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CORK Bibliography: Treatment Matching

110 citations. 2003 to present

Prepared: March 2010

Alexander JA; Nahra TA; Lemak CH; Pollack H; Campbell CI. Tailored treatment in the outpatient substance abuse treatment sector: 1995-2005. Journal of Substance Abuse Treatment 34(3): 282-292, 2008. (41 refs.)

Interest in improving the quality of addiction treatment has led to the development of clinical paradigms that emphasize the principle of tailored care-matching treatments to the specific needs of each client or client subgroup. This work analyzes how trends in the provision of tailored treatment practices (TTPs) have changed between 1995 and 2005 across outpatient substance abuse treatment (OSAT) programs in the United States. Categories of interest include measures to capture needs assessment and treatment planning activities, treatment offerings for special populations, and case management activities. Results show that TTPs have diffused in an uneven fashion in the population of OSAT programs between 1995 and 2005. Specifically, needs assessment/treatment planning and case management remain a relatively common practice among OSAT programs, while treatment for special populations (especially same-race therapy) is less widely practiced and, indeed, experienced some decline over the study period. This trend is troublesome given that minority clients constitute a large proportion of those utilizing OSAT programs.

Allen JP; Babor TF; Mattson ME; Kadden RM. Matching alcoholism treatment to client heterogeneity: The genesis of Project MATCH. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 3-14. (275 book refs.)

This book chapter describes the origins of the matching hypothesis in alcoholism treatment research and the genesis of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). The National Institute on Alcoholism and Alcohol Abuse (NIAAA) determined in 1988 that the potential benefits of client-treatment matching were sufficient to initiate a large-scale randomized trial to assess its overall value and to quantify the effects of different types of client-intervention matches. The research was begun in 1989 and concluded in 1998. Section headings in this chapter include: (1) definitions and forms of matching; (2) matching strategies: reliance on clinical judgment; self-selection or the 'cafeteria' approach; matching guided by exploratory data analysis; matching guided by theoretically derived hypotheses; matching according to professional guidelines; stepped-care approaches; (3) stages of matching: matching before treatment starts; matching at the initiation of treatment; matching during the treatment process; matching following the rehabilitation intervention; (4) previous treatment matching studies; and (5) rationale for Project MATCH.

Public Domain

Angarita GA; Reif S; Pirard S; Lee S; Sharon E; Gastfriend DR. No-show for treatment in substance abuse patients with comorbid symptomatology: Validity results from a controlled trial of the ASAM patient placement criteria. Journal of Addiction Medicine 1(2): 79-87, 2007. (37 refs.)

Purpose: Mismatched placement, according to the American Society of Addiction Medicine's (ASAM) Patient Placement Criteria (PPC), promotes no-shows to treatment; however, little is known about the impact on patients with psychiatrically comorbid substance use disorder. Methods: In a multisite trial, public-sector treatment-seeking adults (N = 700), following a computer-assisted ASAM PPC-1 structured interview, were blindly scored and randomly assigned to Level-of-Care (LOC)-II (intensive outpatient) or LOC-III (residential) settings. Patients scored as needing LOC-II but assigned to LOC-III were, by definition, "overmatched." Results: Among 143 overmatched patients, no-shows were significantly higher in comorbids versus noncomorbids (54% versus 28%; P < 0.01). Among overmatched comorbids, patients who no-showed compared with patients who showed were more likely to be females (70.4% versus 34.8%; P < 0.05), to have anxiety (63% versus 17.4%; P < 0.01), or have supportive family/social environments (81.5% versus 34.8%; P < 0.01). Conclusions: The data support the validity of the PPC for matching comorbid patients. Mismatching increases no-show rates in general with undermatching, but it does so in particular with overmatching in patients with comorbid psychiatric symptomatology. Comorbidity interacts with gender, overmatched status, presence of anxiety, and supportive environment as predictors of treatment no-shows (odds ratios = 2.69, P < 0.05; 3.27, P < 0.05; 5.32, P < 0.001; and 3.12, P < 0.05, respectively).

Arfken CL; Klein S; Agius EJ; di Menza S. Implementation of selected Target Cities components: Analysis of matching, case management and linkages. IN: Stephens RC; Scott CK; Muck RD, eds. Clinical Assessment and Substance Abuse Treatment: The Target Cities Experience. Albany NY: State University of New York Press, 2003. pp. 103-128. (156 book refs.)

This chapter examines the implementation of elements of the Target Cities Program: treatment matching, case management, and linkages to services. The matching was based upon the ASAM (American Society of Addiction Medicine) levels of care, as well as specific client needs, such as for employment counseling, and their availablity withing a single agency or provision to a specific program for a defined clinical problem. Different models for providing case management were present across sites. Linkage was promoted by agreements between agencies, and referral mechanisms. Also discussed is the nature of agency leadership.

Babor TF. Treatment for persons with substance use disorders: mediators, moderators, and the need for a new research approach. Journal of Methods in Psychiatric Research 17(Special Issue 1): s45-s49, 2008. (9 refs.)

This article describes two major studies (i.e. Project MATCH and the US Department of Veterans Affair Effectiveness Study) of mediators and moderators of drinking behavior change following treatment, and considers alternatives to the dominant paradigm that has guided treatment research for more than two decades. Both studies were designed to test the "Technology Model" of therapeutic change, which postulates that patient attributes and treatment process elements, respectively, constitute mediators and moderators of change in drinking and drug use following treatment. The studies show that matching to therapeutic orientation is not an essential ingredient to substantially enhanced outcomes, as previously believed. They also indicate that the mediational mechanisms underlying several of the most popular therapies are different than what is suggested by their proponents. The inability of the Technology Model to explain, much less improve, the effectiveness of addiction treatment suggests the need for a new paradigm. It may be more fruitful to look for matching in larger populations at the level of communities or treatment systems, where a wider range of settings and therapeutic interventions can be evaluated.

Babor TF; Del Boca FK, eds. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. (297 book refs.)

The experience of Project MATCH is described, a major multi-site clinical research effort undertaken by the National Institute on Alcohol Abuse and Alcoholism. The findings of Project MATCH were originally released sequentially in over 100 scientific publications and presentations. This volume assembles a complete description of the origins of this clinical trial as well as its design, implementation, and results. Individual chapters are directed to (1) the genesis of Project MATCH; (2) the structure of the multisite trial, the organizational issues and research design; (3) clinical assessment procedures used; (4) the therapies used in the clinical trials -- Cognitive Behavioral therapy (CBT), Motivation Enhancement Therapy (MET), and Twelve Step Facilitation (TSF) -- their development, implementation, and costs; (5) client characteristics and implementation of the research protocol; (6) matching hypotheses: the rationale and predictions; (7) treatment outcomes and matching effects (8) the treatment process, including therapist effects, the therapeutic alliance, and the process of intentional behavior change; (9) participation and involvement in Alcoholics Anonymous; and (10) the clinical implications.

Public Domain

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

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

Public Domain

Ball D. Addiction science and its genetics. Addiction 103(3): 360-367, 2008. (64 refs.)

Aim: To assess the progress and impact of genetic studies in the addictions arena and to present this information in a form accessible to the general readership of "Addiction." Methods: Review of the evidence that genes are involved in addiction, approaches to their identification, current findings and the potential implications. Results: Family, twin and adoption studies provide strong evidence that addiction runs in families and that this is determined in part by genetic factors. Two main molecular genetic approaches, namely linkage and association, have been adopted to identify the specific genes involved. Both methods are fraught with problems. Linkage is limited by issues of sensitivity, and association by false positives. Perhaps the strongest finding in psychiatric genetics to date is the impressive effect that a single genetic variant, in the aldehyde dehydrogenase 2 gene, has on drinking behaviour and reducing the risk of developing alcohol dependence. Other findings are currently less robust; however, the implications of elucidating the genetic underpinning of addiction will be profound. Conclusions: Addiction genetics is a developing science that has yet to prove its worth in the clinical setting.

Berrettini WH; Wileyto EP; Epstein L; Restine S; Hawk L; Shields P et al. Catechol-O-Methyltransferase (COMT) gene variants predict response to bupropion therapy for tobacco dependence. Biological Psychiatry 61(1): 111-118, 2007. (39 refs.)

Background: Although bupropion is efficacious for smoking cessation, only a minority of smokers are able to quit. Pharmacogenetic research may improve treatment outcomes through discovery of DNA sequences predictive of successful pharmacotherapy for subgroups of smokers. We investigated variants in the catechol-O-methyltransferase (COMT) gene in a smoking cessation trial of bupropion.MethodsA double-blind, placebo-controlled, 10-week trial of bupropion and counseling (with a 6-month follow-up period) was conducted at two university-based smoking cessation research programs. Abstinence was biochemically verified at the end of treatment and at 6 months after the target quit date.ResultsAt the end of the treatment phase, statistically significant interaction effects indicated that COMT haplotypes of two SNPs (rs737865 and rs165599) predicted the efficacy of bupropion compared with placebo. This interaction effect was attenuated at 6-month follow-up. Conclusions: COMT haplotypes at rs737865 and rs165599 may predict a favorable outcome for bupropion treatment for smoking cessation. European-American smokers with a G allele at both SNPs may not benefit from bupropion treatment. Small numbers of some COMT haplotypes limit interpretation of response. If study findings are confirmed in additional large studies, COMT genotyping could be applied to identify likely responders to bupropion treatment for smoking cessation.

2007, Society of Biological Psychiatry

Bottlender M; Kohler J; Soyka M. The effectiveness of psychosocial treatment approaches for alcohol dependence - A review. (review). Fortschritte der Neurologie Psychiatrie 74(1): 19-31, 2006. (65 refs.)

Treatment approaches which are used in the context of inpatient alcoholism treatment are frequently neither theoretically justified nor empirically examined. In view of the enormous method variety the necessity exists for the development of treatment guidelines in order to offer indicators of promising treatment achievement for practitioners and pension funds. In a first step, it must be examined which treatments are effective, which are ineffective and which are possibly even counter-productive. This article aims to give a comprehensive review of randomized-controlled studies/meta-analysis on the efficacy of different treatment approaches. This article reporting the literature review is part of a larger programme to develop clinical practice guidelines for rehabilitation which is supported in form, content and finance by the German Pension Institute for Salaried Employees (Bundesversicherungsanstalt fur Angestellte, BfA). Summing up, treatment is effective compared to no treatment. Cognitive behavioural therapy included in a multimodal treatment program is effective. There are a number of treatment protocols for which controlled research has consistently found positive results like social skills training, community reinforcement approaches, behaviour contracting, motivation-enhancing treatment, and family/marital therapy. There is also a number of commonly used treatment approaches that brought neither a positive result or were counter productive like relapse prevention, non-behavioural marital therapy, and insight psychotherapy, confrontational counseling, education, relaxation training, and milieu therapy. Support for matching to a specific treatment is weak, but interventions against alcohol problems should be differentiated according to the severity of the alcohol problem. Since treatment evaluation is mainly accomplished in the US and supplying structures with respect to the US and Germany are substantially different, a generalized transmission of US-American research results on Germany is to be evaluated carefully. Randomized-controlled studies are needed in Germany.

Buhler KE; Bardeleben H. Heuristic cluster analysis of alcoholics according to biographic and personality features. Addiction Research & Theory 16(5): 453-473, 2008. (55 refs.)

Aims: In spite of the impact of biographical factors on alcoholism and on the therapy of alcoholics, there are few studies that statistically investigate the biographical data of alcoholics. This is the reason why biographical variables in addition to personality variables are taken into consideration in our investigation. Design: At the end of detoxification the "Biographic Questionnaire for Alcoholics" (BIOQUESTAL) was administered. The BIOQUESTAL was used because its biographic scale and its personality scales represent a biographic questionnaire and a personality questionnaire as well. Setting: The patients were consecutively admitted to in-patient treatment. The treatment consisted of clinical management, detoxification from alcohol, and the administration of tranquiliser and clomethiazol, if necessary. What was very important in our procedure was the motivation for long-term treatment in a special clinic for alcoholics. Participants: The random sample consisted of 924 alcoholics (ICD-10: F 10.2). The modal value for age was 38 years. In the sample, 75% was males and 25% females, and 31.7% were single, 42.5% married, 23.5% divorced and 2.3% widowed. Measurements: The BIOQUESTAL is appropriate for the assessment of the biography of alcoholics and for their clinical classification. The dimensions of the scales were constructed by factor analysis, by multidimensional scaling and by cluster analysis of the items. From the data, three oblique rotated factors were extracted: Scale 1: "neuroticism," 15 items; Scale 2: "favourable versus unfavourable primary socialisation, " 12 items; Scale 3: "unspecific motivation and orientation to future," I I items. The reliability of these scales is high. Findings: The five-cluster solution was accepted, yielding an easily interpretable classification. The least impaired cluster is cluster 2 (named: normovalent or syntonous cluster) followed by cluster 4 (named: neurotic aim-related cluster), cluster 1 (named: sociodeprivative cluster), cluster 5 (named: neurotic aimless cluster) and cluster 3 (named: socioneurotic cluster). The syntonous cluster 2 is significantly (F-test; p < 0.001) the eldest cluster and the socioneurotic cluster 3 the youngest one. Female subjects prevail significantly in clusters with higher severity of impairment, i.e. in the socioneurotic cluster 3 and in the neurotic aimless cluster 5. Subjects of the syntonous cluster 2 originate significantly less often from broken homes, whereas subjects of the socioneurotic cluster 3 originate significantly more often from such situations. Subjects of the syntonous cluster 2 were significantly more often brought up by their parents, whereas subjects of the socioneurotic cluster 3 and the neurotic aimless cluster 5 were significantly less often brought up by their parents. Subjects of the syntonous cluster 2 and the neurotic aim-related cluster 4 significantly less often spent their life as singles than the rest of the clusters. Conclusions: The questionnaire is also suitable for the selection of alcoholics and for allocation to appropriate therapy settings. Thus, the reported clusters of alcoholics have not only a descriptive or classificatory importance but also, considering the severity of impairment attributed to the clusters, an impact on differential therapy with regard to the severity of impairment.

Buhringer G. Allocating treatment options to patient profiles: Clinical art or science? Addiction 101(5): 646-652, 2006. (49 refs.)

Background; For many researchers, the disappointing results of Project MATCH were the death blow for any further activities in the field of patient-treatment interactions. On the other hand, we have an increased knowledge of patient heterogeneity and a greater variety of treatment options than before, and allocation guidelines for an ongoing process of patient-placement decisions are of high practical relevance. Aims: To analyse deficits in the current research and to provide suggestions for future action. Findings: It is argued that (1) certain major design aspects of Project MATCH and other research studies-such as stringent patient exclusion criteria and low treatment 'dosage'-minimize the chances of detecting possible patient-treatment interactions and (2) Project MATCH obscures our view of previous treatment-allocation research findings. Conclusions: Several research strategies and specific research topics are suggested for (1) improving the theoretical and methodological basis for detecting possible patient-treatment interactions and (2) stimulating research on major treatment decision needs, such as site, setting, time in treatment (extensiveness and intensity), service components and specific treatment modules. More international research cooperation is needed to clarify the inconsistent findings.

Buhringer G. Research on treatment for substance-use disorders: A case for evolution or revolution? Reply to the commentaries. Addiction 101(5): 655-656, 2006. (4 refs.)

Callaghan RC; Taylor L. Mismatch in the transtheoretical model? American Journal on Addictions 15(5): 403-403, 2006. (12 refs.)

A response to the article "Readiness and stages of change in addiction treatment," by C.C. DiClemente, D. Schlundt, L. Gemmell, that was published in the American Journal of Addictions 2004 is presented.

Carroll KM. Matching and differtial therapies. IN: Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. pp. 637-662. (117 refs.)

Despite the emergence of new treatment approaches, including drug therapies, the goal of matching treatment and client characteristics remains in its infancy. There is discussion of these efforts in terms of alcohol dependence, cocaine dependence, and opiate dependence and newer modalities such as contingency management and manualized approaches.

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

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

Collins SE; Torchalla I; Schroter M; Buchkremer G; Batra A. Development and validation of a cluster-based classification system to facilitate treatment tailoring. Journal of Methods in Psychiatric Research 17(Special Issue 1): s65-s69, 2008. (23 refs.)

Aims: The objectives of this study were to replicate smoker profiles identified in Batra et al. (in press) and to develop a cluster-based classification system to categorize new cases into smoker profiles so that an appropriate tailored intervention could be applied. Methods: Participants were smokers in southwest Germany who sought treatment for smoking cessation. In the first sample, discriminant analysis was used to create classification formulas for a future study (classification sample: n = 165). The second sample served to replicate the smoker profiles, which included participants reporting symptoms of hyperactivity/novelty-seeking, depressivity or high nicotine dependence as well as participants scoring low across smoking and psychological variables (replication sample: N = 134). Results: Part 1 was focused on the development of formulas, using Fisher's coefficients, with which new cases could be classified. Part 2 adequately replicated previous findings concerning the smoker profiles, such that 70% of participants in the second sample were classified identically using cluster analysis and classification formulas. Conclusions: The smoker profiles found in a previous study were replicated, and a classification system was developed for a future study which will test the efficacy of tailored treatments for the different smoker profiles.

Connors GJ; Miller WR; Anton RF; Tonigan JS. Clinical assessment: Measuring matching characteristics and treatment outcomes. IN: Babor TF; Del Boca FK, eds. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 29-41. (275 book refs.)

The clinical assessment procedures used to screen research volunteers for inclusion in the treatment research project, Project MATCH, are described. The assessment procedures provided a clinical description of the study participants, assessed matching attributes, and measured treatment outcomes. This book chapter describes the criteria used to select measures, the sequencing and administration of the assessment battery, the instruments that comprised the battery, and the methodological and practical considerations involved in its administration. Section headings in this chapter include: (1) Screening for study inclusion; (2) Measuring client prognostic variables and matching attributes; (3) Measuring treatment outcomes; (4) Criteria for instrument selection: measurement of a wide range of potential matching variables; measurement of characteristics relevant to matching hypotheses; adoption of standard, widely used assessment instruments; use of instruments with acceptable psychometric properties, and corroboration of verbal reports; (5) Project MATCH assessment battery; and (6) Issues in the administration of assessment instruments, including methodological considerations and practical considerations. The Project MATCH assessment battery is summarized in a table.

Public Domain

Cooney NL; Babor TF; DiClemente CC; Del Boca FK. Clinical and scientific implications of Project MATCH. IN: Babor TF; Del Boca FK, eds. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 222-237. (275 book refs.)

The clinical and scientific implications of the patient-treatment matching study, Project MATCH, are discussed. The following results of the study are presented: (1) a small number of matching effects; (2) a suggestion that clinical efficacy may be improved in some cases if clinicians take into account certain client characteristics: trait anger, alcohol dependence, social support for drinking, and psychiatric severity; (3) a suggestion that affiliation with Alcoholics Anonymous (AA) may be increased with Twelve Step Facilitation (TSF); (4) a suggestion that increased involvement in AA may be associated with long-term sobriety; (5) a suggestion that the Twelve Step approaches and AA may promote sobriety because they provide an alternative social network that does not support alcohol consumption. Section headings in this book chapter include: (1) Treatment matching; (2) Choice of therapy; (3) Outpatient versus Aftercare treatment; (4) Alcoholics Anonymous attendance; (5) Prognostic characteristics; (6) Best practices; (7) Implications for theory and research; and (8) Methodological implications.

Public Domain

Covington SS. Women and addiction: A trauma-Informed approach. Journal of Psychoactive Drugs Supplement 5: 377-385, 2008. (29 refs.)

Historically, substance abuse treatment has developed as a single-focused intervention based on the needs of addicted men. Counselors focused only on the addiction and assumed that other issues Would either resolve themselves through recovery or would be dealt with by another helping professional at a later time. However, treatment for women's addictions is apt to be ineffective unless it acknowledges the realities of women's lives, which include the high prevalence of violence and other types of abuse, A history of being abused increases the likelihood that a woman will abuse alcohol and other drugs. This article presents the definition of and principles for gender-responsive services and the Women's Integrated Treatment (WIT) model. This model is based on three foundational theories: relational-cultural theory, addiction theory, and trauma theory. It also recommends gender-responsive, trauma-informed curricula to use for women's and girls' treatment services.

Covington SS; Burke C; Keaton S; Norcott C. Evaluation of a trauma-informed and gender-responsive intervention for women in drug treatment. Journal of Psychoactive Drugs Supplement 5: 387-398, 2008. (66 refs.)

There is growing recognition of the complex needs of women with dual diagnoses of substance abuse and mental health disorders. Recent research indicates that 55% to 99% of women with co-occurring disorders have experienced trauma from abuse and that abused women tend to engage in self-destructive behaviors. These women often are not well served by the services found in their Communities, which separate substance abuse and mental health programs, despite the fact that research shows that integrated, trauma-informed treatment services will increase the success of their recovery. A recent study examined the use of two gender-responsive, trauma-informed curricula presented in a residential facility for women, 55% of whom had criminal histories. Helping Women Recover and Beyond Trauma are both manualized programs founded on research and clinical practice and are grounded in the theories of addiction, trauma, and women's psychological development. This treatment model is named "Women's Integrated Treatment" (WIT). Women who successfully completed the programs were assessed at several points in time on several scales, including trauma symptomology, depression, and substance use before and after the programs. The findings indicated less substance use, less depression, and fewer trauma symptoms (p <= .05)-including anxiety, sleep disturbances, and dissociation-after participation in the WIT curricula.

Cutler RB; Fishbain DA. Are alcoholism treatments effective? The project MATCH data. BMC Public Health 5: AR 76, 2005. (27 refs.)

Background: Project MATCH was the largest and most expensive alcoholism treatment trial ever conducted. The results were disappointing. There were essentially no patient-treatment matches, and three very different treatments produced nearly identical outcomes. These results were interpreted post hoc as evidence that all three treatments were quite effective. We re-analyzed the data in order to estimate effectiveness in relation to quantity of treatment. Methods: This was a secondary analysis of data from a multisite clinical trial of alcohol dependent volunteers (N = 1726) who received outpatient psychosocial therapy. Analyses were confined to the primary outcome variables, percent days abstinent (PDA) and drinks per drinking day (DDD). Overall tests between treatment outcome and treatment quantity were conducted. Next, three specific groups were highlighted. One group consisted of those who dropped out immediately; the second were those who dropped out after receiving only one therapy session, and the third were those who attended 12 therapy sessions. Results: Overall, a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up. Effect size estimates showed that two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero treatment group. Outcomes for the one session treatment group were worse than for the zero treatment group, suggesting a patient self selection effect. Nearly all the improvement in all groups had occurred by week one. The full treatment group had improved in PDA by 62% at week one, and the additional 11 therapy sessions added only another 4% improvement. Conclusion: The results suggest that current psychosocial treatments for alcoholism are not particularly effective. Untreated alcoholics in clinical trials show significant improvement. Most of the improvement which is interpreted as treatment effect is not due to treatment. Part of the remainder appears to be due to selection effects.

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

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

Del Boca FK; Mattson ME; Fuller R; Babor TF. Planning a multisite matching trial: Organizational structure and research design. IN: Babor TF; Del Boca FK, eds. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 15-28. (275 book refs.)

The organizational structure of Project MATCH, the research design, and the rationales behind the choices that were made are presented. The research design was developed within the framework of a cooperative agreement between 23 investigators, agency staff and consultants. The design consisted of two parallel matching studies of outpatient care and aftercare. The studies differed in terms of their recruitment methods and the treatment stage of study participants. Three theoretically derived psychosocial interventions were selected for use in a randomized clinical trial of client-treatment matching. These interventions were Cognitive-behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), and Twelve Step Facilitation. Section headings in this book chapter include: (1) Rationale for a multisite clinical trial; (2) Organizational structure including the Project MATCH Research Group, funding agency (National Institute on Alcohol Abuse and Alcoholism, NIAAA), coordinating center, clinical research units; (3) Project management; (4) communication and coordination; and (5) research design, including two parallel studies, critical decisions, random assignment, matching strategy, treatment selection, absence of an untreated control group, follow-up evaluations, overview of client participation. The research design for the outpatient and aftercare arms is presented in graphic format.

Public Domain

Dennis ML; Stevens SJ. Maltreatment issues and outcomes of adolescents enrolled in substance abuse treatment. Child Maltreatment 8(1): 3-6, 2003. (14 refs.)

Although they are mandated reporters and work regularly with youth who have experienced abuse and trauma, many substance abuse treatment programs do not systematically screen for or address child maltreatment issues. This special issue provides a collection of articles that consistently demonstrate the feasibility of systematically screening for victimization among adolescents entering these programs and documents that multiple co-occurring types of victimization are actually the norm. Other articles in the section examine how levels of abuse and traumatic victimization are associated with aspects of adolescent substance use disorders, traumatic distress symptoms, co-occurring somatic and health problems, HIV risk behaviors, and a victim-to-abuser spiral. Finally, the articles address how this might affect treatment matching across levels of care. This introduction provides an overview of the articles and then highlights some of the key implications of this collective body of work for practice, policy, and future research.

DiClemente CC. Addiction and Change: How Addictions Develop and Addicted People Recover. New York: Guilford Press, 2003. (Chapter refs.)

While the stages-of-change model is widely known as a framework for understanding recovery, less sustained attention has been given to the stages of becoming addicted. This volume by one of the co-developers of the transtheoretical model, considers the continuum of addictive behavior change. It applies the transtheoretical model to the emergence and establishment of addiction, as well as recovery. The book with 13 chapters is organized into four sections. The first section sets forth framework of addiction, and elaborates the stags of change model. Section II is directed to the processes common to the development of an addiction. Section III focuses upon the recovery process from precontemplation to taking action for change and establishing a solid recovery. Section IV deals with matching clients to the process of change, including their application to prevention as well as treatment. Throughout attention is directed to multiple areas of life functioning--including relationships, beliefs and attitudes, enduring personal characteristics, and social systems-- and how these interact with change processes in addiction and recovery.

DiClemente CC; Carroll KM; Miller WR; Connors GJ; Donovan DM. Look inside treatment: Therapist effects, the therapeutic alliance, and the process of intentional behavior change. IN: Babor TF; Del Boca FK, eds. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 166-183. (275 book refs.)

Therapist effects, the therapeutic alliance, and the process of intentional behavior change are discussed with a focus on the three treatment methods (Cognitive-Behavioral Therapy or CBT; Motivation Enhancement Therapy or MET; Twelve Step Facilitation or TSF) studied in Project MATCH. The authors conclude that motivation and self-efficacy prior to treatment are the most powerful predictors of posttreatment drinking. Client evaluations of the Working Alliance predicted drinking better than therapist reports. Client reports of activities designed to cope with changes in drinking behavior predicted future drinking better than treatment condition or objective ratings of within-treatment activities. Measured at entry into, during, and at the end of treatment, self-evaluations interacted with changes in drinking behavior and predicted successful and unsuccessful outcomes. With the exception of a few outliers, therapists within the three methods produced similar retention in treatment and comparable drinking outcomes. The three treatments affected client attitudes and coping in similar ways. Section headings in this book chapter include: (1) treatment dimensions and the process of behavior change; (2) the treatments; (3) the therapists; (4) the working alliance; (5) client satisfaction with treatment; and (6) the process of intentional behavioral change. Sample items from the client version of the Working Alliance Inventory and sample items from the experiential and behavioral processes of change scale are presented in table format.

Public Domain

Dijkstra A; Conijn B; De Vries H. A match-mismatch test of a stage model of behaviour change in tobacco smoking. Addiction 101(7): 1035-1043, 2006. (35 refs.)

Aims: An innovation offered by stage models of behaviour change is that of stage-matched interventions. Match-mismatch studies are the primary test of this idea but also the primary test of the validity of stage models. This study aimed at conducting such a test among tobacco smokers using the Social Cognitive Stage Model. Design: A match-mismatch field-experiment was conducted in which smokers and ex-smokers in different stages were assigned randomly to one of three information conditions. Participants: Smokers in the pre-contemplation stage, the contemplation stage and the preparation stage, and ex-smokers in the action stage (n = 481), who were recruited through mass media, were assigned randomly to one of three information conditions. Intervention In each of the three information conditions, participants received a four- to six-page computer-tailored letter designed to: (1) increase the positive outcome expectations of quitting, (2) decrease the negative outcome expectations of quitting or (3) increase self-efficacy. Measurements: Forward stage transition was the primary outcome measure, which was assessed 2 months after the participants received the information. Findings At the 2-month follow-up, the matched interventions were significantly more effective in stimulating forward stage transition (44.7%) than were mismatched interventions (25.8%; odds ratio = 2.78; confidence interval = 1.85-4.35). Conclusion The present study provides experimental support for the benefits of stage-matching and for the validity of the Social Cognitive Stage Model.

Donovan DM; Carroll KM; Kadden RM; Diclemente CC; Rounsaville BJ. Therapies for matching: Selection, development, implementation, and costs. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 42-61. (275 book refs.)

The selection, development, implementation, and costs of therapies used in the treatment research project, Project MATCH, are discussed. Three therapies were chosen: Cognitive-Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), and Twelve Step Facilitation (TSF). In this book chapter, the therapies are described, with a focus on selection, training, supervision, and monitoring of therapists; evaluation of interventions in terms of discriminability; procedures for dealing with clients; and costs involved. The therapies selected were capable of producing a strong working alliance between clients and therapists. More than 80 therapists were trained and supervised to deliver these therapies. The costs of the therapies in community settings, although more expensive than typical outpatient treatment, were considered to be reasonable given their quality and potential effectiveness. Section headings in this chapter include: (1) Selection of therapies, including criteria used; (2) Description of the therapies, including CBT, MET, and TSF; (3) Internal versus external validity; (4) Implementation of the therapies, including development of treatment manuals, selection of therapists, therapist training, ongoing supervision of therapists, treatment compliance, discriminability of the therapies, unique versus nonspecific treatment components; (5) Clinical deterioration guidelines; and (6) Costs of Project MATCH therapies. Contrasts among Project MATCH therapies are presented in table format.

Public Domain

Duffy SQ; Dunlap LJ; Zarkin GA. Client Choice among Standard Outpatient, Intensive Outpatient, Residential, and Inpatient Alcohol Treatment in State-Monitored Programs. Chapter 5. Council CL, ed. IN: Health Services Utilization by Individuals with Substance Abuse and Mental Disorders. Analytic Series A-25. Rockville, MD: Office of Applied Studies, 2004. pp. 79-106. (30 refs.)

Treatment for those with substance use disorders has evolved over the years from a largely inpatient to a largely outpatient activity. Several studies conducted in the mid-1980s concluded that outcomes were the same for both treatment settings, and, because outpatient treatment is less costly, it was more cost-effective. Those findings, coupled with the growth of managed behavioral health care led treatment to shift from predominantly inpatient to predominantly outpatient settings. By 1998, 89 percent of the almost 1 million individuals in treatment for substance use disorders were in some form of outpatient treatment. In this chapter, we extend the research on treatment-setting choice by examining the association between characteristics of alcohol-abusing clients and admission to State-monitored inpatient hospital (IPH), short- or long-term residential (STR or LTR), IOP, or SOP rehabilitation treatment settings. Earlier studies of the choice between inpatient and outpatient treatment showed that both alcohol disorder severity factors, such as frequency of use, and socioeconomic variables, such as homelessness and employment status, were associated with admission or referral to inpatient versus outpatient treatment. In this chapter, we study the choice of admission to one of five types of treatment settings among those in the State-monitored treatment sector of two States to examine whether it is appropriate to combine types of inpatient and outpatient treatment into two broad choices for analyses of this population. Then we explore whether the same general findings regarding the associations between client severity and socioeconomic variables and treatment-setting choice are revealed when the determinants of treatment-setting choice are examined in a five-choice model. Our findings suggest that it is preferable to examine treatment-setting choice as a five-setting choice rather than collapsing it into an inpatient versus outpatient choice. We find that the key distinctions among clients occur between SOP and all other clients. Those who enter SOP treatment have less severe alcohol disorders and are more likely to be employed than are those who enter any other type of setting.

Duffy SQ; Zarkin GA; Dunlap LJ. Do Client Characteristics Affect Admission to Inpatient Versus Outpatient Alcohol Treatment in Publicly Monitored Programs? Chapter 4. Council CL, ed. IN: Health Services Utilization by Individuals with Substance Abuse and Mental Disorders. Analytic Series A-25. Rockville, MD: Office of Applied Studies, 2004. pp. 53-78. (53 refs.)

Alcohol use disorders cost the United States some 100,000 lives and $184.6 billion annually, and 14 million people meet the diagnostic criteria for alcohol abuse and alcoholism. The Nation spends approximately $6.1 billion per year on treatment for those with alcohol use disorders, 63 percent of which is funded by Federal, State, and local governments. Of the more than 1.5 million admissions annually to substance abuse treatment facilities in the United States, almost 50 percent list alcohol as the primary substance of abuse. Substance abuse treatment policy is largely a State responsibility, especially since the establishment of the Federal Substance Abuse Prevention and Treatment (SAPT) block grant program in 1981. Descriptive evidence suggests that substantial variations in treatment systems may exist across States. For example, in 1989, per capita alcohol treatment funding varied from $5.85 in Mississippi to $51.76 in Alaska. In 1998, the proportion of clients admitted to inpatient treatment varied from 3 percent of all substance abuse treatment clients in Vermont to 30 percent in North Dakota. Typically States have insufficient publicly funded treatment capacity. One way in which many States attempt to improve care and make the best use of their limited resources is by implementing guidelines to help place clients receiving publicly funded treatment in different levels of care. The purpose of this study is to estimate the effect of disorder severity on the odds of inpatient admission and to explore how that effect varies across States. We extend the analysis of treatment admission to the publicly monitored treatment systems in several States. We examine whether variables, such as age of first intoxication, employment, and housing status, which research has found are associated with referral to inpatient treatment are correlated with inpatient admission. Also, we examine the extent to which the estimated relationships vary across States. Our findings suggest that, although there are differences across States in client characteristics and in the effect of these characteristics on admission, clients with more severe substance use disorders generally are more likely to receive inpatient treatment. The results suggest that States' attempts to manage their substance abuse treatment resources effectively are meeting with some success.

Ellerbeck EF; Choi WS; McCarter K; Jolicoeur DG; Greiner A; Ahluwalia JS. Impact of patient characteristics on physician's smoking cessation strategies. Preventive Medicine 36(4): 464-470, 2003. (26 refs.)

Background. The effectiveness of smoking cessation interventions may be influenced by a variety of patient characteristics, including level of nicotine addiction and readiness to change. We conducted this study to examine the relationship between these characteristics and the frequency of physician-initiated smoking cessation interventions. Methods. We identified smokers seen during office visits to I of 38 primary care physicians in rural Kansas. Trained students observed the frequency and nature of doctor-patient discussions related to tobacco. Telephone surveys were conducted with these patients I to 3 days after the office visit. Results. We completed observations and telephone surveys on 259 smokers. Tobacco-related discussions occurred during 66% of doctor-patient encounters. Although discussions overall were unrelated to a patient's readiness to quit, specific assistance with smoking cessation was offered less often to precontemplators (15%) than to contemplators (31%) or those preparing to quit (37%) (P < 0.05). While bupropion was discussed with 23% of smokers, nicotine replacement therapy was discussed with 12% and was unrelated to markers of nicotine addiction. Conclusions. Current efforts to promote smoking cessation are only marginally related to patient characteristics. Doctors are missing many opportunities to effectively intervene with patients who are contemplating smoking cessation or preparing to quit.

Finney JW. Matching clients to psychosocial treatments: At the cusp of hope and evidence? (editorial). Addiction 103(2): 239-240, 2008. (14 refs.)

This commentary addresses the negative findings of the United Kingdom major study of treatment matching, which parallel those of the earlier U.S. treatment matching research, Project Match. The author points out that in light of these robust findings, one would need to think carefully about what factors may have obscured an effect if indeed one exists. After considsering several, he notes that he has little optimism that a basis of treatment matching will be identified in the foreseeable future.

Fisher GL; Harrison TC. Substance Abuse: information for School Counselors, Social Workers, Therapists, and Counselors, 3rd edition. Boston: Pearson/Allyn and Bacon, 2005. (650 book refs.)

This volume is directed not to those who work in the substance abuse field, but to the range of mental health professionals who while not exclusively involved with substance abuse can anticipate a significant proportion of their clients to have substance abuse problems. The first chapter provides an overview of the book, and considers the need for generalist training. Chapter 2 deals with the major drug classes, the acute and chronic effects, with sections on central nervous system depressants, central nervous system stimulants, opioids, hallucinogens, cannabis, inhalants, steroids, and club drugs. Chapter 3 focuses upon different models of addiction: the moral model, sociocultural and psychological models, the disease concept, and the biopsychosocial model. Chapter 4 considers the major cultural and ethnic groups in the US -- Native Americans and Alaska natives, Asian Americans, African Americans, Latino and Hispanics -- and general principles in working with culturally and ethnically diverse populations. Chapter 5 addresses assessment and diagnosis; Chapter 6, engaging the client and brief interventions; and Chapter 7 treatment approaches and settings, principles of effective treatment, and client-treatment matching. Chapter 8 focuses upon relapse prevention and the process of recovery. Chapter 9 deals with Twelve-Step programs as well as other types of support groups. Chapters 10 and 11 consider the family and children in the family, and adult children. Chapter 12 focuses upon HIV/AIDS. Chapter 13 provides an overview of a variety of other addictions including gambling. The final chapters deal with prevention and confidentiality and ethical concerns.

Foss MA; Barron N; Arfken CL. Identifiy service needs among substance abuse treatment participants. IN: Stephens RC; Scott CK; Muck RD, eds. Clinical Assessment and Substance Abuse Treatment: The Target Cities Experience. Albany NY: State University of New York Press, 2003. pp. 55-72. (156 book refs.)

It is recognized that clients have multiple problems, and the outcome of treatment is dependent upon the manner in which co-occurring problems are addressed. Thus a major goal of the Target Cities program was to address the range and diversity of problems accompanying substance use. Presented here is a methodology for efficiently identifying common profiles, that doesn't focus upon different sub-segments (such as dual diagnosis). The method presented allows for conducting a system-side, comprehensive needs assessment. Differences found among various sites are highlighted, pointing to the need to conduct a local assessment. Based on the range of scores, seven clusters of clients were identified marked by elevated or lever (vis a vis the treatment sample, not the general population), such as those in terms of medical and psychiatric services with elevated substance use; those living alone without social supports; or those with legal problems but not other elevated levels of problems; those with family and social problems and elevated substance use problems, but not elevated employment or legal difficulty.

Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. (Chapter refs.)

This is the third edition of a major reference work in the field of addiction medicine, which was created by the founders of the American Academy of Addiction Psychiatry (AAAP) It is organized into five major sections, with a total of 28 chapters and 51 contributors. This volume provides historical background, diagnostic process and assessment, diagnostic tools, substance specific discussions of the major drug classes, covers the full range of treatment approaches and how these can be adapted to the needs and characteristics of special populations. It also discusses other "behavioral" addictions such as gambling disorders. Section I deals with the foundations of addiction medicine, the neurobiology of substance dependence and the historical and social context of psychoactive substance use disorders. Section II is directed to assessment, both psychological evaluation in adolescents and adults, and laboratory testing. Section III deals with major drug classes: alcohol, nicotine, opiates, marijuana, hallucinogens, and club drugs, cocaine and stimulants, and sedative/hypnotics and benzodiazepines. Section IV considers special populations and special issues: comorbidity, polysubstance abuse; women; the elderly; the workplace; HIV/AIDS; pain; pathological gambling and other "behavioral" disorders. The final section is directed to treatment: individual psychodynamic psychotherapy; cognitive therapy, group therapy; self-help; family-therapy; adolescent treatment; and treatment matching.

Friedmann PD; Hendrickson DC; Gerstein DR; Zhang ZW. The effect of matching comprehensive services to patients' needs and drug use improvement in addiction treatment. Addiction 99(8): 962-972, 2004. (35 refs.)

Aims To examine whether need-service matching in addiction treatment leads to improvements in drug use, and whether treatment duration mediates those improvements. Design, participants, measurements This analysis utilizes prospective data from a US cohort of addiction treatment patients who reported service needs beyond core rehabilitative services (n = 3103). 'Drug use improvement' is the difference between the patient's peak drug use frequency (in days per month) in the year before intake and in the year after treatment. Overall and primary use of the major illicit drugs (heroin, powder or crack cocaine and marijuana) are considered separately. 'Need-service match' means that a patient rated a service as important at intake and reported its receipt during treatment. 'Percentage of needs matched' indicates the proportion of five service domains (medical, mental health, family, vocational and housing) so matched. Findings In mixed regression models controlling for multiple factors, a greater percentage of needs matched tended to improve primary (P = 0.028, P = 0.09) and overall (0 = 0.049, P = 0.05) drug use in the follow-up year. Exclusion of treatment duration as a covariate doubled the magnitude of these coefficients. The benefits of matching were concentrated among the half of patients reporting needs in four to five rather than one to three domains, and were strongest among patients in long-term residential facilities. Addressing vocational and housing needs exerted the greatest effects. Conclusions Matching comprehensive services to needs is a useful addiction treatment practice, especially for high-need patients. Treatment duration might partially mediate its effect.

Garcia AV; Torrecillas FL; de; Arcos FA; Garcia MP. Effects of executive impairments on maladaptive explanatory styles in substance abusers: Clinical implications. Archives OF Clinical Neuropsychology 20(1): 67-80, 2005. (54 refs.)

Our study examined the relation between neuropsychological impairment of executive functions and explanatory styles, according to the Abramson model of learned helplessness in humans, in a sample of substance abusers. Thirty-eight polysubstance abusers were assessed during an abstinence period using a selective neuropsychological battery for the evaluation of the executive functions, as well as the Attributional Style Questionnaire (ASQ) for the assessment of the three dimensions of explanatory style: Internality-Externality, Stability-Instability and Globality-Specificity. Multiple regression analyses showed significant relationships among performance on different neuropsychological tasks sensitive to executive functions and characteristic cognitive styles. The results showed the performance on cognitive flexibility and response inhibition tasks is directly related to making more Internal attributions for positive situations, and inversely related to the appearance of more stable attributions for negative events. Likewise, adequate performance on working memory tasks was related to development of more global attributions for failures. These results are partially congruent with the learned helplessness model and particularly relevant for the clinical management of substance abusers and the success on the treatment and rehabilitation of these subjects.

Garner BR; Godley SH; Funk RR. Predictors of early therapeutic alliance among adolescents in substance abuse treatment. Journal of Psychoactive Drugs 40(1): 55-65, 2008. (62 refs.)

Given the importance of the therapeutic alliance in achieving positive treatment outcomes, research is needed to illuminate the factors that contribute to the development of this important relationship. The aim of the current study was to expand upon the existing literature by examining predictors of the early therapeutic alliance among adolescents treated in two outpatient programs. Use of multilevel modeling techniques revealed that the majority of the variance in adolescents' ratings of the therapeutic alliance was due to adolescent factors (91%), while the variance in therapist ratings of alliance were nearly equally divided between adolescent and therapist factors (52% vs. 48%). Participant age was found to be the only significant predictor of therapist-rated alliance, with therapists reporting higher alliances with older adolescents. Adolescents reporting higher levels of social support, greater problem recognition, and more reasons for quitting also reported higher therapeutic alliance ratings. Future research is needed to examine if early identification of adolescents with low social support and problem recognition combined with brief treatment readiness interventions can be a promising approach to help improve therapeutic engagement and post-treatment substance use outcomes.

Gastfriend D, ed. Addiction Treatment Matching: Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria. Binghamton NY: Haworth Press, 2004. (Chapter refs.)

This edited volume, organized into nine chapters, assembles the research studies of the widely used American Society of Addiction Medicine (ASAM) Patient Placement Criteria that are currently available. These studies address reliability, validity, and utility of the criteria for client classification to guide treatment planning.

Godley SH; Passetti LL; Funk RR; Garner BR; Godley MD. One-year treatment patterns and change trajectories for adolescents participating in outpatient treatment for the first time. Journal of Psychoactive Drugs 40(1): 17-28, 2008. (49 refs.)

The American Society on Addiction Medicine's Patient Placement criteria are commonly used in adolescent treatment. However, the use of these criteria and how they affect the course of treatment and interact with adolescent change has not been examined. Twelve-month treatment patterns were examined for 176 adolescents who entered their first ever episode in a treatment system using these criteria. Forty-one percent of the adolescents received additional treatment after their initial outpatient episode with over 30 unique treatment sequences (i.e., various combinations of outpatient, intensive outpatient, and residential treatment). Significant differences in treatment patterns were found between the change trajectory groups. For example, adolescents who participated in only one outpatient treatment episode were more likely to be in the low alcohol and drug use (AOD) group and less likely to have high rates of time in a controlled environment or to report moderate AOD use. Over one-third of the adolescents participated in additional treatment and almost one-quarter of those who only participated in outpatient treatment had problematic use. These findings suggest the need for clinical monitoring protocols that can be used to identify adolescents needing additional treatment or recovery services.

Graham AW; Schultz TK; Mayo-Smith MF; Ries RK; Wilford BB, eds. Principles of Addiction Medicine. Chevy Chase MD: American Society of Addiction Medicine, 2003. (Chapter refs.)

This volume is a comprehensive text on addictions. It is organized into 14 major sections, each of which has multiple chapters. There are over 200 contributors. The sections deal with the following themes: basic science and core concepts; pharmcology; diagnosis, assessment and early intervention; overview of addiction treatment; management of intoxication and withdrawal; pharmacologic interventions; behavioral interventions; 12-step programs and other recovery-oriented interventions; alcohol and drug problems in the workplace; medical disorders and complications of addiction; co-occurring addictive and psychiatric disorders; pain and addiction; and children and adolescents. There are also six appendices.

Guydish J; Stephens RC; Muck RD. Lessons learned from the National Target Cities Initiative to improve publicly funded substance abuse treatment systems. IN: Stephens RC; Scott CK; Muck RD, eds. Clinical Assessment and Substance Abuse Treatment: The Target Cities Experience. Albany NY: State University of New York Press, 2003. pp. 179-200. (156 book refs.)

At the start of the Target Cities Program, there was an effort to address problems common in substance abuse treatment in the public sector: weak infrastructure, inconsistent quality of services, limited access to treatment, inadequate coordination and continuity of services. This chapter reviews the goals of the Program and summarizes the extent to which these were addressed. The first goal, improvement of staff training was not examined. The second goal was to create a centralized intake system with standardized instruments and physical exam and psychological evaluation and protocol to matching clients with treatment programs. It was found that the least successful components were case management, and mechanisms for treatment matching. Goal 3 was to enhance clients access to social services, such as AFDC, food stamps, SSI, a goal was met. Goal 4 addressed increased access to preventive and primary care health services, there was no data collected which allowed assessment of this feature. Goal 5 was to provide case management for clients in the criminal justice system. Programs adopted different methods to accomplish this. Goal 6 focused upon the creation of a management information system to track intake, assessment, referral and outcome data, as well as charges and costs of treatment. These systems are now being created by CSAT (Center for Substance Abuse Treatment) with the hope that they will become available to public programs generally. Goal 8 addressed quality assurance systems, which were not included as part of this formal evaluation. Each of these domains is briefly discussed.

Heitjan DF; Guo M; Ray R; Wileyto EP; Epstein LH; Lerman C. Identification of pharmacogenetic markers in smoking cessation therapy. American Journal of Medical Genetics. Part B: Neuropsychiatric Genetics 147B(6): 712-719, 2008. (42 refs.)

Pharmacogenetic clinical trials seek to identify genetic modifiers of treatment effects. When a trial has collected data on many potential genetic markers, a first step in analysis is to screen for evidence of pharmacogenetic effects by testing for treatment-by-marker interactions in a statistical model for the outcome of interest. This approach is potentially problematic because (i) individual significance tests can be overly sensitive, particularly when sample sizes are large; and (ii) standard significance tests fail to distinguish between markers that are likely, on biological grounds, to have an effect, and those that are not. One way to address these concerns is to perform Bayesian hypothesis tests [Berger (1985) Statistical decision theory and Bayesian analysis. New York: Springer; Kass and Raftery (1995) J Am Stat Assoc 90:773-795], which are typically more conservative than standard uncorrected frequentist tests, less conservative than multiplicity-corrected tests, and make explicit use of relevant biological information through specification of the prior distribution. In this article we use a Bayesian testing approach to screen a panel of genetic markers recorded in a randomized clinical trial of bupropion versus placebo for smoking cessation. From a panel of 59 single-nucleotide polymorphisms (SNPs) located on 11 candidate genes, we identify four SNPs (one each on CHRNA5 and CHRNA2 and two on CHAT) that appear to have pharmacogenetic relevance. Of these, the SNP on CHRNA5 is most robust to specification of the prior. An ficant by either the Bayesian or the corrected frequentist test.

Hillemacher T; Bleich S. Neurobiology and treatment in alcoholism: Recent findings regarding Lesch's typology of alcohol dependence. Alcohol and Alcoholism 43(3): 341-346, 2008. (76 refs.)

Subtyping in alcohol dependence has become an important issue as studies have proposed different neurobiological mechanisms in alcoholism in the recent years. Studies have shown that alcohol dependence reflects a wide range of different phenotypes, including psychological, social, and neurobiological factors. Different ways of subtyping have been proposed in the last decades, one of them being Lesch's typology of alcohol dependence. Recent investigations have shown that different subtypes of Lesch's typology are associated with specific neurobiological factors which may have important implications for clinical practice. This applies in particular for genetic and neuroendocrinological factors, differences in the regulation of NMDA receptor-mediated glutamatergic neurotransmission, and in response to acamprosate and naltrexone treatment.

Hooten WM; Wolter TD; Ames SC; Hurt RD; Vickers KS; Offord KP et al. Personality correlates related to tobacco abstinence following treatment. International Journal of Psychiatry in Medicine 35(1): 59-74, 2005. (60 refs.)

Objective: The five-factor model of personality was used to describe the correlates of smoking abstinence. Methods; Following treatment in the Mayo Clinic Nicotine Dependence Center, the six month abstinence status was determined by self-report. Sixteen months to 2.4 years following the initial treatment evaluation, and 10 months to 1.9 years after the abstinence status was determined, 475 patients were mailed a Neuroticism, Extraversion, Openness, Five-Factor Inventory questionnaire. Ninety-nine abstinent and 151 smoking patients returned a completed questionnaire. Results: Multivariate analysis showed that low scores on neuroticism and openness were associated with tobacco abstinence. In addition, high scores on neuroticism and low scores on agreeableness and conscientiousness were associated with predictors of poor outcome including greater number of cigarettes smoked per day, initiation of smoking prior to age 18, and a Fagerstrom Test for Nicotine Dependence score of >= 6. Conclusions: Personality characteristics as predictors of smoking abstinence following treatment warrant further investigation in prospective clinical trails. Treatment matching using personality profiling as a guide may be a valuable tool for improving abstinence rates following treatment for nicotine dependence.

Jones HE; Johnson RE; Bigelow GE; Strain EC. Differences at treatment entry between opioid-dependent and cocaine-dependent males and females. Addictive Disorders and Their Treatment 3(3): 110-121, 2004. (43 refs.)

Objectives: This study compared the psychosocial characteristics and psychiatric diagnoses of opioid-dependent and cocaine-dependent men and women. Methods: Opioid-dependent patients fulfilled a current opioid but not current cocaine dependence diagnosis (n = 115); cocaine-dependent patients fulfilled a current cocaine but not current opioid dependence diagnosis (n = 144). All enrolled in a treatment research clinic. Participants completed a demographic questionnaire, the Addiction Severity Index, and the Structured Clinical Interview for the DSM-IV, Axes I and II. Analyses included comparisons between males (n = 153) and females (n = 106) to examine possible interactive effects of sex with primary drug of abuse. Results: Greater number and problem severity for cocaine versus opioid dependent patients was found across multiple domains, and was especially notable for alcohol problems, family/social difficulties, and psychiatric comorbidity. Women differed from men by having more medical and employment problems, higher rates of lifetime Major Depression, and lower rates of personality disorders. Discussion: There are substantial differences between cocaine and opioid dependent patients, and between females and males within dependence types. Assessment and treatment planning for patients and resource allocation by substance abuse treatment programs should recognize these differences. Efforts to match substance-abusing patients to treatments can benefit from recognition of differences between cocaine and opioid dependent females and males.

Kadden RM; Longabaugh R; Wirtz PW. Matching hypotheses: Rationale and predictions. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 81-102. (275 book refs.)

Formulation, approval, and testing of hypotheses underlying client-treatment matching are discussed, along with rationale, supporting evidence, and method for measuring the matching characteristics. Specifically, Project MATCH specified a set of 21 a priori matching hypotheses that were tested by randomly assigning clients to one of three different treatments (cognitive-behavioral therapy or CBT, motivation enhancement therapy or MET, and twelve step facilitation or TSF). The strategy permitted evaluation of a large number of matching hypotheses within the same data set and identification of the success profiles of different treatment groups. Section headings in this book chapter include: (1) Development of the matching hypotheses, including approval process; (2) Primary matching hypotheses, including alcohol involvement, cognitive impairment, conceptual level, gender, meaning seeking, motivation, psychiatric severity, sociopathy, social support for drinking, typology; (3) Secondary matching hypotheses, including alcohol dependence, anger, antisocial personality disorder, interpersonal dependency, psychopathology, prior engagement in Alcoholics Anonymous, readiness to change, religiosity, self-efficacy, and social functioning. Measurement instruments and hypothesized contrasts of slopes or differences between means for each primary and secondary matching variable are presented in table format.

Public Domain

Kalberg WO; Buckley D. FASD: What types of intervention and rehabilitation are useful? (review). Neuroscience and Biobehavioral Reviews 31(2): 278-285, 2007. (27 refs.)

Fetal alcohol spectrum disorders (FASD) occurs worldwide when children are prenatally exposed to alcohol. This paper discusses recent findings regarding the neuropsychological and behavioral effects of prenatal alcohol exposure and how it impacts the developmental and functional abilities of children with FASD. Specifically, recent research focus has concentrated on studies to elucidate a neurobehavioral phenotype for the alcohol-exposed population. As a result, the FASD field has learned what types of neurobehavioral issues occur most frequently with these children. This paper discusses how that information can be used to inform school assessment, intervention planning, and support. Strategies for functional assessment, individualized planning, structured teaching, and developments in cognitive-behavioral methods are described.

Kaminer Y; Bukstein OG. Treating adolescent substance abuse. IN: Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. pp. 559-587. (184 refs.)

It is recognized that between 7 and 10% of adolescents are in need of substance abuse treatment. The goal of this chapter is to review the trends in adolescent substance use, psychiatric co-morbidity, prevention, assessment, and the treatment aftercare continuum. The authors deals with the epidemiology, age of initiation, and prevalence by gender and ethnic groups, and etiology in terms of biological factors, environment, and parental as well as peer influences. Separate sections are devoted to prevention, assessment, level of care, and treatment. discharge and after care.

Karno MP; Longabaugh R. Patient depressive symptoms and therapist focus on emotional material: A new look at Project MATCH. Journal of Studies on Alcohol 64(5): 607-615, 2003. (23 refs.)

Objective: Matching treatment modality to patient attribute generally did not improve outcomes in Project MATCH. Untested was whether actual therapist behaviors, irrespective of treatment modality, interacted with patient attributes to improve outcomes. The present study examined whether patient depressive symptoms interacted with therapist focus on painful emotional material to predict the effectiveness of alcohol treatment. Two competing theoretical approaches to treatment effectiveness were considered in light of the results. Method: A self-report measure of pretreatment depressive symptoms was completed by 141 participants from the Providence Clinical Research Unit of Project MATCH. Therapist focus on emotional material was then judged by independent observer ratings of videotaped treatment sessions. The interaction between these patient and therapy variables was tested as a predictor of percentage of days abstinent (PDA) and percentage of heavy drinking days (PHDD) during treatment and over the first year following treatment. Results: The interaction between patient depressive symptoms and therapist emotion focus consistently predicted PDA and PHDD both during treatment and over the first year posttreatment. For patients with clinically elevated depressive symptoms, improved drinking outcomes occurred with a low therapist focus on painful emotional material. Conversely, depressed patients had worse drinking outcomes when the therapist had a high focus on emotional material. Therapist behavior did not affect drinking outcomes for patients with subclinical depressive symptoms. Conclusions: The interaction between depressive symptoms and therapist focus on emotional material was an important predictor of alcohol treatment effectiveness. The results appear to support a theory in which the reduction of patient arousal is a potential mediator of treatment effectiveness. The consistency and robustness of these findings suggest that matching actual therapist behaviors to patient attributes may improve drinking outcomes more than matching based solely on treatment modality.

Karno MP; Longabaugh R. What do we know? Process analysis and the search for a better understanding of Project MATCH's anger-by-treatment matching effect. Journal of Studies on Alcohol 65(4): 501-512, 2004. (20 refs.)

Objective: A consistent matching result from Project MATCH was the impact of patient trait anger on the effectiveness of alcohol treatments. Despite that finding, subsequent work failed to identify mechanisms underlying the effect. The present study examined a potential mediator, therapist directiveness, to determine its relationship with patient anger, treatment modality and drinking outcomes. Method: Observers rated therapist directiveness for 140 patients (70% men) at one MATCH aftercare site. ANOVA was used to test for the interaction between directiveness and patient anger, treatment differences in level of directiveness, the interaction between treatment modality and anger, and directiveness as a mediator of treatment modality effects. Results: A disordinal interaction was found between patient anger and therapist directiveness. Directiveness was associated with worse drinking outcomes among high anger patients and associated with less frequent drinking among low anger patients. Patient anger also interacted with treatment modality. Motivational enhancement therapy (MET) was more effective than cognitive behavioral therapy (CBT) for patients high in anger, whereas the reverse was true for patients low in anger. A lower level of therapist directiveness in MET mediated its superiority over CBT for high anger patients. Twelve-step facilitation therapy (TSF) was comparably effective to MET for high anger patients; it is interesting to note that TSF and MET did not differ in directiveness. Conclusions: Therapist directiveness is important to consider when working with patients at varying levels of trait anger. Analysis of the therapy process and tests for mediation are critical to further understand active ingredients of psychosocial treatment.

Kiefer F; Helwig H; Tarnaske T; Otte C; Jahn H; Wiedemann K. Pharmacological relapse prevention of alcoholism: Clinical predictors of outcome. European Addiction Research 11(2): 83-91, 2005. (40 refs.)

Objective: The efficacy of pharmacological relapse prevention in alcoholism with acamprosate and naltrexone has been supported by several controlled trials. It remains uncertain whether any differential indication for treatment exists. Methods: We evaluated outcome data of a controlled trial on acamprosate and naltrexone in patients with low vs. high baseline somatic distress, depression and anxiety (Symptom Checklist-90, SCL-90), low vs. high baseline craving, and according to typological differentiation as proposed by Cloninger and Lesch. These variables have previously been suggested to be predictors of outcome. Results: Comparing the course of abstinence rates, acamprosate was mainly efficacious in patients with low baseline somatic distress, whereas naltrexone was effective especially in patients with high baseline depression. Baseline craving showed no predictive value. Pharmacological treatment was efficacious in type II alcoholics according to Cloninger. Applying Lesch's typological differentiation, acamprosate was shown to be mainly effective in type I, whereas naltrexone revealed best treatment effects in type III and IV. Conclusion: The study supports the hypothesis that different subgroups of alcohol dependent subjects might benefit from a differential treatment with either naltrexone or acamprosate. Baseline psychopathology and especially typological differentiation might be useful in matching patients to distinct pharmacotherapeutic interventions.

Kipnis S; Miller NS. Smoking cessation treatment calls for individualized approach. Psychiatric Annals 33(9): 573-581, 2003. (49 refs.)

The goals of this article are to (1) describe the effects of nicotine on the brain; (2) describes approaches to evaluate the extent of dependence; (3) evaluate the side effects of nicotine withdrawal and assess how these and other factors influence treatment options; (4) discuss approaches to smoking cessation and management of both addiction and withdrawal symptoms.

Kuenzler A; Beutler LE. Couple alcohol treatment benefits patients' partners. Journal of Clinical Psychology 59(7): 791-806, 2003. (37 refs.)

This study explored the effects of conjoint therapy on the partner of alcoholic patients. Seventy-five alcohol abusers were randomly assigned to one of two manualized alcoholism treatments. Effects on partners were evaluated on three outcome measures. Results indicated that partner alcohol use was initially high, but was improved by treatment. An assessment of cross-cutting dimensions of patient-treatment matching, found to be effective in predicting patient response, was then applied to the prediction of partner response. These dimensions were unsuccessful in predicting changes in partner response to treatment. Results are discussed in respect to possible differences in matching partners versus clients to treatment. The statistical representation of patient-treatment matching is discussed along with other topics for future Aptitude X Treatment interaction research.

Kuntsche E; von Fischer M; Gmel G. Personality factors and alcohol use: A mediator analysis of drinking motives. Personality and Individual Differences 45(8): 796-800, 2008. (31 refs.)

Current evidence on the association between personality factors, drinking motives, and alcohol use comes exclusively from North America. The present study, however, is based on a sample of 2090 Swiss college students (mean age 23.5, SD = 2,9) and investigates by means of structural equation modeling whether drinking motives mediate the association between personality factors and alcohol use. The results revealed that extraversion was positively related to drinking for enhancement motives; conscientiousness was negatively related to both enhancement and coping motives; and neuroticism was positively related to drinking for coping motives. The association between extraversion and alcohol use was mediated by enhancement motives, while the negative association between conscientiousness and alcohol use was partially mediated by both enhancement and coping motives. This concurs with the findings of North American studies. However, in contrast to these findings, our study finds that coping motives attenuate the "protective" effect of neuroticism with regard to alcohol use. Taken together, the study indicates that alcohol use serves specific purposes depending on particular personality traits. The finding that personality-related effects are partially mediated by motives increases the likelihood that motive-based preventive efforts will help reduce alcohol use among young adults who display particular personality traits.

Kuo P-H; Aggen SH; Prescott CA; Kendler KS; Neale MC. Using a factor mixture modeling approach in alcohol dependence in a general population sample. Drug and Alcohol Dependence 98(1/2): 105-114, 2008. (43 refs.)

Alcohol dependence (AD) is a complex and heterogeneous disorder. The identification of more homogeneous subgroups of individuals with drinking problems and the refinement of the diagnostic criteria are inter-related research goals. They have the potential to improve our knowledge of etiology and treatment effects, and to assist in the identification of risk factors or specific genetic factors. Mixture modeling has advantages over traditional modeling that focuses on either the dimensional or categorical latent structure. The mixture modeling combines both latent class and latent trait models, but has not been widely applied in substance use research. The goal of the present study is to assess whether the AD criteria in the population could be better characterized by a continuous dimension, a few discrete subgroups, or a combination of the two. More than seven thousand participants were recruited from the population-based Virginia Twin Registry, and were interviewed to obtain DSM-IV (Diagnostic and Statistical Manual of Mental Disorder, version IV) symptoms and diagnosis of AD. We applied factor analysis, latent class analysis, and factor mixture models for symptom items based on the DSM-IV criteria. Our results showed that a mixture model with 1 factor and 3 classes for both genders fit well. The 3 classes were a non-problem drinking group and severe and moderate drinking problem groups. By contrast, models constrained to conform to DSM-IV diagnostic criteria were rejected by model fitting indices providing empirical evidence for heterogeneity in the AD diagnosis. Classification analysis showed different characteristics across subgroups, including alcohol-caused behavioral problems, comorbid disorders, age at onset for alcohol-related milestones, and personality. Clinically, the expanded classification of AD may aid in identifying suitable treatments, interventions and additional sources of comorbidity based on these more homogenous subgroups of alcohol use problems.

Lakey B; Ondersma SJ. A new approach for detecting client-treatment matching in psychological therapy. Journal of Social and Clinical Psychology 27(1): 56-69, 2008. (30 refs.)

Identifying the treatments that are most effective for specific clients (i.e., client-treatment matching) is a major goal of research in psychological therapy. Unfortunately, there is little evidence that clients differ in the treatments to which they respond. This could result from the use of between-subjects designs that might be insensitive to client-treatment matching. In other areas of psychology, Generalizability (G) and Social Relations Model (SRM) designs routinely obtain large, conceptually identical matching effects. The current study investigated client-treatment matching using a G/SRM design. Postpartum women with a history of drug use completed three computer-delivered treatment segments of a brief motivational intervention, and rated themselves on state motivation for change following each segment. Strong client-treatment matching effects were found when using G/SRM analyses, but not when using between-subjects analyses. G/SRM methods might be more sensitive to client-treatment matching effects than are commonly used between-subjects designs.

Longabaugh R. Section 6: Behavioral interventions. (editorial). Journal of Studies on Alcohol Supplement 15: 168-169, 2005. (2 refs.)

Longabaugh R; Donovan DM; Karno MP; McCrady BS; Morgenstern J; Tonigan JS. Active ingredients: How and why evidence-based alcohol behavioral treatment interventions work. Alcoholism: Clinical and Experimental Research 29(2): 235-247, 2005. (61 refs.)

This article summarizes the proceedings of a symposium that was organized and chaired by Richard Longabaugh and presented at the 2004 Research Society on Alcoholism meeting in Vancouver, British Columbia, Canada. The aim of the presentation was to focus on evidence for the active ingredients of behavioral therapies for patients with alcohol use disorders. Dennis M. Donovan, PhD, reviewed evidence for the active ingredients of cognitive behavioral therapy. Barbara S. McCrady, PhD, presented a conceptual model for mechanisms of change in alcohol behavior couples therapy and reviewed evidence for this model. J. Scott Tonigan, PhD, presented data testing three hypothesized mechanisms of change in twelve-step facilitation treatment. Mitchell P. Karno, PhD, presented therapy process data that tested whether matching therapist behaviors to client attribute across three therapies affected drinking outcomes. Jon Morgenstern served as discussant.

Longabaugh R; Zweben A; Locastro JS; Miller WR. Origins, issues and options in the development of the combined behavioral intervention. Journal of Studies on Alcohol Supplement 15: 179-187, 2005. (27 refs.)

Objective: The aim of the investigators was to develop a moderate intensity comprehensive behavioral treatment based on the principles of motivational interviewing and Cognitive Behavioral Therapy that, within the confines of a standardized abstinence-oriented treatment, would provide a broad spectrum of modules to assist those seeking treatment to achieve reduction of problematic drinking. Method: The core issue of how to deliver a flexible therapy tailored to the needs of individual clients while at the same time providing a standardized treatment protocol for a randomized clinical trial provided the dilemma out of which this unique standardized protocol arose. By using a single decision tree, client choice, combined with limited options, we were able to reconcile these conflicting demands. Results: Key decisions that were made in developing the treatment protocol and the thinking leading to these decisions are described. Conclusions: Understanding these key issues and the factors that led to the decisions made will assist would-be users in their own clinical and/or clinical research needs.

Magura S; Staines G; Kosanke N; Rosenblum A; Foote J; DeLuca A; Bali P. Predictive validity of the ASAM patient placement criteria for naturalistically matched vs. mismatched alcoholism patients. American Journal on Addictions 12(5): 386-397, 2003. (22 refs.)

This study examined the predictive validity of the ASAM Patient Placement Criteria for matching alcoholism patients to recommended levels of care. A cohort of 248 patients newly admitted to inpatient rehabilitation, intensive outpatient, or regular outpatient care was evaluated using both a computerized algorithm and a clinical evaluation protocol to determine whether they were naturalistically matched or mismatched to care. Outcomes were assessed three months after intake. One common ope of undertreatment (ie, receiving regular outpatient care when intensive outpatient care was recommended) predicted poorer drinking outcomes as compared with matched treatment, independent of actual level of care received. Overtreatment did not improve outcomes. There also was a trend for better outcomes with residential vs. intensive outpatient treatment, independent of matching. Results were robust for both methods of assessment. Corroboration by more research is needed, but the ASAM Criteria show promise for reducing both detrimental undertreatment and cost-inefficient overtreatment.

Mattson ME. Search for a rational basis for treatment selection. IN: Galanter M, ed. Recent Developments in Alcoholism. Volume 16: Research on Alcoholism Treatment. Methodology/Psychosocial Treatment/Selected Treatment Topics/Research Priorities. New York: Kluwer Academic, 2003. pp. 97-113. (53 refs.)

The purpose of this article is to summarize models and results of research on optimizing treatment selection. The goals of the models are to prescribe treatment that will engage and retain the client. Models are classified into two main categories: matching to single or to multiple dimensions of the patient and/or environment. Section headings in this book chapter include: (1) treatment selection models based on single patient characteristics; (2) matches reported by Project MATCH; (3) disorder severity and treatment intensity; (4) psychiatric diagnoses and individual versus relationally oriented therapy; (5) type A/type B alcoholics and interactional versus coping therapy; (6) conceptual level and treatment structure; (7) personality profiles and tailored motivational interventions; (8) emotional distress/reactance; (9) single patient characteristics matched to pharmacological therapies; (10) comorbidity: alcoholics with depression or anxiety; (11) high craving and low cognitive function; (12) multidimensional models of patient selection; (13) matching based on client resource needs and program services; (14) matching based on clients' changing status; (15) stages of change models; (16) Project MATCH a priori hypotheses; (17) self-efficacy and goal attainment; (18) readiness, importance, and confidence; (19) stepped care model; (20) the prescriptive approach to matching; (21) ASAM patient placement criteria; and (22) future prospects for research on treatment selection and matching.

McCaul ME; Petry NM. The role of psychosocial treatments in pharmacotherapy for alcoholism. American Journal on Addictions 12(Special): S41-S52, 2003. (70 refs.)

Medication treatment for alcohol use disorders often includes a psychotherapy component. The most appropriate psychotherapy to use may depend upon characteristics of the patient, the medication, the setting, and the experiences of the provider. To date, little empirical research has investigated these issues with respect to outcomes in clinical trials that combine pharmacotherapy and psychotherapy. This paper reviews seven major types of psychotherapy for treatment of alcohol use disorders: brief interventions, motivational enhancement therapy, cognitive-behavioral therapy, cue exposure therapy, behavioral treatments, behavioral marital therapy, and twelve-step therapy. The theoretical basis for and empirical evidence supporting the efficacy of the therapies are reviewed, with an emphasis on studies that provided pharmacotherapy in conjunction with psychotherapy. Directions for future research in this area are also suggested.

McGeary JE; Monti PM; Rohsenow DJ; Tidey J; Swift R; Miranda R. Genetic moderators of naltrexone's effects on alcohol cue reactivity. Alcoholism: Clinical and Experimental Research 30(8): 1288-1296, 2006. (63 refs.)

Naltrexone (NTX) reduces drinking and craving in alcoholic individuals in treatment and also in heavy drinkers. Polymorphisms in the D4 dopamine receptor (DRD4) gene and mu-opiate receptor gene (OPRM1) may moderate NTX's effects on craving. This study examined these candidate genes as moderators of the effects of NTX on cue-elicited urge to drink in non-treatment-seeking heavy drinkers. Data from the subset of 93 participants who consented for genetic testing in a larger study of medication effects were used to examine pharmacogenetic hypotheses. The non-treatment-seeking male and female heavy drinkers (62% alcohol dependent) were genotyped for the variable number of tandem repeats polymorphism in the DRD4 gene [L=7 or more (n=34), S=less than 7 (n=56)] and Asn40Asp single-nucleotide polymorphism in the OPRM1 gene [29 aspartate (Asp) carriers and 59 asparagine (Asn) homozygotes]. Ten days after randomization to NTX (50 mg) or placebo, participants completed an alcohol cue reactivity assessment. Any medication effects were all accounted for by interaction with genotype. Naltrexone increased urge for alcohol in Asp carriers across alcohol and neutral beverage cue trials and had no effect on homozygous Asn carriers. Asp40 carriers on either medication had greater decreases (from resting baseline) in mean arterial blood pressure across all beverage cue trials compared with Asn carriers. For DRD4, no differential medication effects by DRD4 polymorphism were found. Alcohol dependence diagnosis did not moderate the effects of gene and medication on cue-elicited measures. The differential responses to NTX due to variation in the OPRM1 gene may help explain conflicting results in clinical trials and suggest directions for patient-treatment matching.

Meyers K; McDermott PA; Webb A; Hagan TA. Mapping the clinical complexities of adolescents with substance use disorders: A typological study. Journal of Child & Adolescent Substance Abuse 16(1): 5-24, 2006. (38 refs.)

Because of the vast improvements in adolescent substance use assessment, it is widely recognized that adolescent substance use disorders (SUD) encompasses diverse drugs, patterns and etiologies and are characterized by extensive heterogeneity in other life domains. The next step in advancing adolescent SUD assessment is to classify adolescents with SUD into treatment-oriented typologies so that the question "What works with whom under what conditions?" can be empirically investigated. This paper: (1) identifies and describes seven subtypes of 205 adolescents with SUD in alcohol and other drug (AOD) treatment aged 12-18 years (via dimensions of delinquency, psychosocial problems, chemical dependency, and sexual risk behavior); and (2) examines whether certain patterns are distinctive among youth court-mandated to AOD treatment. Each profile type is described in terms of relative problem severity, prevalence for youth mandated to treatment through the Courts, demographics, and performance on external measures of mental health and substance use disorders. Multiple logistic regression demonstrated that three profile types yielded 75.6% accuracy (sensitivity 75.8%. specificity = 75.5%) for discrimination between court-mandated and non-court-mandated to treatment youth, even when controlled for the contributions of youth age, sex, and ethnicity. This paper discusses the need for triage to multiple treatments with varying levels of intensity for different subgroups of adolescents. If cost-effective services by setting by youth typology could be empirically identified and replicated, perhaps an empirically-guided cost-containment strategy would be developed and implemented by managed care and state government. In this way, the trend for a decline in the number and types of on-site services provided by AOD treatment programs might reverse, improving adolescent SUD outcomes.

2006, Haworth Press

Miller G. Psychopharmacology: Tackling alcoholism with drugs. Science 320(5873): 168-170, 2008. (0 refs.)

New treatments, some now in clinical trials, reflect a growing awareness that people with different genetic profiles and drinking histories may need different therapies. Behavioral interventions help many people, but they often work better when combined with drugs that help loosen the grip of addiction. Drugs such as disulfiram (Antabuse), naltrexone and acamprosate could help in treating patients suffering from alcoholism. New drugs such as Heilig is now in trials for treatment of anxious alcoholics.

Miller WR. Are alcoholism treatments effective? The project MATCH data: Response. (letter). BMC Public Health 5: AR 76, 2005. (13 refs.)

Miller WR; Longabaugh R. Summary and conclusions. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 207-221. (275 book refs.)

The findings of the patient-treatment matching study, Project MATCH, are presented and summarized. The three very different treatment methods of Cognitive-Behavioral Therapy or CBT, Motivation Enhancement Therapy or MET, and Twelve Step Facilitation or TSF produced similarly positive outcomes. The following results of the study were seen: (1) association of involvement with Alcoholics Anonymous with better outcomes; (2) modest support for matching clients to optimal treatments on the basis of pretreatment characteristics; (3) a finding that TSF was more effective than one or both of the other treatments with Outpatient clients without additional psychopathology, Outpatients with high social support for continued drinking, and Aftercare clients high in alcohol dependence; (4) a finding that MET was more effective than the other treatments for Outpatients high in anger; and (5) a finding that CBT was more effective than TSF for Aftercare clients low in alcohol dependence.

Public Domain

Moos RH. Addictive disorders in context: Principles and puzzles of effective treatment and recovery. Psychology of Addictive Behaviors 17(1): 3-12, 2003. (99 refs.)

To consider key issues in understanding effective treatment and recovery, the author reviews selected principles and unresolved puzzles about the context of addictive disorders and the structure, process, and outcome of treatment. The principles focus on the process of problem resolution, the duration and continuity of care, treatment provided by specialist versus nonspecialist providers, alliance and the goals and structure of treatment, characteristics of effective interventions, and the outcome of treatment versus remaining untreated. The unresolved puzzles involve how to conceptualize service episodes and treatment careers, connections between the theory and process of treatment, effective patient-treatment matching strategies, integration of treatment and self-help, and the development of unified models to encompass life context factors and treatment within a common framework.

Najavits LM; Crits-Christoph P; Dierberger A. Clinicians' impact on the quality of substance use disorder treatment. IN: Galanter M, ed. Recent Developments in Alcoholism. Volume 16: Research on Alcoholism Treatment. Methodology/Psychosocial Treatment/Selected Treatment Topics/Research Priorities. New York: Kluwer Academic, 2003. pp. 53-75. (93 refs.)

The impact of the individual clinician on the quality of substance use disorder treatment is discussed, with a focus on several key issues with relevance to clinical practice and to future research. The issues discussed include treatment retention and outcome, professional characteristics, recovery status, adherence to protocols, personality, beliefs about treatment, and professional practice issues. Methodologic issues involved in studying clinicians are addressed and specific recommendations are offered. Section headings in this book chapter include: (1) clinicians' impact on substance use disorder treatment retention and outcome; (2) clinicians' professional background characteristics; (3) matching patients to clinicians; (4) clinicians' recovery status; (5) adherence and competence; (6) clinicians' emotional responses (countertransference); (8) clinicians' interpersonal functioning/therapeutic alliance; (9) clinicians' personality characteristics; (10) clinicians' beliefs about substance use disorder treatment; (11) professional practice issues; (12) clinician-targeted interventions; (13) clinician selection and training; and (14) methodological issues in studying clinicians. Key studies on treatment retention and outcomes are summarized in a table.

O'Brien CP. Prospects for a genomic approach to the treatment of alcoholism. (commentary). Archives of General Psychiatry 65(2): 132-133, 2008. (16 refs.)

This commentary is a response to the article in this issue by Anton , characterized in this commentary as the latest chapter in the story of a how genomic data, may refine patient selection and improve outcome. The key research is identified which demonstrated that alcohol significantly activates the endogenous opioid system in some but not all animal and human subjects, so that part of the reward from alcohol ingestion is mediated via opioid peptides. The evidence for this is that pharmacological blockade of opioid receptors reduces alcohol drinking in a dose-related fashion and blocks the increase in dopamine in the ventral striatum associated with alcohol ingestion. Early reports eventually led to dose-ranging studies in persons with alcoholism and the demonstration that naltrexone reduces alcohol cravings and relapses to heavy drinking, but does not necessarily produce total abstinence The opioidergic mechanisms involved in alcohol reward have subsequently been elucidated in both animal models and human studies. However, the molecular mechanism of alcohol-induced opioid activation remains unknown. The activation of the endogenous opioid system leads to increased extracellular dopamine in reward structures, such as the nucleus accumbens, but this dopamine increase is blocked by naltrexone pretreatment. Presumably the perception of reward is also blocked. It has been recognized that there is great individual variability. Some patients with alcoholism show great benefit (and have remained on the medication for years), while others report no benefit. In effect there are naltrexone-responders and naltrexone non-responders. Some clinical measures have shown promise in characterizing a naltrexone responders; a candidate gene approach has led to the latest improvement in identifying naltrexone responders in advance. Such a clinically relevant biomarker could have an important influence on the DSM classification system.

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The DASIS Report. Facilities Offering Special Treatment Programs or Groups. (June 14, 2007). Rockville MD: Substance Abuse and Mental Health Services Administration, 2007. (2 refs.)

SAMHSA's National Survey of Substance Abuse Treatment Services (N-SSATS) provides information as to whether substance abuse treatment facilities offered special services. These special treatment services include specially designed treatment programs for adolescents, clients with co-occurring substance abuse and mental disorders, criminal justice clients, persons with HIV or AIDS, gays or lesbians, pregnant or postpartum women, adult women, adult men, seniors or older adults, and persons arrested for driving under the influence of alcohol or drugs (DUI) or driving while intoxicated (DWI). A total of 13,371 substance abuse treatment facilities responded to the 2005 National Survey of Substance Abuse Treatment Services and 83% of them offered at least one special program or group addressing particular needs of specific client types. Among the largest facilities the proportion was 88% and among the smallest, 72%. The most commonly offered special program or group was for persons with co-occurring substance abuse and mental disorders (38%), followed by programs for adult women (33%), adolescents (32%), DWI offenders (31%), criminal justice system clients (28%), adult men (25%), pregnant or post-partum women (14%), those with HIV/AIDS (11%), seniors (7%), and gays/lesbians (6%).

Public Domain

Orford J. Is treatment-matching dead? Comments on Buhringer (2006). (editorial). Addiction 101(5): 653-654, 2006. (6 refs.)

O'Toole TP; Freyder PJ; Gibbon JL; Hanusa BJ; Seltzer D; Fine MJ. ASAM patient placement criteria treatment levels: Do they correspond to care actually received by homeless substance abusing adults? Journal of Addictive Diseases 23(1): 1-15, 2004. (19 refs.)

We report findings from a community-based two-city survey of homeless adults comparing the level of substance abuse treatment assigned to them using the ASAM Patient Placement Criteria with care actually received during the previous 12 months. Overall 531 adults were surveyed with 382 meeting DSM-IIIR criteria of being in need of treatment or having a demand for treatment. Of those with a treatment need, 1.5% met criteria for outpatient care, 40.3% intensive outpatient/partial hospitalization care, 29.8% medically monitored care and 28.8% managed care levels. In contrast, of those receiving treatment (50.5%, 162 persons), almost all care received by this cohort was either inpatient or residential based (83.6%). Unsheltered homeless persons and those without insurance were significantly more likely to report not receiving needed treatment. Lack of treatment availability or capacity, expense, and changing one's mind while on a wait list were the most commonly cited reasons for no treatment.

Palm J. Women and men: Same problems, different treatment. International Journal of Social Welfare 16(1): 18-31, 2007. (55 refs.)

The focus on difference between men and women has been important in the development of gender-specific treatment for alcohol and drug problems. The aim of this article is to examine the views of alcohol and drug treatment staff on differences between men and women in treatment and compare men and women in treatment on issues related to staff attitudes. One data set consists of questionnaires sent to staff working with alcohol and drug problems in Stockholm County (n = 918). Another data set consists of interviews with women and men in treatment for alcohol and drug problems in Stockholm (n = 1865). The results show that staff experience differences between men and women both in their problems and in how they should be treated. Some of these differences are supported by the comparison of women and men in the client-data, but mostly the differences are relatively small or even non-existent.

2007, Blackwell Publishing

Pederson MU. Drug-free treatment of substance misusers: Where are we now, where are we heading? IN: Pederson MU; Segraeus V; Hellman M, eds. Evidence Based Practice? Challenges in Substance Abuse Treatment. NAD Monograph no. 47. Helsinki Finland: Nordic Council for Alcohol and Drug Research, 2005. pp. 11-26. (73 refs.)

A review article published in the early 1970s found that for 84 studies, that 20-25% of clients were still drug-free one year after discharge from treatment. The author notes that this figure is essentially unchanged 30 years later. It has been noted that in comparing drug treatment with other chronic illness, such as diabetes, hypertension and asthma, or obesity, depression, the outcomes are in the similar range. This chapter begins with a definition and discussion of evidence based treatment methods. Meeting the criteria set forth are the following: 12th-step treatment, contingency management, therapeutic community, motivational interviewing, family therapy, brief interventions, behavioral contracting, social skills training, aversion therapy, case management, marital therapy, community reinforcement, bibliotherapy, behavioral therapy, interpersonal/dynamic psychotherapy. It is noted that the effectiveness depends on a variety of factors. Given the range of approaches the question becomes why this accumulated knowledge has not led to improve treatment outcome, which leads to consideration of treatment matching efforts. Some of the issues which will impact treatment outcome relate to the nature of the treatment systems, the levels of staff turnover, interagency cooperation (or lack thereof) and the array of other problems which co-exist with substance use problems are discussed. It is note that any method, e.g. cognitive therapy, cannot be regarded as effective irrespective of the setting in which it is being offered. The conclusion is that evidence-based treatment methods are never better tan the treatment system that they are a part of, no better than the treatment givers' practical and interpersonal competence.

Pederson MU; Segraeus V; Hellman M, eds. Evidence Based Practice? Challenges in Substance Abuse Treatment. NAD Monograph no. 47. Helsinki Finland: Nordic Council for Alcohol and Drug Research, 2005. (Chapter refs.)

This monograph emerged from an international symposium on drug free treatment. The meeting was convened in response to calls for researchers and practitioners alike to consider the meaning of evidence-based knowledge to the development of treatment. There were feelings that despite extensive research and the introduction of a variety of wide range of evidence-based methods, it appeared that treatments were not living up to the expectations. The meetings included 9 major presentations. Several presentations consider the nature of evidence-based methodologies and their limitations, e.g. randomized trials require large numbers, involve a number exclusion criteria, making them difficult to conduct and not representative of the treatment population. It is noted too that treatment outcome is influenced as much by psychosocial factors, as witnessed by the lack of support for the treatment marching (Project Match) results. Another topic discussed was to encourage treatment programs to better document their current practices to define the treatment actually provided. In this context qualitative research tools developed in Belgium, Sweden, and Denmark are considered. Several presentations address research evidencing the impact of policy and practice (as opposed to clinical approaches) on clinical outcome. Another area addressed is that of client perspective, and models with differing degrees of distance vs. proximity and equality vs. inequality in the relationship between client and clinician. The volume is divided into four section. The first two sections focuses on the limitations of evidence-based research to guide clinical care. The third part considers alternative ways to get evidence based knowledge, including the use of qualitative methods. The final section incorporates five examples of research results of practical significance and includes consideration of motivation, therapeutic alliance, personality factors, and increasing treatment retention.

Pulford J; Adams P; Sheridan J. Unilateral treatment exit: A failure of retention or a failure of treatment fit? Substance Use & Misuse 41(14): 1901-1920, 2006. (70 refs.)

This article highlights perceived weaknesses in the current understanding of unilateral client exit from alcohol and other drug psychosocial treatment. It is argued that unilateral client exit is typically interpreted as a "failure of retention" when it could equally be interpreted as a "failure of treatment fit"; that is, the failure to deliver treatment optimally suited to actual client attendance. The results from an exploratory study conducted within a failure of treatment fit framework are presented. This study explored the possibility that short-term outpatient alcohol and other drug (AOD) treatment attendance may be an intentional service use strategy and that short-term attendees may exit AOD treatment as satisfied, successful, consumers. Standardized questionnaires were administered to clients (n = 109) starting a new treatment episode between June-August 2003 at admission and two-months post admission. Questionnaires explored the accuracy of client estimates of future appointment attendance, the reasons for short-term service exit, the satisfaction and outcome ratings of short-term clients, and the extent to which these compared with their longer-term peers. Findings suggest short-term treatment attendance is not an intentional service use strategy. However, despite attending fewer appointments than intended, most short-term participants reported significant levels of service satisfaction and problem improvement, and at a level comparable with their longer term peers. Problem-improvement was endorsed as the number one reason for short-term service exit. Implications for treatment delivery are discussed in light of these findings.

2006, Taylor & Francis

Rahav G; Teichman M; Zweben A; Del Boca FK; Mattson ME; McRee B. Client characteristics and implementation of the research protocol. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 62-80. (275 book refs.)

The treatment research project, Project MATCH, is discussed with a focus on client characteristics and implementation of the research protocol. Project MATCH required the recruitment of a large group of alcohol-dependent volunteer research project participants. The clients who participated in the Outpatient arm of the study demonstrated less severe alcohol-related problems compared to those participating in the Aftercare arm of the study, who were recruited from residential or day-hospital treatment programs. Section headings in this book chapter include: (1) Participant enrollment including client characteristics and random assignment to treatment; (2) Implementation of the research protocol, including training/supervision of the research staff and reliability of measurement; (3) Data processing and management; (4) Participation in research activities, including compliance enhancement strategies, clear communication regarding roles and responsibilities, minimizing logistical barriers, compliance monitoring, reminders and incentives, and special accommodations for "hard-to-reach" clients; (5) Research compliance including indicators of data quality, completeness, timeliness, and accuracy; (6) Correlates of research compliance; and (7) Association between compliance and treatment outcome. Characteristics of Outpatient and Aftercare clients; Rates and timeliness of data provision for each follow-up period; and Drinking outcomes by treatment compliance subgroups and treatment condition are presented in table format.

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

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

Public Domain

Ravndal E. Drug treatment in 2004: Evidence based research or qualified beliefs? IN: Pederson MU; Segraeus V; Hellman M, eds. Evidence Based Practice? Challenges in Substance Abuse Treatment. NAD Monograph No. 47. Helsinki Finland: Nordic Council for Alcohol and Drug Research, 2005. pp. 47-54. (14 refs.)

The author considers the pressures to improve treatment efforts, noting e.g. that abstinence for heroin is essentially the same as it was 20 years ago. At the same time there have been a call for more rigorous designs for program evaluation, the call for "evidence-based" methods. The author notes that attention to "evidence-based" methods can prove myopic. It ignores what might be termed clinical wisdom/experience, and the possibility that methodology drives the questions examined, rather than identifying pressing issues and selecting the research design to examine them. The author reviews the experience of Project Match in the US, which found for the most part little differences between the different treatments provided. Among potential factors is the rate of exclusion of potential clients, significant external factors, the commonalities between therapies that were not quantified, and the intentity of research which may have been therapeutic. [One client recalled name of research interviewer, but not the therapist.]

Rosenblum A; Cleland C; Magura S; Mahmood D; Kosanke N; Foote J. Moderators of effects of motivational enhancements to cognitive behavioral therapy. American Journal of Drug and Alcohol Abuse 31(1): 35-58, 2005. (65 refs.)

Patient treatment matching hypotheses were tested for substance users randomly assigned to a group cognitive behavioral therapy (CBT; n = 114) or a group motivational intervention (GMI; n = 116). Treatment was scheduled twice weekly for 10 weeks. Using a patient attribute by treatment interaction design with a 15-week follow-up, the study predicted that alexithymia, antisocial personality disorder (ASPD), and network support for alcohol and drug use would be associated with less substance use for CBT subjects and that hostility and lower treatment motivation would be associated with less substance use for GMI subjects. Three of the hypothesized moderators were empirically supported: alexithymia, network support for alcohol, and ASPD. Results indicate the use of assessing specific patient attributes to better inform treatment recommendations.

Short D; Frischer M. Supporting the evidence-based treatment of individual drug users: The case for 'patient profile decision analysis'. (editorial). International Journal of Drug Policy 16(3): 143-147, 2005. (18 refs.)

Practitioners treating problematic drug users face a significant challenge to (1) evaluate the evolving evidence base regarding treatment options, and (2) apply guidelines to individual patients with their unique combinations of characteristics, risks and histories. In this commentary we highlight patient profile decision analysis as a rigorous and updateable means of assisting doctors deliver evidence-based care at a more patient focused level than current guidelines. patient profile decision analysis uses decision analytical modelling to calculate the evidence-based risks and benefits of different treatment options for multiple patient profiles. The output is presented in a user-friendly decision support system, enabling doctors and patients to quickly access the data to support their decision making. We outline the main features of patient profile decision analysis and review its potential for developing profile specific guidelines for the treatment of drug users.

Smith DC; Hall JA; Jang MJ; Arndt S. Therapist adherence to a motivational-interviewing intervention improves treatment entry for substance-misusing adolescents with low problem perception. Journal of Studies on Alcohol and Drugs 70(1): 101-105, 2009. (31 refs.)

Objective: This study evaluated whether adherence to the Strengths-Oriented Referral for Teens (SORT) model, a motivational interviewing (MI)-consistent intervention addressing ambivalence about attending treatment, positively predicted adolescents' initial-session attendance. Method: Therapist adherence was rated in 54 audiotaped SORT sessions by coders who were blind to treatment-entry status. Higher adherence scores reflected greater use of MI and solution-focused language, discussion of client strengths, and dialogue with families on treatment need and options. Results: Therapist adherence during adolescent segments interacted with adolescent problem perception. Predicted probabilities of attending initial sessions increased for low-problem-perception adolescents at increasingly higher therapist adherence. Conclusions: Although replication studies are needed, the SORT model of providing MI-consistent debriefing following initial assessments appears to be a promising approach for increasing treatment entry initial support for the treatment-matching hypothesis was found for substance-misusing adolescents contemplating treatment entry

Stenius K. To profit from the variability of the system: Comments on Buhringer (2006). (editorial). Addiction 101(5): 654-655, 2006. (6 refs.)

Stout R; Del Boca FK; Carbonari J; Rychtarik R; Litt MD; Cooney NL. Primary treatment outcomes and matching effects: Outpatient arm. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 105-134. (275 book refs.)

The primary treatment outcomes and matching effects in the Outpatient arm of Project MATCH are discussed. Project MATCH tested matching hypotheses across three treatments (cognitive-behavioral therapy or CBT, motivation enhancement therapy or MET, and twelve step facilitation or TSF) in two parallel studies: one with clients recruited directly into outpatient clinics and the other with clients receiving aftercare following the completion of inpatient or day-hospital treatment. In the present book chapter, the main effects of the three treatments along with matching effects are presented for two primary outcome measures, Percent Days Abstinent and Drinks per Drinking Day. The following results are seen: (1) considerable reductions in the frequency and intensity of drinking following enrollment in Project MATCH; (2) sustained decreases over a 3-year period; (3) no consistent and clinically meaningful differences in the efficacy of the three treatments; (4) unqualified support for only 3 of the 21 a priori matching hypotheses: Psychiatric Severity, Support for Drinking, and Anger; and (5) variation of the matching effects of these attributes as a function of drinking outcome and analysis time frame. It is concluded that the sustained outcomes seen across months 4-15 and again at the 3-year follow-up are evidence that alcoholism is a treatable disorder with a long-term course that is not necessarily one of uniform deterioration.

Public Domain

Thornton C; Gottheil E; Patkar A; Weinstein S. Coping styles and response to high versus low-structure individual counseling for substance abuse. American Journal on Addictions 12(1): 29-42, 2003. (31 refs.)

We compared outcomes during and after treatment for mixed substance dependent patients (N = 143) randomly assigned to a high-structure, behaviorally-oriented (HSB) or a low-structure, facilitative (LSF) individual counseling style. We hypothesized that patients with different coping characteristics would respond differently to the two styles of counseling. Patients were treated in once-weekly individual HSB or LSF counseling for up to 12 weeks. Outcome measures included patient and counselor ratings of benefit, retention, symptom reduction and negative urines; follow-up assessments included control of substance use and psychosocial adjustment. While no differences in outcomes during or after treatment were found for the HSB and LSF patients, both groups did improve equally. Contrary to our hypothesis, our coping measures did not predict different outcomes for patients treated in the LSF and HSB soles. Post-hoc analyses, however, revealed that outcomes could be predicted in each sole from patterns of pretreatment characteristics, which included measures of coping strategies, psychological characteristics, and treatment readiness. Moreover, the patterns associated with positive outcomes were different for the HSB and LSF patients: high treatment readiness was most important for success in HSB counseling, while low psychiatric severity and positive coping styles were important for the LSF clients. The finding of no HSB-LSF outcome differences calls into question the exclusive emphasis on behavioral treatment approaches by the present-day managed care industry. Also, the traditional approach to matching studies, ie, employing one patient characteristic at a time to predict differential outcomes for particular treatments, may be simplistic. An alternative approach employing multivariate statistical procedures to predict outcomes from several patient characteristics may hold more promise.

Thornton KEB; Lazzarini A. The use of reliability techniques to predict the recovery rate of recovering alcohol addicts. Journal of the American Society for Information Science and Technology 56(4): 356-363, 2005. (4 refs.)

In this article, we describe a new means of presenting and analyzing information regarding recovering alcoholics. We show that the use of reliability life-test techniques-specifically Weibull plots-can be used not only to gain an understanding of the recovery rate of alcoholics who are undergoing counseling during their recovery process, but also to present a visual indication of the speed and nature of their recovery. We show that by considering the movement of the recovering addicts with time-as a direct analogy with the degradation of samples on device life-test-it is possible to predict the time and path that will be taken for a recovering addict to reach a given recovery stage. We also show that, in a direct analogy with overstress life-tests, it is possible to predict the "time to recovery of addict" based upon the time taken to reach a "part-way" recovery step (or stage). The results also show that those presenting with different addiction types follow varying recovery models as do those from different locations. This information could be particularly useful in providing appropriate support to those recovering from multiple addictions as well as those living in different locations. The results of this work have great potential for use in this and any other therapeutic interventions, and in medical applications such as the observed stepwise recovery from major operations and RTAs (road traffic accidents). Hence the results of this work have the potential to affect the health of the nation by enabling appropriate patient support, and, by the ensuing cost-effective support, enable the maximum number possible of patients to be supported by the limited resources of the centralized health-care umbrella.

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

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

Tonigan JS; Connors GJ; Miller WR. Participation and involvement in Alcoholics Anonymous. IN: Babor TF; Del Boca FK. Treatment Matching in Alcoholism. Cambridge, UK: Cambridge University Press, 2003. pp. 184-204. (275 book refs.)

Participation and involvement in Alcoholics Anonymous (AA) is discussed. It is noted that AA has rarely been studied with the kind of rigorous methodology used in Project MATCH, which is a study of patient-treatment matching. In this book chapter, the patterns of AA utilization, the relationship between AA participation and abstinence, and the benefits associated with AA participation are described. It is concluded that Twelve Step Facilitation (TSF) therapy was associated with increased AA attendance. Increased AA attendance was associated with increased abstinence from alcoholic beverages. The authors concluded that the findings highlight the importance of starting AA attendance during formal treatment, that there is compelling evidence for the value of AA as an adjunct to professional treatment. They suggest practical ways to maximize the potential benefits of AA through TSF. Section headings in this book chapter include: (1) prior research on Alcoholics Anonymous; (2) measurement issues of reliability and validity including Form-90, Alcoholics Anonymous Involvement Inventory (AAI), and subjective ratings of AA; (3) Outpatient and Aftercare differences; (4) treatment group differences; (5) evaluation of treatment; (6) patterns of AA utilization; and (7) AA attendance and alcohol use.

Public Domain

Turner AP; Bombardier CH; Rimmele CT. A typology of alcohol use patterns among persons with recent traumatic brain injury or spinal cord injury: Implications for treatment matching. Archives of Physical Medicine and Rehabilitation 84(3): 358-364, 2003. (84 refs.)

Objective: To describe empirically valid and clinically meaningful types of alcohol use among persons with recent traumatic brain or spinal cord injury. Design: Cross-sectional cohort survey. Setting: Acute inpatient rehabilitation program in a level I trauma center. Participants: A total of 218 (87%) of 250 consecutive initial admissions who met inclusion criteria and completed interviews. Interventions: Not applicable. Main Outcome Measures: Alcohol and drug use questionnaires, alcohol problem questions, admission toxicology results, readiness to change, and treatment preference questions. Results: Participants were on average 37 years old, 84% were men, and 82% were white. Four types were identified by using k-means cluster analysis based on pre-injury alcohol consumption, alcohol problems, and alcohol dependence. Cluster groups differed on extrinsic variables such as drug use, readiness to change, and interest in treatment or in attending Alcoholics Anonymous. The 4 types corresponded to those with a history of (1) alcohol abuse; (2) alcohol dependence; (3) alcohol dependence in remission, partial remission, or relapsed; and (4) normal or nondrinkers. Conclusion: More effective care may be possible if clinicians match common patient types to specific interventions such as education, motivational interventions, formal substance abuse treatment, and relapse prevention.

Uhl GR; Liu QR; Drgon T; Johnson C; Walther D; David SP et al. Molecular genetics of successful smoking cessation: Convergent genome-wide association study results. Archives of General Psychiatry 65(6): 683-693, 2008. (59 refs.)

Context: Smoking remains a major public health problem. Twin studies indicate that the ability to quit smoking is substantially heritable, with genetics that overlap modestly with the genetics of vulnerability to dependence on addictive substances. Objectives: To identify replicated genes that facilitate smokers' abilities to achieve and sustain abstinence from smoking (hereinafter referred to as quit-success genes) found in more than 2 genome-wide association (GWA) studies of successful vs unsuccessful abstainers, and, secondarily, to nominate genes for selective involvement in smoking cessation success with bupropion hydrochloride vs nicotine replacement therapy (NRT). Design: The GWA results in subjects From 3 centers, with secondary analyses of NRT vs bupropion responders. Setting: Outpatient smoking cessation trial participants from 3 centers. Participants: European American smokers who successfully vs unsuccessfully abstain from smoking with biochemical confirmation in a smoking cessation trial using NRT, bupropion, or placebo (N = 550). Main Outcome Measures: Quit-success genes, reproducibly identified by clustered nominally positive single-nucleotide polymorphisms (SNPs) in more than 2 independent samples with significant P values based on Monte Carlo simulation trials. The NRT-selective genes were nominated by clustered SNPs that display much larger t values for NRT vs placebo comparisons. The bupropion-selective genes were nominated by bupropion-selective results. Results: Variants in quit-success genes are likely to alter cell adhesion, enzymatic, transcriptional, structural, and DNA, RNA, and/or protein-handling functions. Quit-success genes are identified by clustered nominally positive SNPs from more than 2 samples and are unlikely to represent chance observations (Monte Carlo P<.0003). These genes display modest overlap with genes identified in GWA studies of dependence on addictive substances and memory. Conclusions: These results support polygenic genetics for success in abstaining from smoking, overlap with genetics of substance dependence and memory, and nominate gene variants for selective influences on therapeutic responses to bupropion vs NRT. Molecular genetics should help match the types and/or intensity of anti-smoking treatments with the smokers most likely to benefit from them.

Villanueva M; Tonigan JS; Miller WR. Response of Native American clients to three treatment methods for alcohol dependence. Journal of Ethnicity in Substance Abuse 6(2): 41-48, 2007

Objective: It is well-documented that American Indians suffer disproportionately high rates of alcohol use disorders as well as correspondingly high rates of alcohol based mortality, health, and social problems. Despite these health disparities, anecdotal evidence continues to guide alcohol treatment approaches in Indian Country, in part due to a dearth of clinical trials with Native Americans. Project MATCH, a multisite clinical trial, included 25 Native Americans (1.4% of the total sample) whowere randomized to three psychosocial treatments. Based on cultural compatibility, our a priori hypothesis was that Native Americans in Motivational Enhancement Therapy (MET) would fare better than those assigned either to Cognitive Behavioral Therapy (CBT) or to Twelve-step Facilitation (TSF). Method: Of 25 Native Americans in Project MATCH, 23 (92%) were interviewed at all six assessment points. Four ANOCOVA's were computed to investigate possible differential treatment response. Results: Despite a small sample, Native Americans assigned to MET reported significantly less drinking intensity relative to those assigned to CBT or TSF, with the highest proportion of abstinent days and lowest drinking intensity at both proximal and distal follow-ups. Conclusions: These findings suggest a differentially better response to MET than to TSF or to CBT among Native Americans with alcohol dependence. Although this is, to date, the largest randomized trial of treatments for alcohol dependence in Native Americans, the findings require replication.

Waldron HB; Turner CW; Ozechowski TJ. Profiles of change in behavioral and family interventions for adolescent substance abuse and dependence. IN: Liddle HA; Rowe CL, eds. Adolescent Substance Abuse: Research and Clinical Advances. Cambridge: Cambridge University Press, 2006. pp. 357-374. (58 refs.)

This is one of five chapters dealing with empirically based interventions for adolescent substance abuse -the research and practical implications. While numerous reports demonstrate the efficacy of various treatments, there is limited information on the process of change and which clients do best with which treatments. This chapter presents variety of analytic techniques, with attention to cluster analysis, that promise to assist in identifying the process of change.

2006, Project Cork

Westermeyer J. A sea change in the treatment of alcoholism. American Journal of Psychiatry 165(9): 1093-1095, 2008. (13 refs.)

This commentary deals with a paper by Gilder et al in this issue that signal to the author's mind significant changes in treating Native American populations, as well as society at large. The significant finding is the relatively high rate of 6-month remission: 59% in an ethnic group whose remission rates 25 years ago ranged from 0% to 21%. A number of factors are suggested as potentially having an impact, including changes in treatment programs that entail a better tailoring of treatment to the special needs of segments of the population, such as women, or adolescents, higher levels of staff development, as well as broader social support within the Native American community as well as the larger society.

Young RMD; Lawford BR; Feeney GF; Ritchie T; Noble EP. Alcohol-related expectancies are associated with the D-2 dopamine receptor and GABA(A) receptor beta 3 subunit genes. Psychiatry Research 127(3): 171-183, 2004. (84 refs.)

Molecular genetic research has identified promising markers of alcohol dependence, including alleles of the D-2 dopamine receptor (DRD2) and the GABA(A) receptor beta3 subunit (GABRB3) genes. Whether such genetic risk manifests itself in stronger alcohol-related outcome expectancies, or in difficulty resisting alcohol, is unknown. In the present study, A1+ (A1A1 and A1A2 genotypes) and A1-(A2A2 genotype) alleles of the DRD2 and G1+(G1G1 and G1 non-G1 genotypes) and G1-(non-G1 non-G1 genotype) alleles of the GABRB3 gene were determined in a group of 56 medically ill patients diagnosed with alcohol dependence. Mood-related alcohol expectancy (AE) and drinking refusal self-efficacy (DRSE) were assessed using the Drinking Expectancy Profile (Manual for the Drinking Expectancy Profile, Behaviour Research and Therapy Centre, Brisbane, 1996). Patients with the DRD2 A1+ allele, compared with those with the DRD2 A1 - allele, reported significantly lower DRSE in situations of social pressure. Similarly, lower DRSE was reported under social pressure by patients with the GABRB3 G1+ allele when compared to those with the GABRB3 G1 - alleles. Patients with the GABRB3 G1+ allele also revealed reduced DRSE in situations characterized by negative affect than those with the GABRB3 G1 - alleles. Patients carrying the GABRB3 G1+ allele showed stronger AE relating to negative affective change (for example, increased depression) than their GABRB3 G1 - counterparts. Biological influence in the development of some classes of cognitions is hypothesized. The clinical implications, particularly with regard to patient-treatment matching and the development of an integrated psychological and pharmacogenetic approach, are discussed.

Zywiak WH; Stout RL; Longabaugh R; Dyck I; Connors GJ; Maisto SA. Relapse-onset factors in project MATCH: The Relapse Questionnaire. Journal of Substance Abuse Treatment 31(4): 341-345, 2006. (20 refs.)

Previously, items on the relapse-onset section of the Relapse Questionnaire have been grouped together based on face validity. In the present article, an empirical scoring method for this measure is derived through a factor analysis of Project MATCH data. Three factors replicate the factor solutions of other measures of alcohol relapse onset and relapse risk. The three factors found in this study include the following: Negative Affect/Family Influences, Craving/Cued, and Social Pressure. This study also replicates earlier findings that social pressure relapses are most likely to repeat, and that negative affect relapses are more severe. Earlier studies typing relapses have hypothesized that this may be one method to detect treatment effects that might otherwise be missed if relapses are not differentiated and only generic measures (such as time to first drink) are used. This hypothesis is tested in the present article, and Motivational Enhancement Therapy is revealed to offer protection against social pressure relapses that is less than those offered by Cognitive-Behavioral Coping Skills Therapy or Twelve-Step Facilitation Therapy.

2006, Elsevier Science