Outpatient Substance Abuse Treatment Programs Research Articles

Buprenorphine Added on Brief Cognitive Behavioral Therapy for Treatment of Methamphetamine Use Disorder

Background: Methamphetamine (MA) use remains a major public health concern around the world. Recent findings suggest that buprenorphine may be helpful for cocaine use reduction. Moreover, animal studies described reduced dopamine peak effect following MA use, due to the administration of low dose buprenorphine. Objectives: This study examined the effectiveness of buprenorphine with brief cognitive behavioral therapy on MA use disorder. Methods: The study was conducted in an outpatient substance abuse treatment center in Qazvin, Iran. Nineteen MA users received buprenorphine for 24 weeks combined with brief cognitive behavioral therapy in an outpatient substance abuse treatment program, three times per week, as a before and after non - randomization study. Clinical outcomes included treatment retention, MA use, degree of MA dependency and craving, quality of life, cognitive abilities questionnaire, addiction severity and also adverse events. Data was analyzed by performing repeated measures analysis and the Friedman test for nonparametric variables. Results: Fifteen participants completed the study during six months and frequency of MA use was significantly decreased at 24 weeks (P < 0.001). There were also significant reductions in craving (P < 0.001), degree of MA dependence (P < 0.001), and improvements in quality of life, cognitive ability, and some subscales of addiction severity. Conclusions: The results of this preliminary clinical study demonstrated that buprenorphine could potentially attenuate MA craving and alternate rewarding effects of MA and had promising effects on cognitive impairment. Furthermore, buprenorphine can be considered as a harm reduction intervention in some communities, in which the people, as a result of cultural beliefs, do not accept a therapy, which only consists of counseling and no medications.

Implementation and results of a symptom-triggered opioid withdrawal protocol at a Veterans Affairs medical center.

Introduction:The Chillicothe Veterans Affairs Medical Center serves veterans from southern Ohio, Kentucky, and West Virginia, where the rates of non-medical opioid use are some of the highest in the nation. Prior to this project, there was not a standardized practice for the treatment of veterans undergoing opioid withdrawal at the facility. In May 2015, a symptom-triggered protocol was initiated to improve the quality of care and decrease the length of detoxification for veterans treated at the Chillicothe Veterans Affairs Medical Center.Methods:This paper reflects a 2-phase project that took place from August 2014 through June 2016. Phase 1 focused on the development of a symptom-triggered opioid withdrawal protocol using the Clinical Opiate Withdrawal Scale for assessment and buprenorphine/naloxone or clonidine for treatment. Phase 2 was a retrospective cohort analysis comparing outcomes between group 1, before protocol initiation; group 2, after protocol initiation with clonidine; and group 3, after protocol initiation with buprenorphine/naloxone. The primary outcome assessed was length of detoxification (in days). Secondary outcomes included length of hospitalization (in days) for the index admission, outpatient substance abuse treatment program participation rates, and opioid sobriety rates at 3 months after detoxification.Results:A statistically significant reduction in the duration of detoxification days was detected after protocol initiation in veterans who received buprenorphine/naloxone or clonidine in accordance with the protocol.Discussion:This retrospective quality analysis supports the use of a symptom-triggered opioid withdrawal protocol using the Clinical Opiate Withdrawal Scale for assessment and clonidine or buprenorphine/naloxone for detoxification treatment.

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OBJECTIVES/SPECIFIC AIMS: This study sought to determine the accessibility, utilization, and preference for mobile phone use among a marginalized population of teens enrolled in an adolescent substance abuse treatment program and their parents. Specific study aims were to: (1) characterize mobile phone use, (2) assess the accessibility and reliability of mobile phone usage, (3) determine specific barriers to mobile phone use, and (4) examine parent and teen perceptions of the utility of integrating communication technology in substance use treatment. METHODS/STUDY POPULATION: In total, 103 (78.6% female; 75.7% Hispanic) parents of teens participating in an outpatient substance abuse treatment program with an average age of 42.60 (SD=9.28) participated in our study. Upon enrollment in a substance abuse treatment program between October 2014 and July 2016, parents completed a technology use survey as part of program development and a chart review of clinic outbound calls to parent mobile phones was completed to evaluate reliability of parent mobile phone access throughout treatment. Survey collection among teens is ongoing. Study population information for teens will be presented at the conference. RESULTS/ANTICIPATED RESULTS: The vast majority of parents owned a cell phone and used it as their primary phone (97.1%); 83% of parents owned smart phones in particular, with the majority being Android phones (68.7%). Parents were more likely to have pay-as-you-go (41.4%) and yearly (32.3%) contracts, and only 15% of the sample endorsed changing their phone number more than once in the past year (64%=never; 21%=once). Parents reported using several of the phone features: text (97%), email (76%), pictures (93%), and accessing the internet (92%); 92% reported they did not have a texting limit; and the most popular use of the mobile phone was to send and receive text messages (58.6%), followed by accessing the internet (19.2%). During the course of a 10-week treatment program, the clinic made 2776 confirmation phone calls to parents who completed surveys. Report of accessibility matched the clinic’s ability to reach parents. Of the 2776 calls, 97.2% were made to the original number provided, which was in service. Only 2.7% were determined to be disconnected, with the median number of days for disconnected service being 2 days with no voice and no texting capabilities (range=14) and 2 days with no voice, but with texting capabilities (range=28). In terms of parent perceptions of the utility of integrating communication technology in substance use treatment, 91% of parents reported they would be receptive to receiving text messages with parenting tips as aftercare support. Preferred content areas included: strategies for monitoring teen substance use (56%), strategies for using consequences (62%), suggestions for encouraging positive activities (62%), and ways to improve parent-child communication (63%). Accessibility, utilization, and preference for mobile phone use in a treatment program among teen respondents will be presented at the conference. DISCUSSION/SIGNIFICANCE OF IMPACT: This study characterized both subjective and objective mobile phone accessibility and usability among teens participating in an adolescent substance abuse treatment program and their parents. This study also provides information on teen and parent perceptions of using mobile phones during the aftercare period and ratings of acceptable messages following treatment. This data will help researchers design mobile-based interventions both during and after treatment, which is the future direction of our research group.

Did you get any help? A post-hoc secondary analysis of a randomized controlled trial of psychoeducation for patients with antisocial personality disorder in outpatient substance abuse treatment programs

BackgroundPeople in treatment for substance use disorder commonly have comorbid personality disorders, including antisocial personality disorder. Little is known about treatments that specifically address comorbid antisocial personality disorder.MethodsSelf-rated help received for antisocial personality disorder was assessed during follow-ups at 3, 9 and 15 months post-randomization of a randomized trial of psychoeducation for people with comorbid substance use and antisocial personality disorder (n = 175).ResultsRandomization to psychoeducation was associated with increased perceived help for antisocial personality disorder. Perceived help for antisocial personality disorder was in turn associated with more days abstinent and higher treatment satisfaction at the 3-month follow-up, and reduced risk of dropping out of treatment after the 3-month follow-up, and perceived help mediated the effects of random assignment on days abstinent at 3-month.follow-up.ConclusionsBrief psychoeducation for antisocial personality disorder increased patients’ self-rated help for antisocial personality disorder in substance abuse treatment, and reporting having received help for antisocial personality disorder was in turn associated with better short-term outcomes, e.g., days abstinent, dropout from treatment and treatment satisfaction.Trial registrationISRCTN registry, ISRCTN67266318, retrospectively registered 17/7/2012.

Abstract PR05: Cancer screening uptake among women in substance abuse treatment

Abstract Purpose: Women in residential and out-patient substance abuse treatment programs represent a broad range of criminally affected indigent women and vulnerable street sex workers at highest risk of cervical cancer. This population is underrepresented in research, but through a nontraditional partnership with law enforcement this project capitalized on reaching a previously hard to reach population that is at high risk for cervical cancer and more likely to not have participated in recommended cervical screens. Scientific studies describe female jail populations receptive to cervical screenings with approximately 70-90% reporting a Pap screen in the last three years; however, knowledge of screening for cancer was poor. Preliminary findings from focus groups conducted among the target population suggest that self-administered HPV testing would not be well accepted or trusted among this population. Thus, the purpose of this study was to evaluate the uptake rate of cervical cancer screening from female nurse practitioners. Methods: Using findings from preliminary focus groups conducted among the target population, investigators adapted and integrated an evidence-based, culturally appropriate, and trauma sensitive women's health education into the largest female substance abuse center in Dallas, Texas, to prepare women for the opportunity to participate in a cervical exam the following day. Cervical screenings were provided at the AIDS Arms outpatient clinic which specializes in providing medical care to extremely poor and vulnerable populations. Other screenings provided included anal, breast, HIV/ sexually transmitted infections, and Hepatitis B and C. Screening positives are navigated by care coordinators for diagnostic screening. Results: Over a five month period, 214 women in residential substance abuse treatment have completed the education seminar on cancer prevention and screening. One third of those participating were African American, Hispanic, or American Indian. Over 98% of women completing education seminar signed up for the cancer screening opportunity and completed the screening the next day. Approximately 5% of cervical pap smear results received thus far were abnormal (ASCUS or LSIL). Nearly 15% reported last pap smear 5 - 10 years ago. One out of every four tested positive for anal high risk HPV. Conclusion: The uptake rate observed in this population exceeded what was anticipated based on the few studies of jail populations available. Thus, women in substance abuse treatment present an exceptional window of opportunity to engage them in cancer screening programs. We hypothesize that trauma-based education prior to offering a cervical exam is a critical factor in increasing screening uptake among this population. Three year project funded by Cancer Prevention Research Institute of Texas. Screening is ongoing through 2016. This abstract was also presented as Poster B71. Citation Format: Martha J. Felini, Raquel Qualls-Hampton, Saritha Bangara, Darius Taylor, Gene W. Voskuhl. Cancer screening uptake among women in substance abuse treatment. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr PR05.

The Effect of Self-Efficacy on Treatment.

Becker's (1974) Health Belief Model has been used successfully to address behavior change in chronic diseases, including smoking and alcohol dependence. This project applies the Health Belief Model to opiate addiction treatment, specifically medication-assisted treatment (MAT). The purpose of this study was to measure the relationship between self-efficacy and treatment outcomes for opiate-dependent clients on MAT. A convenience sample of 50 persons with addiction to opiates was admitted to an outpatient substance abuse treatment program for MAT and followed for a period of 6 months. Pretreatment and posttreatment self-efficacy scores were obtained using a modified General Self-Efficacy Scale (GSE). Treatment outcomes were measured by the number of negative random monthly urine screens, attendance at group and individual counseling sessions, and retention in treatment for at least 6 months. Pretreatment and posttreatment self-efficacy scores were compared using a t test, and self-efficacy scores were compared with client outcomes using Pearson's correlation. GSE scores showed improvement after 6 months in treatment (p ≤ .01). However, no statistically significant relationship was found between GSE scores and treatment outcomes.

How did you know you got the right pill? Prescription opioid identification and measurement error in the abuse deterrent formulation era

Background Self-report of nonmedical prescription opioid use (NMPU) is a cornerstone of drug abuse surveillance, policymaking, and treatment service planning, but misclassification creates bias and may confuse or undermine NMPU estimates [1]. We detected old OxyContin (OC) abuse reports long after a reformulated version (OP) was released (August 2010). This study explored sources of possible NMPU misclassification and proposed solutions. Materials and methods A mixed-methods approach identified demographic, behavioral, and cognitive factors influencing endorsement of old formulations in: a) multivariable regression analyses of NMPU data from the ASI-MV surveillance program [2] examined predictors of endorsing old (vs. new) formulations during the post-reformulation period (n = 8032); b) prevalence estimates of OC availability from an online recreational drug user forum survey (fall 2013; n = 459); and c) semistructured interviews (n = 29) and cognitive interviews (n = 7) among residential and outpatient substance abuse treatment program clients reporting past 2-year use of OC/OP. A coding guide identified patterns and themes of misidentification in transcribed interviews.

PrEP in substance abuse treatment: a qualitative study of treatment provider perspectives.

ObjectivesTo examine substance abuse treatment providers’ views on engaging clients in Pre-exposure Prophylaxis (PrEP) care and research trials.MethodsThirty-six medical and counseling service providers in six New York City outpatient substance abuse treatment programs participated in semi-structured qualitative interviews. Thematic content analysis was conducted by three coders, independently.ResultsProviders’ perspectives toward PrEP were characterized by six salient themes: 1) Limited PrEP awareness. 2) Ambivalence about PrEP; 3) Perception of multiple challenges to delivery; 4) Uncertainty about clients’ ability to be adherent to medication; 5) Concerns about medication safety/side effects; and 6) Perception of multiple barriers to conducting clinical trials.ConclusionsDespite anticipated challenges, providers supported the introduction of PrEP in outpatient substance abuse treatment. Comprehensive training for providers is needed and should include PrEP eligibility criteria, strategies to support adherence and medication monitoring guidelines. Linkages between substance abuse treatment and primary care and/or enhancement of capacity within clinics to offer PrEP may help facilitate PrEP delivery. When conducting research in outpatient clinics, it is particularly important to protect client confidentiality.

Current thinking on the premarketing evaluation of abuse-deterrent opioid formulations

Aims: Numerous prediction studies have identified variables (e.g., substance use and psychiatric severity) associated with attrition from outpatient substance abuse treatment (SAT). Very few studies have examined factors associated with dropout from the client’s perspective. Those that have indicate that dissatisfaction with aspects of treatment as well as individual status factors are reported reasons for dropout. The present study rates clients’ selfreported reasons for early attrition from outpatient SAT. Methods: Clients (N=106) recently admitted to two outpatient SAT programs, who irregularly attended treatment during the first 2–3weeks,were contacted for a brief telephonemotivational intervention. During this call they were queried about reasons for lack of attendance, which were then abstracted and coded. Results: Clients reported various and multiple reasons for poor early engagement in treatment that roughly paralleled those reported for dropping out of treatment by clients in previous studies. These reasons can be categorized as: Client Factors—particularly medical and psychological problems, and acute life stressors; Treatment Factors including issueswith clients and staff, as well as the schedule and nature of the treatment itself; and Environmental or Logistical Factors such as transportation, finances, and competing employment demands. Conclusions: Client attributions for outpatient treatment attrition are not fully parallel with variables identified in prediction studies obtained via patient assessments. Further, clients identify many issues that appear to be actionable in some way, and that if prepared for or dealt with by the clinics at both the programmatic and individual client levels, could improve retention. Financial support: NIAAA 1-P01-AA016821-01A1 and NIDA 2P60-DA005186-21.

Examination of the Role of Therapeutic Alliance, Treatment Dose, and Treatment Completion in the Effectiveness of The Seven Challenges

Adolescent alcohol and illicit drug (AOD) use is a major public health concern. This longitudinal study examines the effectiveness of The Seven Challenges in reducing adolescent substance use and mental health problems, as well as the process by which it is effective. Participants were 89 adolescents (72 male, 17 female) enrolled in a 3 month intensive outpatient adolescent substance abuse treatment program using The Seven Challenges and who provided self-report data at pre- and post-treatment. Results indicated that The Seven Challenges was effective at increasing the number of days refrained from using AOD, reducing use of tetrahydrocannabinol (THC) and other drugs, and reducing substance use problems and internal mental distress. Results also indicated that The Seven Challenges drug counselors effectively established and maintained therapeutic alliance but this seems to not play a role in the effectiveness of The Seven Challenges. Both treatment dose and completion played a role in the effectiveness of The Seven Challenges; they were both positively related to post-treatment days refrained from AOD use, and negatively related to days of THC use, substance use problems, and internal mental distress. However, the strength of the influence of treatment completion was stronger when treatment dose was low than when it was high. Despite a small sample and other limitations, findings add to existing literature that suggests that The Seven Challenges is an effective substance abuse treatment for adolescents. Furthermore, findings suggest that adolescent substance abuse treatment should focus on clients meeting pre-determined program goals as well as on dose.

The Predictive Validity of the Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index

Objective: The study examined the degree to which licensed outpatient substance abuse treatment programs were capable of delivering integrated services for individuals with co-occurring substance use and psychiatric disorders. Aggregate measures of client retention were also obtained, and their relationship with capability scores was explored. Methods: The co-occurring or dual diagnosis capability of each program was measured with the Dual Diagnosis Capability in Addiction Treatment (DDCAT) index, a 35-item rating tool organized into seven dimensions that categorizes programs along a continuum where 1 = addiction-only services, 3 = dual diagnosis–capable, and 5 = dual diagnosis–enhanced. Admission and discharge data were obtained from a state regulatory agency database for clients with co-occurring disorders who received services from state-licensed outpatient substance abuse clinics and who had been discharged from treatment over a 6-month period defined as the 3 months before and after the DDCAT assessment. Admission and discharge data were then aggregated to the program level and their relationship with the DDCAT data was examined. Results: A total of 185 state-licensed outpatient substance abuse clinics were included in the analysis. Generalized linear models showed a significant positive relationship between DDCAT scores and length of stay (odds ratio = 1.209; p < .001), which indicated that clients with co-occurring disorders stayed longer in treatment programs with higher DDCAT scores. Analyses also demonstrated that five DDCAT dimensions were significantly related to length of stay (odds ratios ranged from 1.057 to 1.155; p < .01); the two exceptions were the screening/assessment and treatment dimensions. Conclusions: Given that prior research established treatment retention as a predictor of long-term outcomes, such as relapse to drug use, this study represents an important first step toward validating the DDCAT. Further validation of the DDCAT should consider incorporating a broader range of treatment quality indicators and client outcomes.

Onset of Cocaine Use

Cocaine abuse is widespread in Europe, and Ireland ranks among the leading countries for prevalence of cocaine use among adolescents. This study aimed to examine demographic and substance use correlates of lifetime cocaine use among adolescents with substance use disorder, and to explore the relationship between alcohol intoxication and cocaine initiation. Data from a cross-sectional study of 171 adolescents presenting to an outpatient substance abuse treatment program in the Dublin metropolitan area were analyzed. Bivariate and multivariate analyses were conducted. Approximately 64% of the participants reported ever used cocaine: 70% reported the first use of cocaine was while alcohol intoxicated and 96% reported the onset of cocaine use was preceded by cannabis use. Later age at treatment entry, unstable accommodation, non engagement in educational/vocational functions, and greater frequency of alcohol and cannabis use had robust associations with lifetime cocaine use. Male gender was significantly associated with first use of cocaine while alcohol intoxicated. Alcohol frequently plays a central role in cocaine initiation in Irish adolescents. Efforts to delay, avoid, or reduce adolescent drinking may yield benefits in terms of reducing cocaine use initiation in this population.

Patient Perspectives on Choosing Buprenorphine Over Methadone in an Urban, Equal‐Access System

Recent policy initiatives in Baltimore City, MD significantly reduced access disparities between methadone and buprenorphine in the publicly funded treatment sector. This study examines reasons for choosing buprenorphine over methadone among patients with access to both medications. This study was embedded within a larger clinical trial conducted at two outpatient substance abuse treatment programs offering buprenorphine. Qualitative and quantitative data on treatment choice were collected for new patients starting buprenorphine treatment (n = 80). The sample consisted of predominantly urban African American (94%) heroin users who had prior experience with non-prescribed street buprenorphine (85%), and opioid agonist treatment (68%). Qualitative data were transcribed and coded for themes, while quantitative data were analyzed using descriptive and bivariate statistics. Participants typically conveyed their choice of buprenorphine treatment as a decision against methadone. Buprenorphine was perceived as a helpful medication while methadone was perceived as a harmful narcotic with multiple unwanted physical effects. Positive experiences with non-prescribed "street buprenorphine" were a central factor in participants' decisions to seek buprenorphine treatment. Differences in service structure between methadone and buprenorphine did not strongly influence treatment-seeking decisions in this sample. Personal experiences with medications and the street narrative surrounding them play an important role in treatment selection decisions. This study characterizes important decision factors that underlie patients' selection of buprenorphine over methadone treatment.

Patient Perspectives on Choosing Buprenorphine Over Methadone in an Urban, Equal-Access System

Background Recent policy initiatives in Baltimore City, MD significantly reduced access disparities between methadone and buprenorphine in the publicly funded treatment sector. Objectives This study examines reasons for choosing buprenorphine over methadone among patients with access to both medications. Method This study was embedded within a larger clinical trial conducted at two outpatient substance abuse treatment programs offering buprenorphine. Qualitative and quantitative data on treatment choice were collected for new patients starting buprenorphine treatment (n = 80). The sample consisted of predominantly urban African American (94%) heroin users who had prior experience with non-prescribed street buprenorphine (85%), and opioid agonist treatment (68%). Qualitative data were transcribed and coded for themes, while quantitative data were analyzed using descriptive and bivariate statistics. Results Participants typically conveyed their choice of buprenorphine treatment as a decision against methadone. Buprenorphine was perceived as a helpful medication while methadone was perceived as a harmful narcotic with multiple unwanted physical effects. Positive experiences with non-prescribed “street buprenorphine” were a central factor in participants' decisions to seek buprenorphine treatment. Conclusions Differences in service structure between methadone and buprenorphine did not strongly influence treatment-seeking decisions in this sample. Personal experiences with medications and the street narrative surrounding them play an important role in treatment selection decisions. Scientific Significance This study characterizes important decision factors that underlie patients' selection of buprenorphine over methadone treatment. (Am J Addict 2013; 22:285–291)

Computer simulation games as an adjunct for treatment in male veterans with alcohol use disorder

This study examined the impact of a computer simulation designed to provide the opportunity for individuals with alcohol use disorders (AUDs) to practice relapse prevention skills. Participants were 41 male veterans enrolled in an intensive outpatient substance abuse treatment program. Participants were randomly assigned to either view educational slides about treatment for AUD or play a simulation videogame for eight sessions within 12weeks. Participants were assessed at a 4-week follow-up visit. Outcome measures included relapse rates as well as ratings on the Obsessive Compulsive Drinking Scale (OCDS) and a custom-designed relapse prevention self efficacy scale. While rates of relapse did not differ between groups, those who played the game showed overall reductions in ratings on the OCDS, as well as higher ratings of self-efficacy at week 8, suggesting that the videogame simulation may be a useful adjunct to AUD treatment.

Characterizing and improving HIV/AIDS knowledge among cocaine-dependent outpatients using modified materials

BackgroundOnly 56% of outpatient substance abuse treatment programs in the U.S. provide HIV/AIDS education, likely due to the time required to complete existing educational interventions. This report describes results of a third study in a series to develop a brief educational intervention to increase HIV/AIDS knowledge among cocaine-dependent outpatients. MethodsParticipants (N=90) were randomized to experimental or control conditions and completed two HIV/AIDS knowledge pre-tests with response formats modified to “true–false–don’t know.” Pre-test results were later compared to historical controls that completed pre-tests in their original “true–false” format. Next, participants in the experimental condition completed an HIV/AIDS educational intervention while participants in the control condition completed a sham intervention. Participants in both conditions then completed knowledge tests a second time. Participants in both conditions were subsequently crossed over, and then completed knowledge tests a third time. Post-intervention analyses were conducted using test data from all participants who completed the educational intervention (N=56). A subset of these participants (N=40) completed follow-up tests approximately 9weeks after completing the educational intervention. ResultsScores on both pre-tests were lower than those observed in historical controls (p<.001). Scores on knowledge tests increased from baseline after participants completed the educational intervention (p<.001), but not after the sham intervention (p>.05). Scores at follow-up remained higher than baseline scores (p<.001). ConclusionsModifying response formats to include a “don’t know” option likely increases identification of baseline knowledge deficits. This brief intervention is effective at increasing HIV/AIDS knowledge among cocaine-dependent outpatients.

A controlled trial of the adjunct use of d-cycloserine to facilitate cognitive behavioral therapy outcomes in a cocaine-dependent population

Cocaine dependence is a chronically relapsing disorder for which its predominant behavioral therapies are associated with only partial efficacy. The goal of this study was to determine if the N-methyl-d-aspartate (NMDA) glutamate receptor partial agonist and cognitive enhancer, d-cycloserine (DCS), could boost the cocaine abstinence and treatment retention goals of cognitive behavioral therapy (CBT). This study employed a placebo-controlled, randomized double-blind trial design of 44 cocaine-dependent men enrolled in a 4-week outpatient Substance Abuse Treatment Program (SATP) at the Atlanta Veteran's Administration Medical Center. Subjects received 50mg of DCS or placebo prior to four weekly sessions of a condensed version of a manual-based CBT for cocaine dependence. Cocaine abstinence and treatment retention measures represented primary outcome variables. Relative to a 12-step based treatment-as-usual, an under-dosed CBT was associated with significant improvements in drug abstinence and treatment retention at 4-weeks and for maintenance of drug abstinence after four more weeks of follow-up. The robust response to the under-dosed CBT was not enhanced by the adjunct administration of DCS at either the 4- or 8-week endpoints. This controlled clinical trial failed to demonstrate an ability of DCS to boost the relapse prevention or treatment retention goals of CBT.

Abstinence‐contingent recovery housing and reinforcement‐based treatment following opioid detoxification

To conduct a randomized, controlled trial of abstinence-contingent recovery housing delivered with or without intensive day treatment among individuals exiting residential opioid detoxification. Random assignment to one of three conditions: recovery housing alone (RH), abstinence-contingent recovery housing with reinforcement-based treatment RBT (RH + RBT) or usual care (UC). RH and RH + RBT participants received 12 weeks of paid recovery housing contingent upon drug abstinence. RH + RBT participants also received 26 weeks of RBT, initiated concurrently with recovery housing. Assessments were conducted at 1, 3 and 6 months after treatment enrollment. Out-patient drug-free substance abuse treatment program in Baltimore, Maryland. Patients (n = 243) who completed medication-assisted opioid detoxification. Primary outcome was drug abstinence (opioid- and cocaine-negative urine and no self-reported opioid or cocaine use in the previous 30 days). Secondary outcomes included abstinence at all time-points (1, 3 and 6 months), days in recovery housing and employment. Overall rates of drug abstinence were 50% for RH + RBT, 37% for RH and 13% for UC (P < 0.001). At 6 months, RH + RBT participants remained more likely to meet abstinence criteria than UC participants (37% versus 20%, P = 0.016). Length of stay in recovery housing mediated abstinence outcomes and was longer in RH + RBT (49.5 days) than in RH (32.2 days; P < 0.002). Abstinence-contingent recovery housing improves abstinence in opioid-dependent adults following medication-assisted detoxification. The addition of intensive 'reinforcement-based treatment' behavioural counseling further improves treatment outcomes, in part by promoting longer recovery house stays.

Organizational consequences of staff turnover in outpatient substance abuse treatment programs

The purpose of this study was to examine the impact of staff turnover on perceptions of organizational demands and support among staff who remained employed in substance abuse treatment programs. The sample consisted of 353 clinical staff from 63 outpatient agencies. Two scales from the Survey of Organizational Functioning measured work environment demands (stress and inadequate staffing), and 3 measured supportive work relationships (communication, cohesion, and peer collaboration). Results from a series of multilevel models documented that counselors working in programs that had previously experienced high staff turnover perceived higher demands and lower support within their organization, even after controlling for other potentially burdensome factors such as budget, census, and individual measures of workload. Two individual-level variables, caseload and tenure, were important determinants of work environment demands but were not related to supportive work relationships. Findings suggest that staff turnover increases workplace demands, decreases perceptions of support, and underscores the need to reduce stress and minimize subsequent turnover among clinical staff.

Program needs and change orientation: Implications for counselor turnover

Although evidence suggests that turnover rates are higher in high-stress/high-needs work environments, it is unclear whether agencies' attempts at improving practices influence individuals' decisions to stay at or leave a job. The purpose of this study was to examine whether program needs and change orientation influence individual decisions to quit. A sample of 206 counselors from 25 outpatient substance abuse treatment programs completed the Survey of Organizational Functioning, rating the organization on program needs, leadership, and change. They also rated themselves on stress, burnout, and job satisfaction. Multilevel modeling indicated a significant interaction between program needs and change orientation, even after controlling for stress, burnout, job satisfaction, tenure, and selected program characteristics. When perceptions of program needs were high, counselors were more likely to stay if they felt that the organization was making progress toward change. These findings suggest that an orientation toward change can counteract negative effects of perceived need within the workplace.