Drug Abuse Treatment Outcome Study Research Articles

Religion and Substance Abuse Treatment: Individual and Program Effects

The relationship between personal religiousness and substance abuse treatment outcomes has emerged as an important issue in the public health arena. Using the “moral community” perspective, a conceptual framework developed by Stark, Kent, and Doyle (1982) to analyze the contextual effects of religion, we explore the degree to which religion influences two drug treatment outcome measures—critical retention and commitment to treatment. The data are derived from the Drug Abuse Treatment Outcome Studies (DATOS), a national study of 10,010 clients enrolled in 70 drug treatment programs. Three research questions were addressed: (1) What is the relationship between an individual's level of religiosity and retention in treatment and commitment to treatment? (2) How does the ecological context of treatment programs shape the individual‐level relationships? (3) To what extent are program practices and characteristics directly linked to outcome level? The findings are supportive of the literature that shows a weak to moderate relationship between religiosity and treatment outcomes. However, the findings did not show strong support for the “moral community” hypothesis. Although there was a wide variation in the size of the individual‐level religiosity–treatment correlations, the variation could not be conclusively attributed to the overall religious emphasis of the programs. The findings suggest that further research is needed in order to understand fully the role of religion in substance abuse treatment.

What future for the Therapeutic Community in the field of addiction? A view from Europe

What future for the Therapeutic Community in the field of addiction? A view from Europe

The Treatment of Opioid Dependence

Back to table of contents Previous article Next article Book ForumFull AccessThe Treatment of Opioid DependenceMARC GALANTER M.D.,MARC GALANTER M.D.Search for more papers by this author,Published Online:1 Sep 2006https://doi.org/10.1176/ajp.2006.163.9.1650AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Opioid dependence is manifest in a variety of syndromes, ranging from intravenous use of heroin by street addicts to excessive use of oral narcotic analgesics by middle-class pain patients. The approaches to treating these syndromes are diverse as well, ranging from psychosocially based residential therapeutic communities to pharmacological approaches such as methadone maintenance. This volume covers the broad array of these issues in a comprehensive and readable manner.It also provides a useful perspective on the history of narcotic addiction, the complexity of regulatory issues, and the epidemiology of use and abuse, all quite important in order to present a meaningful context for treatment. These issues are important. Anyone who wishes to understand why successful treatment of narcotic-addicted people is difficult to achieve will benefit from reading about how the Harrison Narcotics Act of 1914 reflected a social bias against opioid addicts, one that we still live with, and how Vincent Doe and Marie Nyswander struggled to develop methadone maintenance, achieving the first of the research-based pharmacological treatments now available.The volume draws on the important work of the editors as well as that of other leading figures in the field. David Feillin, for example, writes about office-based buprenorphine treatment, George De Leon and his colleagues about medication-free treatment, Michael Gossop about medically-supervised withdrawal, and Edward Nunes and colleagues about the pharmacology and clinical practice use of naltrexone. Methadone maintenance treatment is represented in a series of chapters ranging from the medication’s pharmacology to the organization of counseling programs.One example of the utility of the book is the clarity it provides on the many diverse entities that constitute the universe of the field. Many are represented by acronyms. Survey approaches used to determine rates of prevalence of drug abuse are described, such DAWN (the Drug Abuse Warning Network), and the MTF (Monitoring the Future) epidemiologic surveys. Assessment instruments such as the ASI (the Addiction Severity Index) and AUDIT (the Alcoholic Use Disorders Identification Test) are discussed. Approaches to evaluation such as DATOS (the Drug Abuse Treatment Outcome Study) and the TSR (Treatment Services Review) are presented as well.The volume serves as a treatment manual, in that pharmacological and psychosocial approaches as well as clinic organization are presented. This can be quite useful to the clinician working with addicted patients. Certain chapters also deal with clinical aspects of specific populations, such as women, patients under legal restriction, and adolescents.If there is a problem with this volume, it resides in the difficulty in keeping up with the changing patterns of abuse and new approaches to treatment that emerge. The recent epidemic of controlled-release oxycodone (Oxycontin) abuse is discussed, but information on its clinical and cultural manifestations would be useful. Fentanyl abuse and dependence, particularly by anesthesiologists and other physicians (and now by street addicts), is an issue that is of public health importance, and readers might want to learn about it and the complexity of its role in physician impairment.Perhaps most problematic are issues important to the clinician that neither the authors nor contemporary researchers can effectively address because of limitations in reliable empirical findings: What can be said about the long-term outcome of a variety of treatments now in use? We know relatively little about the morbidity and mortality experienced by patients who have terminated their methadone maintenance treatment, seemingly successfully. (Anecdotally, it is not good.) The same can be said about heroin addicts now being maintained in office practice receiving buprenorphine. How many will successfully come off this medication, and how many will relapse later? What role will buprenorphine play in the treatment of the variety of patients with pain syndromes? This latter use is turning out to be more common than anticipated. How long will patients continue to return for their monthly injections of depot naltrexone? Will they relapse to heroin use in the absence of intensive counseling? How effective are 12-step approaches, used widely by the residential rehabilitation community, and, similarly, what role do Narcotics Anonymous groups play in some patients" recovery? These are questions that the authors cannot answer on the basis of controlled studies but are compelling issues for clinicians, important to clinical investigators, and often overlooked by the federal government in research planning. All this leaves us with an excellent book in a field where some very important questions remain to be answered.New York, N.Y. FiguresReferencesCited byDetailsCited ByNone Volume 163Issue 9 September, 2006Pages 1650-1650THE AMERICAN JOURNAL OF PSYCHIATRY August 2006 Volume 163 Number 9 Metrics PDF download History Published online 1 September 2006 Published in print 1 September 2006

Prospective validation of substance abuse severity measures from administrative data

Background Severity measures for clients in substance abuse treatment programs are becoming increasingly important as funders adopt payment systems linked to agency performance. Recently, two severity measures based on administrative data have been developed. This study validated these measures using prospective data. Methods Subjects were participants in the Drug Abuse Treatment Outcomes Study (adult or adolescent components) or the Substance Abuse and Mental Health Services Administration Medicaid Managed Behavioral Healthcare and Vulnerable Populations project (adult or adolescent chemical dependency components). Severity measures were calculated based on data obtained at entry into substance abuse treatment. The baseline severity measures were included along with age, gender, and race/ethnicity in logistic regression models predicting abstinence at follow-up for alcohol use, marijuana use, cocaine use, or heroin use. Results For adults, the severity measures were highly statistically significant ( p < 0.001) for all models in both data sets, indicating that adults with higher severity were more likely (and much more likely in many cases) to use alcohol, marijuana, cocaine, or heroin at the follow-up interview than were those with lower severity. For adolescents, the severity measure was highly statistically significant ( p < 0.001) for marijuana in both data sets and for alcohol in the Medicaid data set. Conclusions Baseline severity measures were powerful predictors of abstinence at follow-up. These measures, derived from routinely available electronic records, appear to have noteworthy predictive validity. The severity indicators can be used for administrative purposes such as risk-adjustment when examining treatment agency performance.

Contrasting predictors of readiness for substance abuse treatment in adults and adolescents: A latent variable analysis of DATOS and DATOS-A participants

Although readiness for substance abuse treatment is a potent predictor of short-term clinical response, predictors of readiness are still poorly understood. Predictive models are customarily not predicated on dependence or abuse, but usually focus instead on intrapsychic motivational change or external contextual incentives. Based on a secondary analysis of the drug abuse treatment outcome studies (DATOS) data set for adults and a similar data set for adolescents (DATOS-A), latent variables were constructed to represent readiness for treatment, various psychosocial and behavioral features of substance use, substance-related problems and specific substance use frequency. Identical measures were used for each group. The two groups were then directly compared using a series of constrained covariance structure models. A path model using all hypothesized latent variables, treatment modality and demographics predicted Readiness for treatment in each separate group. Substance problems, a latent variable reflecting cross-substance symptoms of dependence and abuse, was the strongest predictor of Readiness for treatment in both age groups. Health problems and deviant family/peers were also strong predictors of readiness in both age groups. Demographic variables and specific substances used predicted readiness directly and indirectly in an age-specific manner. This study links readiness for substance abuse treatment to the core disorders targeted by that treatment in adults and adolescents for the first time.

DERIVED TRAIL MAKING TEST CUTOFFS AND MALINGERING AMONG SUBSTANCE ABUSERS

The Trail Making test (TMT) is often used to screen for cognitive impairment in substance abusers. A possible limitation of the TMT in clinical settings is that substance abusers may malinger and give poor effort. Data from the Drug Abuse Treatment Outcome Study (DATOS) were analyzed to develop derived TMT cutoffs. Data were analyzed to determine number of substance abusers that fell beyond the upper end of the distribution of selected derived TMT scores at the 10, 5, and 1 percentiles. These percentiles were set for alcoholics (n = 1000), cocaine abusers (n = 4306), and heroin abusers (n = 1548) for TMT selected derived scores. Inspection of the selected TMT derived scores yielded an impression that the percentile values for the 3 sub-samples of primary drugs of abuse, alcohol, cocaine, and heroin, are actually very similar at each of the 3 percentile levels. This would suggest that these estimates are actually quite stable and reinforces the notion that they may be creditable estimates. The proper use of the derived TMT cutoff scores is to alert clinicians to the increasingly higher probability of poor effort when a substance abuser in one of the three groups scores beyond the one percent cutoff for the primary drug of abuse sample. Clearly, the use of these cutoffs needs further empirical validation before they would be considered as a single source to suggest malingering. Great caution is suggested in using these cutoff scores for clinical purposes with substance abusing patients in their current state of validation. In short, further research is warranted.

Depression and hostility as predictors of long-term outcomes among opiate users.

This study used data from the national Drug Abuse Treatment Outcome Studies (DATOS) to investigate the associations that pre-treatment depression and hostility have with drug use and criminal behavior at 1 year and 5 year follow-up in patients with and without additional treatment involvement in the year prior to each follow-up. Following a naturalistic, non-experimental evaluation design, admissions to methadone treatment were followed up approximately 1 and 5 years later. Data analysis was conducted using multiple logistic regression. Eighteen programs from DATOS were included. An analytic sample consisting of 727 patients at 1 year follow-up and 432 patients at 5 year follow-up was included. Multiple logistic regression analyses revealed that greater depression predicted less drug use in the year preceding each follow-up, whereas greater hostility predicted increased drug use and more arrests at each follow-up. Furthermore, these predictive relationships appeared only among individuals not involved in additional treatment. Depression and hostility showed opposite associations with outcomes, underscoring the need to assess these psychological conditions separately and tailor treatment plans appropriately.

Effects of Comorbidity on Treatment Processes and Outcomes Among Adolescents in Drug Treatment Programs

ABSTRACT This study examined the relationship between treatment processes and posttreatment abstinence using data from the Drug Abuse Treatment Outcomes Studies for Adolescents (N = 810), with a focus on differences between adolescents with and without a comorbid mental disorder. The majority of the sample (62%) was diagnosed with at least one co-occurring mental disorder, most often conduct disorder. Overall, comorbid youth had more service needs and received more services compared with non-comorbid youth, and there were significant differences in service delivery by type of treatment modality. Posttreatment abstinence among the comorbid youth was positively associated with rapport with counselors and participation in 12-step groups while in treatment.

Introduction to 5-year followup treatment outcome studies

National evaluations of drug treatment outcomes and processes over the past 30 years have been an important source of ‘‘real-world’’ evidence for the effectiveness of treatment in the U.S. While they are more limited than experimental protocols in their capacity to establish scientific causality, they excel in documenting naturally occurring patterns of treatment delivery and patient recovery. The Drug Abuse Treatment Outcome Studies (DATOS) is the third national evaluation of community-based treatment effectiveness funded by the National Institute on Drug Abuse (Flynn, Craddock, Hubbard, Anderson, & Etheridge, 1997) following the Drug Abuse Reporting Program from the 1970s (see Simpson & Sells, 1982, 1990) and the Treatment Outcomes Prospective Study from the 1980s (see Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989). The National Treatment Outcome Research Study (NTORS) has followed the same general model to provide the first large-scale evaluation of its kind in the United Kingdom (Gossop, Marsden, Stewart, & Kidd, 2003). Sets of papers focused on 1-year outcomes and treatment process from DATOS and NTORS have been published in special issues of Psychology of Addictive Behaviors (Simpson & Curry, 1997) and Drug and Alcohol Dependence (Simpson & Brown, 1999), and evaluations of treatment for adolescents in DATOS were reported in a special issue of the Journal of Adolescent Research (Grella & Hser, 2001). Overviews of 1-year and 5-year treatment outcomes for adult cocaine users were also reported in Archives of General Psychiatry (Simpson, Joe, Fletcher, Hubbard, & Anglin, 1999; Simpson, Joe, & Broome, 2002), along with 1-year treatment outcomes for adolescents (Hser et al., 2001). Bullet reports and charts that summarize findings of 75 publications from DATOS are available on its website at www.datos.org. Outcome evaluations reported in this issue and previously were conducted by the four collaborating research cen-

Overview of 5-year followup outcomes in the drug abuse treatment outcome studies (DATOS)

Followup results from the Drug Abuse Treatment Outcome Studies (DATOS) 1-year and 5-year followups were used to describe the long-term outcomes of drug treatment and to further clarify the relationship between treatment duration and post-treatment outcomes in four treatment modalities: outpatient methadone, long-term residential (LTR), outpatient drug free (ODF), and short-term inpatient. Methods replicating those used in earlier analyses of the DATOS 1-year followup of 2,966 patients admitted to treatment in 1991–1993 and those of the Treatment Outcome Prospective Study patients admitted in 1979–1981 were employed. DATOS is a non-experimental longitudinal study conducted within the natural settings of 96 treatment programs in the U.S.A. The study followed patients during and after treatment at specified periods of time. Prevalence of drug use and behaviors were evaluated for the year prior to treatment; and the post-treatment time frames defined by the 1- and 5-year followups. In addition, the multivariate analytic technique of generalized estimating equations was used to examine the relationship of treatment duration and outcomes across both followups while also controlling for patient characteristics and pretreatment levels of behaviors. The 5-year stratified followup sample included 1,393 of the same individuals in the 1-year followup sample. Analyses were restricted to patients participating in both followups. Reductions in prevalence of cocaine use in the year after treatment (compared to the preadmission year) by patients were associated with longer treatment durations (particularly 6 months or more in LTR and ODF). In addition, reductions in illegal activity and increases in full-time employment were related to treatment stays of 6 months or longer for patients in LTR. The DATOS results from the 1-year and 5-year post-treatment followup combined suggest the stability of outcomes of substance abuse treatment. While results are generally consistent with the full 1-year followup, reduced sample size and bias of the sample toward patients with longer treatment retention may have attenuated the findings.

Patient and program factors in obtaining supportive services in DATOS

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients ( N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.

Drug-use initiation and conduct disorder among adolescents in drug treatment

This study investigated effects of drug-use initiation and conduct disorder (CD) among 1031 adolescents who participated in the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) sponsored by the National Institute on Drug Abuse (NIDA). The mean age of first drug use was 12.7 ( s. d.=2.2), 57% met DSM-III-R criteria for CD, and earlier initiators were more likely to have CD. About 78% of the adolescents with CD reported that their first CD symptom occurred prior to drug-use initiation. The proportions of adolescents who had prior treatment were similar (about 28%) across all groups, but earlier initiators reported a greater number of treatment episodes and younger ages at their first treatment. Conduct disordered adolescents revealed greater problems prior to DATOS-A treatment, but they appeared to be more motivated and ready for treatment. Although adolescents with CD still showed worse outcomes after treatment, the impact of CD appeared to lessen when pretreatment differences were controlled. To a lesser extent, adolescents who began using drugs at earlier ages had greater alcohol and drug use and other problems at intake, but their treatment outcomes appeared to be similar to later initiators. There were few significant interaction effects of initiation and CD. Findings from this study highlight the importance of better understanding the progression of drug use, treatment utilization, and psychiatric comorbidity among adolescents with substance abuse problems.

Science Is Revolutionizing Our View of Addiction—and What to Do About It

Science Is Revolutionizing Our View of Addiction—and What to Do About It

Course of alcohol problems in treated adolescents.

Knowledge of the clinical course in treated adolescents is fundamental to determining the influence of treatment on long-term functioning and the factors associated with change in the severity of alcohol problems over time. This symposium, held at the 2002 annual Research Society on Alcoholism meeting and organized by Tammy Chung and Christopher S. Martin, presented research on the course of alcohol-related problems in treated adolescents who were followed prospectively for 1 to 8 years. Presentations included (1) Alcohol use outcomes at 1 year among adolescents in the drug abuse treatment outcomes studies (DATOS-A), by Christine E. Grella; (2) Pathways and predictors of the course of adolescent alcohol problems across 1- and 3-year follow-ups, by Tammy Chung; (3) Young adult outcomes of an adolescent clinical sample at 5-year follow-up, by Ken C. Winters; and (4) Trajectories of alcohol involvement following addiction treatment through 8-year follow-up in adolescents, by Ana M. Abrantes, Denis M. McCarthy, Gregory A. Aarons, and Sandra A. Brown. Sandra A. Brown, discussant, commented on the presentations. Results from these studies indicate multiple pathways of change, distinguished by fluctuations in the chronicity and severity of alcohol problems. Across studies, most adolescents showed reductions in alcohol use and problems after treatment, with concurrent improvements in psychosocial functioning. Findings highlight the influence of other drug use on posttreatment patterns of alcohol involvement and the need to consider the effect of normative developmental transitions on the course of adolescent-onset substance use disorders.

TRAIL MAKING TEST CUT-OFFS FOR MALINGERING AMONG COCAINE, HEROIN, AND ALCOHOL ABUSERS

The Trail Making Test (TMT) is frequently used to screen for cognitive impairments in substance abusers; however, an existing problem is that substance abusers may give poor effort and the TMT results may not be valid. In this study, cutting scores for malingering were developed from three samples drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS), a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 drug abuse treatment programs in 11 cities in the United States. The DATOS enrolled 7689 substance abusers. The three drawn samples were for subjects with primary drugs of abuse. Number of subjects were as follows: alcohol-1000, cocaine/crack-4306, heroin-1548. Data were analyzed to determine number of substance abusers that fell beyond the upper end of the distribution of TMT scores at the ten, five, and one percentiles. These percentiles were set for alcoholics, cocaine abusers, and heroin abusers. The proper use of the cut-off scores is to alert clinicians to the increasingly higher probability of poor effort when a substance abuser in one of the three groups scores beyond the one percent cut-off or his or her sample of primary drug of abuse. Clearly, the use of these cut-offs needs further empirical validation.

Demographic effects on the Trail Making Test in a drug abuse treatment sample

Appreciation of the importance of screening for cognitive impairment among substance abusing populations has increased in recent years. In this article, demographic effects on the Trail Making Test (TMT), a test often used for screening for cognitive impairment, are examined in a sample of patients in drug abuse treatment programs. A sample of 5619 males and 2902 females was drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS). The DATOS was a naturalistic cohort study that collected data from 1991 to 1993 in 96 programs in 11 cities in the US. Data were analyzed to determine the effects of demographic variables on the two parts of the TMT in this large sample of patients. Consistent with previous research, demographic variables such as age, gender, education level, and ethnicity were statistically significantly related to both TMT Parts A and B. More importantly, however, the percentage of variance accounted for was quite small. These results suggest that, while clearly present, demographic effects on the TMT are weak.

DEPRESSION AND TRAIL MAKING TEST SCORES IN A SAMPLE OF COCAINE ABUSERS

Depression effects on the Trail Making test (TMT), a test often used for screening cognitive impairments, were examined in a sample of cocaine abusers in drug abuse treatment programs. A mixed race sample of 4299 subjects was drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS). DATOS was a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 programs in 11 cities in the United States. Data were analyzed to determine the effects of depression on the TMT scores A and B, and also derived indices created by adding, subtracting, multiplying, and dividing parts A and B of the TMT in this large treatment sample of cocaine abusers. The variables of sex, age, ethnicity, and education were included in analyses to control for demographic effects. The TMT part A and the difference score were the least sensitive TMT scores to the effects of depression but all TMT R- squares were quite small.

ANXIETY AND TRAIL MAKING TEST SCORES IN A SAMPLE OF COCAINE ABUSERS

Anxiety effects on the Trail Making test (TMT), a test often used for screening for cognitive impairments, were examined in a sample of cocaine abusers in drug abuse treatment programs. A mixed race sample of 4306 subjects was drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS). The DATOS was a naturalistic, prospective cohort study that collected data from 1991-1993 in 96 programs in 11 cities in the United States. Data were analyzed to determine the effects of anxiety on the TMT scores A and B, and also derived indices created by adding, subtracting, multiplying, and dividing parts A and B of the TMT in this large treatment sample of cocaine abusers. The variables of sex, age, ethnicity, and education were included in analyses to control for demographic effects. The ratio derived score was the least sensitive TMT score to the effects of anxiety, but all TMT R-squares were quite small.

Demographic effects on the Trail Making Test in a drug abuse treatment sample

Appreciation of the importance of screening for cognitive impairment among substance abusing populations has increased in recent years. In this article, demographic effects on the Trail Making Test (TMT), a test often used for screening for cognitive impairment, are examined in a sample of patients in drug abuse treatment programs. A sample of 5619 males and 2902 females was drawn from electronic files of data from the Drug Abuse Treatment Outcome Study (DATOS). The DATOS was a naturalistic cohort study that collected data from 1991 to 1993 in 96 programs in 11 cities in the US. Data were analyzed to determine the effects of demographic variables on the two parts of the TMT in this large sample of patients. Consistent with previous research, demographic variables such as age, gender, education level, and ethnicity were statistically significantly related to both TMT Parts A and B. More importantly, however, the percentage of variance accounted for was quite small. These results suggest that, while clearly present, demographic effects on the TMT are weak.

Assessing Sex Differences on Treatment Effectiveness from the Drug Abuse Treatment Outcome Study (DATOS)

Men and women entering drug treatment programs are known to differ in demographic characteristics and psychosocial behavioral patterns. To be effective, any such program that caters to individuals from both sexes should identify and address these gender-based variations. Studies have also reported clinical differences in the effect of drugs on men and women addicts. Here, we examine whether the treatment is equally effective on men and women, when several demographic covariates are controlled. We construct a “problem severity index” to categorize individuals based on how acute their problems were at the start of the program. We also examine how the choice of treatment modality affects treatment success. Cumulative logit models were used in our analysis. The choice of treatment modality is sex specific, although sex did not appear to be a significant factor for treatment effectiveness when we controlled for other explanatory variables.