Index Treatment Episode Research Articles

Coerced Treatment for Methamphetamine Abuse: Differential Patient Characteristics and Outcomes

Policymakers have responded to the increase in the prevalence of methamphetamine (MA) use and the associated social costs (such as crime and child abuse and neglect) by mandating a growing number of MA users to substance abuse treatment via the criminal justice system (CJS) and/or child protective service (CPS) agencies. However, empirical evidence remains sparse about treatment outcomes specifically for MA users who report that their treatment admission occurred under such pressures. This analysis uses natural history interview data from 350 clients treated for MA use in Los Angeles County to examine clients' self-reported CJS/CPS pressure to enter treatment, comparing background and treatment characteristics and selected treatment outcomes across groups defined by existence of such perceived pressure and source of pressure. Approximately half the clients reported legal pressure to enter the index (used for sampling) treatment episode. Those reporting pressure were younger, less likely to have received residential treatment, and had longer treatment episodes than those not reporting pressure. Outcomes (treatment completion, relapse within 6 months, time to relapse, and percentage of days with MA use in 24 months following treatment) did not differ significantly in simple comparisons between the pressured and nonpressured groups; however, when client and treatment characteristics were controlled, the short term outcome of relapse within 6 monthswas worse for those reporting legal pressure. Outcomes did not differ by source of pressure.

Predictors of drug treatment re-entry following relapse to cocaine use in DATOS

Many drug abusers have repeated exposure to treatment, yet little is known about the reasons some individuals re-enter treatment following relapse to drug use. This paper examines the predictors of treatment re-entry among cocaine abusers who relapsed to cocaine use ( N = 347) within 5 years following their index treatment episode. In-depth assessments were conducted at treatment intake in 1991–93 and at 1 and 5 years following treatment discharge. About 44% of the sample returned to treatment, at an average of 2.6 years following discharge. A logistic regression analysis demonstrated that individuals who were African American, were previously married, used cocaine at least weekly after treatment discharge, and had more service needs at the time of index treatment were more likely to re-enter treatment. The findings suggest that a longer-term perspective on treatment utilization is needed to more fully address chronic substance abuse and the problems typically associated with it.

Transitions through homelessness and factors that predict them: residential outcomes in the Chicago Target Cities treatment sample

The course of homelessness was examined among adult substance abusers entering treatment in the Chicago Target Cities treatment sample. The research objectives were (1) examine client movement in and out of homelessness over for 2 years post entry into the index treatment episode, and (2) determine the treatment and non-treatment factors that predict achieving and sustaining residential stability. The sample, recruited from treatment programs on Chicago's West Side, was 59% female and predominantly African-American (87%), unemployed (86%), and unmarried (90%). Approximately one-third self-presented as homeless. Descriptive results showed that 73% of initially homeless clients had improved their residential status at 6 months, and 60% were stably housed at 24 months. By contrast, 28% of initially housed clients were not stably housed at 6 months (the majority of these had gone into residential treatment), and only 16% were homeless at 24 months. Sample-wide, homelessness was reduced by 37% between baseline and the 2-year follow-up. The high percentage of homeless substance abusers that achieved and maintained stable housing is consistent with a conclusion that treatment reduced homelessness in the Chicago Target Cities sample. Alternative explanations cannot be entirely ruled out, but are insufficient to nullify the general conclusion. Factors discriminating homeless and housed clients at baseline were consistent with prior literature. Several treatment and non-treatment factors predicted 6- and 24-month housing outcomes in conditional logistic regression models, although the significance and direction of effect estimates varied across conditions. The most consistent predictors were crack as the primary substance, which appears to be a persistent risk factor for becoming and remaining homeless, and whether or not the participant reported that persons were dependent on him/her for food/shelter, which appears to be a persistent protective factor for achieving housing and preventing homelessness. Implications for program planning are discussed.

Drug treatment completion and post-discharge employment in the TOPPS-II Interstate Cooperative Study

The objective of this study was to use administrative data to examine the effect of drug treatment completion on patients' subsequent employment and wages earned in the year following discharge, and to compare the consistency of these results across three states. Drug treatment and wage data from 20,495 drug treatment patients were used in this study. Treatment data were provided by the state substance abuse management information systems for Baltimore City, Washington State, and Oklahoma. Wage data were provided by the agency in each state responsible for collecting and reporting wage information. A quasi-experimental design was used to compare treatment completers and non-completers in the year after an index treatment episode. In addition, employment history in the year prior to the index episode was used to statistically adjust for group differences. The index episode of care may have included services under more than one treatment modality. The full social security number was used to link the drug treatment and wage administrative datasets. Treatment completers were 22% to 49% more likely than non-completers to be employed and to earn higher wages in the year following treatment, holding other variables constant. Patients staying in treatment longer than 90 days were 22% to 43% more likely to be employed in the year following treatment than those who stayed a shorter time. These findings were consistent across the three project states with different client populations, treatment delivery systems, and labor markets.

Two-year mental health service use and course of remission in patients with substance use and posttraumatic stress disorders.

Comorbid diagnoses of substance abuse/dependence and posttraumatic stress disorder (SUD-PTSD) adversely affect substance abuse patients' treatment outcomes. Recently, several practices have been recommended for the treatment of SUD-PTSD patients based on empirical findings, including providing PTSD-specific care. Accordingly, this study examines the association between outpatient PTSD treatment and the long-term course of SUD-PTSD patients. Male substance abuse/dependence patients (N = 125) with a comorbid diagnosis of PTSD completed 1-and 2-year follow-ups. Based on these reports, 26 patients were stably remitted from substance abuse, 39 were partially remitted and 60 were not remitted at either follow-up. These three groups were compared on mental health service use indices gathered from patients' self-reports of inpatient treatment and nationwide Veterans Affairs (VA) databases abstracting outpatient visits. SUD-PTSD patients who attended more outpatient substance abuse, psychiatric and PTSD services in the first year following treatment (and cumulatively over the 2-year follow-up) were more likely to maintain a stable course of remission from substance use in the 2 years following inpatient SUD treatment. When the three types of sessions were examined in regression analyses, PTSD sessions in the second year and the total number of PTSD sessions over the 2 years following the index treatment episode emerged as the most significant predictors of remission. Self-help group participation was also associated with a remitted course for SUD-PTSD patients. These data suggest that PTSD-focused treatment services are an essential treatment component for substance abuse/dependence patients with PTSD.

Prior treatment history and its impact on criminal recidivism.

This study examines the hypothesis that treatment is a cumulative process; that is, treatment success is best viewed in terms of the patient's entire treatment history, rather than the index treatment episode. Three-hundred and eight patients with a primary heroin addiction were studied for 2 years posttreatment. Using posttreatment arrests as the dependent variable, the effects of prior treatment were assessed. Those with six or more prior treatment episodes and who had been in treatment for 12 or more months during the most recent episode averaged only 0.2 arrests in the 2 years posttreatment, while those with no prior treatment, but 12 or more months in the recent treatment averaged 0.88 arrests. Logistic analysis found that each prior treatment reduced the probability of a posttreatment arrest by 25%. Based on a linear regression, patients with six or more treatments prior treatments averaged half the number of posttreatment arrests as someone with no treatments before the index episode.

Antisocial behavioral syndromes among residential drug abuse treatment clients

We compared residential addictions treatment clients meeting full criteria for antisocial personality disorder (ASPD+) with those reporting syndromal levels of antisocial behavior only in adulthood (AABS+) on demographics, antisocial symptomatology, drug history, axis I comorbidity and characteristics of index treatment episode. We examined these issues in the sample as a whole, as well as separately in male and female respondents. Among both men and women, ASPD+ initiated their antisocial behavior earlier, met more ASPD criteria and endorsed more violent symptoms, than AABS+. Male ASPD+ also met criteria for more lifetime axis I diagnoses and reported more years of drug involvement than male AABS+. Trends were observed toward poorer retention in treatment among ASPD+ than among AABS+ participants of both genders randomized to a planned duration of 180 days, but retention did not differ between ASPD+ and AABS+ randomized to a planned duration of 90 days. Our findings, which replicate and extend previously published results, carry potential implications for treatment programming and for the nosology of ASPD.

Psychopathology as a predictor of treatment outcome in alcoholics.

We performed a one-year follow-up study of 266 alcoholics who had received extensive psychiatric assessment, including diagnosis with the National Institute of Mental Health Diagnostic Interview Schedule and DSM-III criteria, during their index treatment episode. The aims were to evaluate the relationship between additional DSM-III diagnoses in alcoholics and outcome at follow-up, assess the relative prognostic power of different ways of measuring psychopathology by comparing categorical DSM-III diagnoses and a global symptom severity measure, and assess whether ratings of psychopathology add to the prognostic power of an alcohol-dependence measure. While coexistent psychiatric diagnoses generally predicted poorer treatment outcome, there were significant interactions in the relationship between diagnoses and treatment outcome for men and women. For men, having an additional diagnosis of major depression, antisocial personality, or drug abuse was associated with poorer outcome. For women, having major depression was associated with a better outcome in drinking-related measures, while antisocial personality and drug abuse were associated with poorer prognosis. The value of determining psychiatric diagnosis was supported by covariance analyses that suggested that prognostic significance of specific disorders was not accounted for by general psychopathology or general dependence dimensions.