the form of insults, a loss of role/respect, and a global loss of resources such as poorer quality health care or no health care provided. The stigma is conceptualized in four themes: (1) staff of medical referral sources stigmatizing against rural dual-diagnosis clients, (2) physicians stigmatizing against rural dual-diagnosis clients, (3) medical specialists stigmatizing against rural dual-diagnosis clients, and (4) client-perceived stigma. These themes were expressed equally among all of the providers, regardless of geographic location, type of HIV-related organization, or job title.

Zarkin GA; Dunlap LJ; Wedehase B; Cowell AJ. The effect of alternative staff time data collection methods on drug treatment service cost estimates. Evaluation and Program Planning 31(4): 427-435, 2008. (21 refs.)

Although a limited number of service cost estimates exist, no study has evaluated how differences in the method used to collect the staff time allocation across treatment services contribute to differences in service cost estimates. Three alternative data collection methods for estimating service-level costs in methadone treatment programs were evaluated: key informants, staff surveys, and staff diaries. We analyzed data from 25 methadone clinics across the United States. Results indicate that for the three primary services offered at methadone clinics-individual counseling, group counseling, and methadone dosing-no statistically significant differences exist in the mean estimates of costs per session across programs. Of the other five services analyzed, we found no statistically significant differences in two of the mean costs per session and a small but statistically significant difference in another service. We found large and statistically significant differences in mean costs for two services, initial patient assessment and initial medical services. Although there is no gold standard available to judge which method is the best to use, we concluded that the key informant method yields more reliable cost estimates compared with the staff methods and is less burdensome to both the treatment programs and to researchers. Our findings suggest that the key informant method is the preferred method for costing substance abuse treatment services.