National Treatment Improvement Evaluation Study Research Articles

Identifying relative strength of methadone versus health and social services in comprehensive substance use disorder treatment using a variance decomposition approach

BackgroundThe purpose of this study is to identify the relative strengths of association of medication and health and social services in comprehensive substance use disorder (SUD) treatment. Objectives: The study uses a novel variance decomposition method to assess the relative strength of association of six active ingredients of comprehensive SUD treatment: methadone medication, access services, SUD counseling, matched service ratio, client–provider relationship, and treatment duration. MethodsThe study uses data from the National Treatment Improvement Evaluation Study (1992–1997), a dataset with an unusual number of services and service strategies measured. The data include 3012 clients from 45 SUD treatment programs. Linear mixed models are used to assess the relation of service variables to the outcome of posttreatment substance use. Variance decomposition methods are used to assess the relative importance of the ingredients in the treatment model. ResultsAlong with a random intercept and background variables, receipt of methadone accounted for the greatest relative strength of association at 35.4%, compared with 23.8% for treatment duration, 15.4% for client–provider relationship, and 11.2% for matched service ratio. Access and SUD counseling accounted for modest strengths of association at 1% and 3% each. ConclusionFindings indicate somewhat greater strength of association of methadone compared with other services and service strategies and overall, reinforce the importance of both medication and services and service strategies in the design and development of effective models of service delivery. SignificanceThis study, among the first to evaluate the relative importance of specific services and service strategies of comprehensive SUD treatment, provides insights relevant to the development of effective models of service delivery.

Prospective prediction of first lifetime onset of suicidal ideation in a national study of substance users

Suicide rates have increased over the past several decades. Prior research has evaluated risk factors for suicidal behavior, but much of this work does not adequately differentiate between risk factors for suicidal ideation (SI) and suicide attempts, nor does it differentiate between first-onset SI and recurrent ideation. This study seeks to identify risk factors for first-onset SI among a high-risk group: individuals receiving treatment for substance use disorders. Data were drawn from the National Treatment Improvement Evaluation Study, a prospective study examining the impact of addiction treatment programs. Patients with no lifetime history of suicide attempts or ideation (n = 2560) were assessed at baseline and one year later for prospectively-occurring SI. Sociodemographic variables, mental health indices, interpersonal factors, and substance use severity indicators were evaluated as prospective predictors of first-onset SI in linear regression models. Current mental health problems (OR = 1.54, 95% CI = 1.19–2.01), current substance use problems (OR = 1.33, 95% CI = 1.04–1.70), and difficulty accessing treatment for substance use problems (OR = 1.90, 95% CI = 1.16–3.11) emerged as significant predictors of first-onset SI in a multivariate analysis, suggesting that individuals with current mental health or substance use related symptoms are among the most at risk for developing SI. Difficulty obtaining treatment remained significant, highlighting the importance of treatment accessibility. Future clinical work and research would benefit by addressing these issues, potentially by focusing on mental health treatment in substance abuse programs and evaluating barriers to treatment.

Prospective prediction of first lifetime suicide attempts in a multi-site study of substance users

Although considerable empirical work has been devoted to identifying risk factors for suicide attempts, most longitudinal research has studied recurrent attempts rather than first lifetime attempts. The present study sought to examine prospective predictors of first lifetime suicide attempts among adults receiving treatment for substance use. Data were drawn from the National Treatment Improvement Evaluation Study, a study of addiction treatment programs. Data were collected at treatment intake, treatment exit, and one year post-treatment. Patients (n = 3518) with no lifetime history of suicide attempts at treatment intake were followed at treatment exit and one year post-treatment, when they reported on the occurrence of suicide attempts since the prior assessment. Prospective suicidal behavior was assessed using logistic regression in relation to sociodemographic variables, health-related work impairment, history of psychiatric treatment utilization, history of suicidal ideation, history of depressive symptoms, substance use, and childhood abuse, assessed at intake. Health-related work impairment, history of suicidal ideation, and childhood physical abuse significantly predicted first lifetime attempts in a multivariate analysis. Suicidal ideation, health-related functional impairments, and childhood physical abuse may be particularly important in assessing risk for first lifetime suicide attempts. Findings suggest that future clinical work and research would benefit from considering these factors when identifying individuals at heightened risk of making a first suicide attempt.

Gender disparities in utilization and outcome of comprehensive substance abuse treatment among racial/ethnic groups

This study examined gender differences within Black, Latino, and White subgroups in the utilization of comprehensive services and their relation to posttreatment substance use. Survey data were collected during the National Treatment Improvement Evaluation Study (NTIES), a prospective, longitudinal, multisite study of substance abuse treatment programs and their clients in the United States. The analytic sample consisted of 1,812 Blacks (734 women and 1,078 men), 486 Latinos (147 women and 339 men), and 844 Whites (147 women and 339 men) from 59 service delivery organizations. Results related to service utilization indicated that compared to men, women in all racial and ethnic groups needed and received more services targeted to their needs and reported more positive relations with service providers. Gender was a significant moderator of the relationship between service receipt and treatment outcomes for all racial and ethnic groups, but especially for the Latino subsample. Findings point to the need to consider race-specific gender differences in the development of culturally competent, comprehensive substance abuse treatment.

Social and Health Service Use and Treatment Outcomes for Sexual Minorities in a National Sample of Substance Abuse Treatment Programs

This study examines substance use severity, levels of social and health service utilization, and the impact of service utilization on treatment outcomes for sexual minorities versus non-minorities. The sample included 3,094 clients from the National Treatment Improvement Evaluation Study (NTIES). Substance use severity among sexual minorities and non-sexual minorities was similar at treatment entry and at 12 months post-discharge. Differences in social and health service utilization were significant for substance abuse counseling and health services. Significant interactions between sexuality and access services and sexuality and mental health services were also found. Practice and research implications are discussed.

Client–Provider relationship in comprehensive substance abuse treatment: Differences in residential and nonresidential settings

As the substance abuse service system shifts from primarily residential to primarily nonresidential settings, it becomes important to understand how substance abuse treatment processes and outcomes may vary across service setting. Research increasingly indicates that, along with specific treatment and service strategies, client–provider relationship is an important ingredient in effective substance abuse treatment. This study uses a moderator–mediator analysis of a comprehensive service model to examine how the relation between client–provider relationship and substance abuse treatment outcomes may differ in residential and nonresidential settings. The study used data collected for the National Treatment Improvement Evaluation Study, a prospective, cohort-based study of U.S. substance abuse treatment programs and their clients, with an analytic sample of 59 publicly funded service delivery units and 3,027 clients. Structural equation modeling is used to assess the structural relations and causal connections between treatment process and treatment outcome variables. Results indicate that for nonresidential settings, a better client–provider relationship is directly related to improved outcomes of treatment duration and reduced posttreatment substance use and is indirectly related to both outcomes through provision of services matched to client needs. In residential settings, the quality of the client–provider relationship is unrelated to process or outcome variables. The findings point to the importance of the client–provider relationship in all settings but particularly in outpatient settings where there are limited physical constraints on the treatment process.

Improving Health and Social Outcomes with Targeted Services in Comprehensive Substance Abuse Treatment

Background: Improved life functioning along with substance use reduction is increasingly recognized as the definition of effective addiction treatment. Objectives: To assess whether targeted health and social services contribute to improved physical/mental health and employment. Methods: This study used data from the National Treatment Improvement Evaluation Study (N = 3027) and modeled the improvement in physical/mental health and employment at discharge or 12 months after discharge compared with intake measures as a function of receipts of matched services. Results: Receiving matched medical service improves physical health only at treatment discharge; receiving matched mental health services improves mental health at discharge and 12 months after discharge; receiving matched vocational services improves employment only 12 months after discharge. Conclusions: Need–service matching contributes to improved health and social outcomes when longitudinal assessments of treatment outcomes are used to evaluate treatment effectiveness. Scientific Significance: Study findings document the value of targeted services for achieving success in health and social functioning in comprehensive substance abuse treatment.

The Impact of Comprehensive Services in Substance Abuse Treatment for Women With a History of Intimate Partner Violence

This study examines the impact of comprehensive services on posttreatment substance use among women with a history of intimate partner violence. The sample includes 1,123 women from 50 treatment facilities derived from the National Treatment Improvement Evaluation Study (NTIES). Generalized linear mixed modeling was used to determine whether a history of intimate partner violence moderates the association between service receipt and posttreatment substance use. Significant interactions were found between history of intimate partner violence and concrete ( p = .016) and family services (p = .023) in predicting substance use.

Closing the Need--Service Gap: Gender Differences in Matching Services to Client Needs in Comprehensive Substance Abuse Treatment

Despite the broad recognition in social work that services are more effective when they are tailored to individual client needs, we have only limited evidence of the impact that services matched to client needs have on treatment outcomes. This study examines gender differences in the impact of matched services, access services, and outcome-targeted services on substance abuse treatment outcomes by using data collected from 1992 through 1997 for the National Treatment Improvement Evaluation Study, a prospective, cohort study of substance abuse treatment programs and clients. The analytic sample consists of 3,027 clients (1,105 women and 1,922 men) who reported needed services from 59 treatment facilities. Findings from the study indicate that overall programs have only limited success in targeting services to client needs, but when they do, receipt of substance abuse counseling and matched services predicts both remaining in treatment and reduced posttreatment substance use for both women and men, but especially for women.

Gender differences in client–provider relationship as active ingredient in substance abuse treatment

The client–provider relationship is increasingly evaluated as an active ingredient in the delivery of substance abuse treatment services. This study examines gender differences in client–provider relationship as an important treatment ingredient affecting retention in treatment and reduced post-treatment substance use. The study uses data collected for the National Treatment Improvement Evaluation Study (NTIES), a prospective, cohort study of U.S. substance abuse treatment programs and their clients. Data on individual characteristics were collected at the pre-treatment interview; on client–provider relationship and services received at treatment exit; and on post-treatment drug use at 12 months post-treatment. The analytic sample consists of 3027 clients from 59 service delivery units (1922 men and 1105 women). Structural equation modeling (SEM) was used to assess the structural relations and causal connections between relationship and service variables and treatment outcome variables. Results indicate that a positive client–provider relationship is related directly to longer duration and reduced post-treatment drug use for the total sample and for men analyzed separately. For women, a positive client–provider relationship was related directly to treatment duration and only indirectly to reduced post-treatment drug use. The findings point to the significance of including client–provider relationship in service delivery models – both as a therapeutic element as well as an element facilitative of matching services to specific client needs.

Women's Past-Year Prostitution Status and Receipt of Substance Abuse Treatment Services

The study compared services received in substance abuse treatment programs by women who reported involvement in prostitution and by those who did not. Women (N=1,604) in a national study of substance abuse programs completed a structured interview assessing substance abuse, demographic characteristics, and past-year prostitution at program entry. At discharge, information was gathered on treatment modality (residential including inpatient, or outpatient), duration, and amounts of medical, mental health, and psychosocial services received during treatment. Analyses compared women involved in prostitution and those not involved. Women involved in prostitution were more likely to enter residential treatment. No differences between involvement groups were found in residential treatment duration, services received in residential treatment, or length of outpatient enrollment. In outpatient programs, women involved in prostitution received more psychosocial services. Substance abuse treatment programs appear responsive to the greater needs of women involved in prostitution. However, more research is needed on outcomes.

Need-service matching in substance abuse treatment: Racial/ethnic differences

This study examines the impact of ancillary health and social services matched to client needs in substance abuse treatment for African Americans, Latinos and Whites. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3142 clients (1812 African Americans, 486 Latinos, 844 Whites) from 59 treatment facilities. Results show that racial/ethnic minorities are underserved compared to Whites in the substance abuse service system. Different racial/ethnic groups come into treatment with distinct needs and receive distinct services. Although groups respond differentially to service types, substance abuse counseling and matching services to needs is an effective strategy both for retaining clients in treatment and for reducing post-treatment substance use for African Americans and Whites. Receipt of access services was related to reduced post-treatment substance use for Latinos. Study findings are relevant to planning special services for African Americans and Latinos.

Gender and Racial/Ethnic Disparities in the Impact of HIV Prevention Programming in Substance Abuse Treatment

Objective: The objective of the study was to evaluate the capacity of HIV prevention programs offered in substance abuse treatment to reduce HIV-related risk behavior for women and men and for Black, Latino, and White groups. Methods: Prospective data was collected at intake, discharage, and 12 months post-treatment from 1992 to 1997 for the National Treatment Improvement Evaluation Study with a sample consisting of 3,142 clients from 59 service delivery units: 972 females, 1,870 males, 1,812 Blacks, 486 Latinos, and 844 Whites. Results: Study findings show that receipt of HIV prevention programming as part of substance abuse treatment services resulted in reductions in HIV-related risk behavior for the sample overall and for women as well as men. However, although Blacks received more prevention services than Latinos and Whites, the significant positive effect of HIV services on reduced HIVrisk behavior held only for Whites. Conclusions: Racial/ethnic disparities exist in the capacity for HIV prevention programming offered as part of substance abuse treatment to reduce HIV-risk behavior. The findings highlight the need for the development of culturally competent service delivery strategies to enhance the impact of these services for all groups.

A comparison in the quality of care among legally coerced and voluntary clients in outpatient substance abuse treatment programs

Methods This study used data from the National Treatment Improvement Evaluation Study (NTIES). The NTIES was a prospective study of the impact of treatment programs on persons in publicly funded substance abuse treatment program. Subjects for this study were from outpatient non-methadone and non-correctional settings (N = 1,439) from 31 different treatment programs. Objective quality of care was measured by the presence of a treatment plan, whether subjects were in agreement with the treatment goals, and the proportion of service needs that were matched. Subjective quality was measured using an indicator of overall treatment satisfaction. The primary analytic strategy was multilevel linear and logistic modeling.

Social costs of robbery and the cost-effectiveness of substance abuse treatment.

Reduced crime provides a key benefit associated with substance abuse treatment (SAT). Armed robbery is an especially costly and frequent crime committed by some drug-involved offenders. Many studies employ valuation methods that understate the true costs of robbery, and thus the true social benefits of SAT-related robbery reduction. At the same time, regression to the mean and self-report bias may lead pre-post comparisons to overstate crime reductions associated with SAT. Using 1992-1997 data from the National Treatment Improvement Evaluation Study (NTIES), we examined pre-post differences in self-reported robbery among clients in five residential and outpatient SAT modalities. Fixed-effect negative binomial regression was used to examine incidence rate reductions (IRR) in armed robbery. Published data on willingness to pay to avoid robbery were used to determine the social valuation of these effects. Differences in IRR across SAT modalities were explored to bound potential biases.All SAT modalities were associated with large and statistically significant reductions in robbery. The average number of self-reported robberies declined from 0.83/client/year pre-entry to 0.12/client/year following SAT (p<0.001). Under worst-case assumptions, monetized valuations of reductions in armed robbery associated with outpatient methadone and residential SAT exceeded economic costs of these interventions. Conventional wisdom posits the economic benefits of SAT. We find that SAT is even more beneficial than is commonly assumed.

Do Treatment Services for Drug Users in Outpatient Drug-Free Treatment Programs Affect Employment and Crime?

Using the 1992–1995 National Treatment Improvement Evaluation Study data, we employ principal components analysis to create treatment service factors based on both patient self-reports and treatment record extracts. We included these factors in multivariate models for 1,136 outpatient drug-free treatment patients to estimate the relationship between services and post-treatment employment and crime. Although our models indicated some significant predictors of employment and crime, the overall effects of services were generally insignificant. We conclude that either services are unrelated to outcomes or if they are related then we are not measuring the key aspects of service provision that may be important. The study's limitations are noted.

Do Mechanisms that Link Addiction Treatment Patients to Primary Care Influence Subsequent Utilization of Emergency and Hospital Care?

Patients with drug use disorders are heavy users of emergency department (ED) and inpatient hospital care. This study examines whether formal mechanisms to link addiction treatment patients to primary medical care, either directly on site or by off-site referral-when compared with an absence of said mechanisms-might reduce these patients' use of ED and hospital services after substance abuse treatment. We used longitudinal data from 6 methadone maintenance programs with 232 patients, 24 outpatient nonmethadone programs with 1202 patients, and 14 long-term residential programs with 679 patients in the National Treatment Improvement Evaluation Study. Multivariate logistic models controlling for health status and medical service utilization before treatment examined whether provision of medical services on- or off-site during treatment linkage led to reduced use of ED and hospital services in the year after treatment compared with no such provision. On-site delivery of primary care reduced subsequent ED and hospital use among patients in methadone maintenance and long-term residential compared with the nonlinkage condition but not in outpatient nonmethadone programs. Off-site referral for medical care reduced subsequent ED visits but not hospitalizations in long-term residential programs. These findings suggest that for some treatment modalities, stronger primary care linkage mechanisms decrease subsequent utilization of expensive ED and hospital services. Future study should examine the cost implications of these strong linkage mechanisms and ways to strengthen linkages to off-site medical care.

Parents in substance abuse treatment: Implications for child welfare practice

Substance abuse treatment in parents of young children is an important element of child welfare services. This study compares the predictive factors of post-treatment drug use in organizational, service and individual characteristics between parents and non-parents, mothers and fathers. The analysis sample is derived from the National Treatment Improvement Evaluation Study (NTIES), a longitudinal study designed to evaluate the implementation and effectiveness of the specialty substance abuse service system. The results show that treatment duration and the frequency of counseling available in treatment facilities are the most predictive factors for parents when other factors are controlled. Further, treatment duration, onsite service availability, and frequency of counseling available are significant factors in predicting post-treatment drug use for fathers, but not for mothers. These findings have implications for improving substance abuse treatment services for parents in child welfare settings.

Gender differences in the impact of comprehensive services in substance abuse treatment

This study examines the impact of comprehensive services on treatment outcomes for women and men. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective, cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3,142 clients (1,123 women and 2,019 men) from 59 treatment facilities. The results show that substance abuse treatment benefits both women and men. Further, both women and men benefit from comprehensive services provided as part of substance abuse treatment: specifically, the receipt of educational, housing and income support services is related to reduced post-treatment substance abuse for both women and men. Gender differences are revealed by the fact that, overall, greater proportions of women receive services and, when individual, service, and treatment organizational characteristics are controlled, women show greater reductions in post-treatment substance use. Further, women and men differ in their responsiveness to organizational characteristics: the availability of on-site services and the frequency of counseling significantly predict reduced post-treatment substance use for men but not for women.

Does retention matter? Treatment duration and improvement in drug use.

This study examines whether there is a minimum threshold, continuous or non-linear relationship between the duration of addiction treatment and improvements in drug use. Longitudinal cohort study of 62 drug treatment units and 4005 clients in the US National Treatment Improvement Evaluation Study, fielded from 1993 to 1995. Baseline and 1-year follow-up interviews with clients in methadone maintenance, out-patient non-methadone, short-term residential and long-term residential treatment programs. Improvement in drug use is the difference between the client-reported peak frequency of drug use (in days per month) in the year prior to the baseline interview minus the peak frequency in the year after discharge. Primary drug, and overall use of the major illicit drugs (heroin, cocaine powder, crack cocaine, and marijuana) are considered separately. Controlling for multiple factors, treatment duration had a positive linear relationship with primary drug use improvement among methadone clients and an inverted-U-shaped relationship with overall and primary drug use improvements among out-patient and long-term residential clients. Improvement with longer duration is greatest for long-term residential clients. Contrary to previous arguments for a sharp retention threshold for onset of treatment effects, we find smooth curves relating treatment duration to drug use improvements in methadone maintenance, out-patient non-methadone and long-term residential modalities. These relationships are effectively linear for durations typically observed in single treatment episodes, but unusually long retention in out-patient non-methadone and long-term residential units appear steadily less predictive of improvement.