Outpatient Treatment Facilities Research Articles

Geographic Access to Specialty Mental Health Care Across High- and Low-Income US Communities

ImportanceWith the future of the Affordable Care Act and Medicaid program unclear, it is critical to examine the geographic availability of specialty mental health treatment resources that serve low-income populations across local communities.ObjectivesTo examine the geographic availability of community-based specialty mental health treatment resources and how these resources are distributed by community socioeconomic status.Design, Setting, and ParticipantsMeasures of the availability of specialty mental health treatment resources were derived using national data for 31 836 zip code tabulation areas from 2013 to 2015. Analyses examined the association between community socioeconomic status (assessed by median household income quartiles) and resource availability using logistic regressions. Models controlled for zip code tabulation area–level demographic characteristics and state indicators.Main Outcomes and MeasuresDichotomous indicators for whether a zip code tabulation area had any (1) outpatient mental health treatment facility (more than nine-tenths of which offer payment arrangements for low-income populations), (2) office-based practice of mental health specialist physician(s), (3) office-based practice of nonphysician mental health professionals (eg, therapists), and (4) mental health facility or office-based practice (ie, any community-based resource).ResultsOf the 31 836 zip code tabulation areas in the study, more than four-tenths (3382 of 7959 [42.5%]) of communities in the highest income quartile (mean income, $81 207) had any community-based mental health treatment resource vs 23.1% of communities (1841 of 7959) in the lowest income quartile (mean income, $30 534) (adjusted odds ratio, 1.74; 95% CI, 1.50-2.03). When examining the distribution of mental health professionals, 25.3% of the communities (2014 of 7959) in the highest income quartile had a mental health specialist physician practice vs 8.0% (637 of 7959) of those in the lowest income quartile (adjusted odds ratio, 3.04; 95% CI, 2.53-3.66). Similarly, 35.1% of the communities (2792 of 7959) in the highest income quartile had a nonphysician mental health professional practice vs 12.9% (1029 of 7959) of those in the lowest income quartile (adjusted odds ratio, 2.77; 95%, 2.35-3.26). In contrast, outpatient mental health treatment facilities were less likely to be located in the communities in the highest vs lowest income quartiles (12.9% [1025 of 7959] vs 16.5% [1317 of 7959]; adjusted odds ratio, 0.43; 95% CI, 0.37-0.51). More than seven-tenths of the lowest income communities with any resource (71.5% [1317 of 1841]) had an outpatient mental health treatment facility.Conclusions and RelevanceMental health treatment facilities are more likely to be located in poorer communities, whereas office-based practices of mental health professionals are more likely to be located in higher-income communities. These findings indicate that mental health treatment facilities constitute the backbone of the specialty mental health treatment infrastructure in low-income communities. Policies are needed to support and expand available resources for this critical infrastructure.

Continuous quality improvement in substance abuse treatment facilities: How much does it cost?

Continuous quality improvement (CQI) has grown in the U.S. since the 1970s, yet little is known about the costs to implement CQI in substance abuse treatment facilities. This paper is part of a larger group randomized control trial in a large urban county evaluating the impact of Plan-Study-Do-Act (PDSA)-CQI designed for community service organizations (Hunter, Ober, Paddock, Hunt, & Levan, 2014). Operated by one umbrella organization, each of the eight facilities of the study, four residential and four outpatient substance abuse treatment facilities, selected their own CQI Actions, including administrative- and clinical care-related Actions. Using an activity-based costing approach, we collected labor and supplies and equipment costs directly attributable to CQI Actions over a 12-month trial period. Our study finds implementation of CQI and meeting costs of this trial per facility were approximately $2000 to $10,500 per year ($4500 on average), or $10 to $60 per admitted client. We provide a description of the sources of variation in these costs, including differing intensity of the CQI Actions selected, which should help decision makers plan use of PDSA-CQI.

One-year sobriety improves satisfaction with life, executive functions and psychological distress among patients with polysubstance use disorder

IntroductionPolysubstance use disorder is prevalent in treatment-seeking patients with substance use disorder (SUD), with a higher risk of developing comorbid psychiatric symptoms, more pervasive deficits in cognitive functions, and inferior treatment results. The present study investigates if individuals with polysubstance use disorder who achieve at least one year of abstinence show greater improvements in satisfaction with life, executive functions, and psychological distress, compared to relapsers and controls. The prospective recovery from polysubstance use disorder assessed with broad output indicators remains understudied. A better understanding of the pattern of recovery of the chosen output indicators could shed light on the recovery process for this group of patients. Material and methodsWe investigated changes in satisfaction with life, executive functions and psychological distress over a period of 12months in patients who remained abstinent and in those who relapsed. Subjects with polysubstance use disorder (N=115) were recruited from outpatient and residential treatment facilities; healthy controls (N=34) were recruited by posters exhibited at social welfare and GP offices. Executive functions were assessed by the Behaviour Rating Inventory of Executive Function-Adult self-report version (BRIEF-A), psychological distress by the Symptom Checklist-90-R (SCL-90-R), and satisfaction with life by the Satisfaction With Life Scale (SWLS). Substance use was assessed by self-reports on the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT). Participants were categorized as “relapsers” if they had AUDIT score ≥8, or DUDIT score ≥2 for women and ≥6 for men. ResultsResults indicated that the abstinent group had the greatest improvement on all the indicators compared with relapsers and controls. Participants who successfully quit substance use for one year showed improved satisfaction with life, executive functions, and psychological distress compared to participants who relapsed and controls. ConclusionsOur study provides support for the view that there is a clinically and statistically significant recovery of satisfaction with life, executive functions, and psychological distress for SUD patients following one-year of abstinence. This knowledge highlights the importance of time and continued abstinence.Our findings suggest that a gradual and careful step-up of learning requirement should be adopted, and SUD treatment should initially focus on stabilizing the patient and achieving abstinence, while interventions for co-morbid problems and more cognitively demanding treatment components are more likely to succeed later in the treatment sequence.

Quality of life improvement in Latinas receiving combined substance use disorders and trauma-specific treatment: a cohort evaluation report

BackgroundThis study evaluates the benefits of integrating behavioral health and trauma services for Latinas with a history drug use. Changes in quality of life (QOL) domains were documented after participation in a manualized intervention in a cohort of Latinas.MethodsParticipants were part of a prospective cohort study of 136 Latinas with co-occurring disorders (COD) who may have experienced trauma and receiving services in our outpatient treatment facility in Bayamón, Puerto Rico. The WHOQOL-BREF Spanish version was used to score physical, psychological, social, and environmental QOL domains, at intake and after six months. Sociodemographic variables, alcohol, drug use, mental health disorders, and severity of substance use disorders (as defined by the DSM-5) were also tabulated. Descriptive statistics and paired t test or the Wilcoxon signed-rank test were computed for comparison.ResultsA median age of 39 years was seen and with 76% high school education or higher degree. The majority were unemployed (95.9%). A diagnosis of severe cocaine use (51.4%) was present and almost half (49.5%) had three or more DSM-5 diagnoses. Mean QOL scores were higher at six months with statistically significant differences in each domain. Women with neurodevelopmental disorders and schizophrenia yielded higher mean QOL scores for each domain at six months except for the social domain. Women with polydrug use and women who reported exposure to trauma and depressive disorder experienced statistically significant increments in the physical, psychological and social domains in comparison to counterpart women.ConclusionsSignificant and positive changes in QOL were found in each domain. Latinas who reported traumatic events had lower scores in the physical and psychological QOL domains. There was a high prevalence of diminished physical and mental functioning in Latinas with COD. The exposure to trauma and the lack of social support negatively affect treatment access and retention for Latinas.

The Connection Between Thwarted Belongingness, Alcohol Consumption, Suicidal, and Homicidal Ideation in a Criminal Justice Sample.

To determine if thwarted belongingness in combination with frequent alcohol use increased suicidal and homicidal ideation when known predictors were controlled for (eg, depressive disorders, anxiety disorders, drug use, race, sex, age, and employment status). This study utilized an archival database. Participants were 574 individuals at an outpatient substance abuse treatment facility who were under community corrections supervision. The average age was 34.5 (SD = 10.9) years; there were 371 (64.6%) men and 287 (50.0%) Black participants. Data were originally gathered from face-to-face interviews with the participants by their case manager or an intake specialist when they entered treatment. Self-reported suicidal and homicidal ideation was used as a dependent variable in unadjusted and adjusted binary logistic regressions to determine the influence of thwarted belongingness and frequent alcohol use. Thwarted belongingness alone (ie, without frequent alcohol use) was associated with risk for suicidal ideation, and was approaching significance for homicidal ideation. The combination of thwarted belongingness and frequent alcohol use was associated with the greatest risk for suicidal and homicidal ideation. Cocaine use and employment status were also identified as significant predictors for suicidal and homicidal ideation in the fully adjusted models. Thwarted belongingness in combination with frequent alcohol use seems to have a large and meaningful relationship with both suicidal and homicidal ideation. Additional research is needed to better understand the relationship between alcohol, thwarted belongingness, and outcomes such as suicide and homicide.

Performance-Based Contingency Management in Cognitive Remediation Training: A Pilot Study

Impairments in attention, working memory, and executive function are common among substance users and may adversely affect SUD treatment outcomes. The ability of cognitive remediation (CR) interventions to improve these deficits is hindered in part because levels of engagement in CR training may be inadequate to achieve benefit. This pilot study aimed to increase CR engagement and improve outcome by implementing contingency management (CM) procedures that reinforce performance improvements on CR tasks. Participants were forty individuals (50% male; 65% African American) in an outpatient substance use treatment facility with mild cognitive impairment who had ≥30-days of abstinence from alcohol and drugs. They were randomized to standard (CR-S; n=21) or CM-enhanced (CR-CM; n=19) cognitive remediation training. CR consisted of 1-hour sessions, three times per week for four weeks (12 sessions). A neuropsychological assessment battery was administered prior to and after the four-week intervention. Both groups had high rates of CR session attendance (mean CR-S=11.7, CR-CM=10.9 sessions). Performance on 8 of the 9 CR tasks significantly improved over time for both conditions, with the CR-CM condition demonstrating greater improvement on a CR Sequenced Recall task [F(1,37)=5.81, p<.05]. Significant improvement was also evident on 4 of 9 neuropsychological assessment measures, with the CR-CM condition showing differential improvement on the Trail Making Test – Part B [F (1,37)=5.34, p<.05]. These findings support the feasibility of using CM procedures to enhance substance users' engagement with CR training and suggest the potential value of more research in this area.

Establishing a clinical pharmacy technician at a United States Army military treatment facility

ObjectivesTo describe the creation of a clinical pharmacy technician position within the U.S. Army and to identify the personal skills and characteristics required to meet the demands of this role. SettingAn outpatient military treatment facility located in Maryland. Practice descriptionThe clinical pharmacy technician position was designed to support clinical pharmacy services within a patient-centered medical home. Practice innovationFunding and a position description were established to hire a clinical pharmacy technician. Expected duties included administrative (45%), patient education (30%), and dispensing (25%). Local policy, in accordance with federal law and U.S. Army regulations, was developed to define the expanded technician responsibility to deliver patient medication education. ResultsIn the initial 3 months, the clinical pharmacy technician spent 24 hours per week on clinical activities, affording an additional 10-15 hours per week for clinical pharmacists to provide patient care. Completed consults increased from 41% to 56%, and patient-pharmacist encounters increased from 240 to 290 per month. The technician, acting as a clinical pharmacist extender, also completed an average of 90 patient encounters independently each month. As a result of these improvements, the decision was made to hire a second technician. Currently, the technicians spend 28-40 hours per week on clinical activities, offsetting an average of 26 hours per week for the clinical pharmacists. ConclusionA patient-centered medical home clinical pharmacy technician can reduce the administrative workload for clinical pharmacists, improve their efficiency, and enhance the use of clinical pharmacy services. Several characteristics, particularly medication knowledge, make pharmacy technicians particularly suited for this role. The results from the implementation of a clinical pharmacy technician at this military treatment facility resulted in an Army-wide expansion of the position and suggested applicability in other practice sites, particularly in federal pharmacies.

Acceptance of Reduced-Risk Drinking as a Therapeutic Goal within the Polish Alcohol Treatment System.

To assess views on the feasibility and acceptability of reduced-risk drinking (RRD) strategies within the very homogenous and abstinence-oriented Polish alcohol treatment system. By online survey in 2014/15 we enquired into current attitudes of nationwide sample of professionals working in outpatient alcohol treatment facilities regarding non-abstinence goals as a function of severity of the disorder (abuse/dependence) and the finality of the outcome goal. Questionnaires were completed by experienced addiction therapists, trained primarily in cognitive-behavioral therapy (n= 246, response rate = 50%). Only one third accept RRD for alcohol dependent clients (fully or partially), the three fourths accept RRD for alcohol abusing clients (fully or partially). RRD as an intermediate goal of treatment is more accepted than when set up as a final treatment objective. RRD had significantly higher level of acceptance among younger professionals. Compared to male respondents, females were more open to offering RRD to patients experiencing alcohol-related problems. Finally, therapists working according to the principles of motivational interviewing or solution focused brief therapy were significantly more in favor of RRD than others. Comparing with other countries, the acceptance of RRD as a therapeutic objective in Poland is moderately low. Mistrust toward RRD strategies is mainly fueled by a belief that this strategy is not effective plus its inconsistency with therapists' own therapeutic philosophy.

Commentary on Guydish et al. (2016): The continuing deadly threat of tobacco use in addiction treatment.

Guydish and colleagues document the high prevalence of tobacco use among addiction treatment patients in many countries. Tobacco accounts for widespread premature mortality among individuals with addiction disorders, yet smoking cessation does not receive the attention it deserves in treatment settings. The bidirectional linkages between cigarette use and illicit substance use are well established. Tobacco misuse is a powerful marker for other substance use disorders in many populations, such as pregnant women 1. Tobacco use disorders are also pervasive comorbidities that accompany many other forms of substance use. Among US respondents in the 2013 National Survey of Drug Use and Health (NSDUH), 55% of those who reported illicit substance use in the past month also reported tobacco use during the same period. Smoking prevalence is higher among individuals who satisfy the criteria for alcohol and illicit drug disorders. The current systematic review by Guydish and colleagues underscores the importance of these linkages in a global context 2. These authors find a particularly high prevalence among patients receiving opiate addiction treatment, but find a high prevalence in almost all treatment populations for which data are systematically collected. Smoking cessation poses difficult challenges in addiction treatment, partly because smoking is so deeply embedded within these settings. Partly for that reason, tobacco use comprises a leading threat to life and health among individuals who experience a wide range of substance use disorders. Hurt and colleagues followed a cohort of in-patient addiction treatment patients. One hundred and nine of 214 attributable deaths occurred from tobacco-related causes 3 In similar fashion, Hser and colleagues performed a 24-year follow-up study of a patient cohort admitted to addiction treatment in 1964. The death rate among smokers was four times that found among non-smokers 4. Despite these findings, in many treatment organizations smoking cessation does not appear to be a high priority. High smoking prevalence among staff, passive staff attitudes regarding the intractability of smoking behaviors and limited access to smoking cessation treatments remain key obstacles to quitting within treatment populations 5. Cookson and colleagues’ survey of clients and staff associated with the South London and Maudsley NHS Foundation Trust underscores these difficulties. Eighty-eight per cent of clients and 45% of staff were current smokers. Fifty-six per cent of clients had never received assistance from clinicians with smoking cessation. Only 15% of clients received smoking cessation support during their current treatment stay, even though 79% expressed a desire to quit. Treatment staff rated smoking cessation as markedly less important than addressing clients’ use of other substances alongside their primary addiction 6 This pattern persists, despite evidence that smoking cessation interventions can be effective with this population within treatment settings without compromising other treatment goals 7. Analyzing 2004–05 US data, Friedmann and colleagues reported that only 41% of US out-patient treatment facilities offered smoking cessation counseling or pharmacotherapy 8; 38% offered individual/group counseling, and only 17% provided pharmacotherapy. Analyzing 2012 data, Shi and colleagues found similar results. Only 47% of the organizations surveyed offered behavioral counseling or pharmacotherapy for smoking cessation 9. Public policies can influence these practices. Shi and colleagues find that treatment facilities in US states that adopted strong tobacco control measures were more likely to offer smoking cessation services. Clinical guidelines and accreditation bodies can also play a helpful role 7. Policy findings in many other national settings are more sparse. Regulatory policies requiring addiction treatment providers to pay greater attention to smoking cessation deserve high priority in both services research and tobacco control policy. Guydish and collaborators perform an important service by drawing attention to this issue. The treatment community must improve its efforts to address this deadly and pervasive comorbidity. Millions of patients with addiction disorders seek help from the treatment system; whatever their treatment course and whatever their primary diagnosis, most have serious tobacco issues that are typically unaddressed. As a result, many will die prematurely of tobacco-related causes. We as a field can do much better. None.

Gender Comparison in Referrals and Treatment Completion to Residential and Outpatient Alcohol Treatment.

BACKGROUNDResidential treatment for alcoholism is associated with high completion rates for clients, yet there appear to be gender disparities in patient referrals and treatment completion rates. We studied whether (A) gender is associated with differential patient placement to outpatient vs. residential treatment facilities and (B) completion rates differ by gender.METHODSIn this cross-sectional study, we analyzed the admission and discharge data from 185 publicly funded substance abuse treatment facilities across Los Angeles County between 2005 and 2010.RESULTSAmong the 33,745 studied cases, women were referred to residential treatment facilities less frequently than men (75% vs. 66%). The adjusted results derived from logistic regression models confirmed that females were more likely to be referred to outpatient treatment than to residential treatment facilities (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.05–1.26). In addition, we observed that compared to White/Caucasian patients, all other races were associated with more referral to outpatient facilities (ie, less referral to residential facilities), indicating a racial disparity on the top of the observed gender disparity. However, there was no significant link between gender and treatment completion rates (OR: 0.93, 95% CI: 0.86–1.00).CONCLUSIONSWomen seem to have treatment completion rates comparable to men, yet they are less likely to be referred to residential treatment facilities. Hence, there still remains a gender disparity in alcoholic patient referrals. Further studies should delineate which specific therapeutic aspects and programmatic components of women-focused treatments are essential to augment positive treatment outcomes.

Race/ethnicity and quality indicators for outpatient treatment for substance use disorders.

Initiation and engagement, performance measures that focus on the frequency and timely receipt of services in the early stages of substance use disorders (SUD) treatment, are useful tools for assessing treatment quality differences across racial/ethnic groups. The purpose of this study was to examine whether there are racial/ethnic disparities in these quality indicators and to explore whether predictors of treatment initiation and engagement differ by clients' race/ethnicity. This study used administrative data from outpatient treatment facilities licensed by the state of Massachusetts that receive public funding. The sample consisted of 10,666 adult clients (76% White, 13% Latino, 11% Black) who began an outpatient treatment episode in 2006. Client data were linked with facility data from the National Survey on Substance Abuse Treatment Services. Multilevel regressions were used to examine racial/ethnic disparities and to explore whether predictors for initiation and engagement differed by client's race/ethnicity. We did not find evidence of racial/ethnic disparities in treatment initiation or engagement. However, we found that predictors of initiation and engagement differed by client's race/ethnicity. Disparities may be context specific, and thus it is important that they be examined at state or local levels. Our results point to the importance of examining predictors of quality indicators separately by group to better understand and address the needs of diverse client populations.

Inclusion as the goal of psychiatric care – Impact of the UN Convention on the Rights of Persons with Disabilities

Summary The UN Convention on the Rights of Persons with Disabilities has a great impact on the care for persons with mental maladies, because it also protects persons with longer lasting mental impairments. Central aims and regulations of the UN convention challenge some established treatment patterns since they demand to focus strictly on the needs of the individual person, even if this might require institutional changes and additional resources. A central aim of the UN Convention is the social inclusion of all subjects with disabilities, which in psychiatry and psychotherapy includes a focus on supported decision-making and empowerment. We discuss how social inclusion with a focus on these aspects that are relevant to personal well-being and self-determination can be achieved for subjects with mental disorders. This should be achieved in the living environment in the community, in the work place (particularly on the regular job market), and in institutions such as homes and hospitals with in- and outpatient treatment facilities.

Incidence of Acute Odontogenic Maxillofacial Infections in Lithuania

Despite achievements in Lithuanian health care system and good accessibility to medical service, life threatening infections of odontogenic origin are still prevalent in Lithuania. Aim of the study: To analyse the prevalence of odontogenic maxillofacial infections and to examine distribution of treatment facilities accepting patients with acute odontogenic infections in Lithuania. Methods: A five-year (2009-2013) retrospective study included information about all patients treated in outpatient (N=482) or inpatient (N=61) treatment facilities in Lithuania, Adjusted Inci- dence Ratios of acute odontogenic maxillofacial infections were calculated separately for each type of infection and for each year, and each type of treatment facility. Results: High annual incidence of acute odontogenic maxillofacial infections, i.e. ~1% of a total population was diagnosed.

The impact of oral health conditions, socioeconomic status and use of specific substances on quality of life of addicted persons.

BackgroundThe aim of this cross-sectional study was to evaluate the impact of oral health conditions, socioeconomic status and use of specific substances on quality of life of alcohol and drug addicted persons, receiving care at outpatient treatment facilities in Brazil.MethodsA random sample of 262 participants, mean age 37 years, from Psychosocial Care Centers for Alcohol and Drugs (CAPS AD) located in three cities in the state of São Paulo, Brazil, were clinically examined for caries experience (DMFT index) by a calibrated examiner. They were asked to complete a series of questionnaires, including the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), socioeconomic characteristics, and the World Health Organization Quality of Life assessment (WHOQOL), which were considered the outcome variables of the study. Associations between oral health status, socioeconomic characteristics, substance involvement with WHOQOL were investigated by means of the chi-square test and multiple logistic regression analysis with a level of significance α < 0.05.ResultsThe mean DMF index of the group was 13.0. Subjects with DMFT >14 (OR = 2.25; CI 95% = 1.30-3.89); low-income (OR = 2.41; CI 95% = 1.22-4.77) and users of cocaine/crack (OR = 2.02; CI 95% = 1.15-3.59) were more likely to have poor general quality of life.ConclusionThis study demonstrated that the general quality of life of addicted persons was associated with caries experience, low income and cocaine/crack use.

Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans.

To examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on suicidal ideation among Veterans with insomnia. Longitudinal data collected in the course of an uncontrolled evaluation of a large-scale CBT-I training program. Outpatient and residential treatment facilities. Four hundred five Veterans presenting for treatment of insomnia. Cognitive behavioral therapy for insomnia (CBT-I). At baseline, 32% of patients, compared with 21% at final assessment, endorsed some level of suicidal ideation [χ(2)(df = 1) = 125; P < 0.001]. After adjusting for demographic variables and baseline insomnia severity, each 7-point decrease in Insomnia Severity Index (ISI) score achieved during CBT-I treatment was associated with a 65% (OR = 0.35; 95% CI = 0.24 to 0.52) reduction in odds of suicidal ideation. The effect of change in insomnia severity on change in depression severity was also significant. After controlling for change in depression severity and other variables in the model, the effect of change in insomnia severity on change in suicidal ideation remained significant. This evaluation of the largest dissemination of CBT-I in the United States found a clinically meaningful reduction in suicidal ideation among Veterans receiving CBT-I. The mechanisms by which effective treatment of insomnia with CBT-I reduces suicide risk are unknown and warrant investigation. The current results may have significant public health implications for preventing suicide among Veterans.

A polytomous rasch analysis of the english version of health-related quality of life for drug abusers test.

The specific aim of this study was to analyze the psychometric properties of the English version of the Health-Related Quality of Life for Drug Abusers Test (HRQoLDA Test) applying the Rasch model, and emphasizing fit between empirical data and theoretical Rasch model assumptions; item(s) category probability curve; and precision in terms of information function. In this study, the authors present the results of the translation and adaptation of the original Spanish version to English, as applied to a sample of substance users in Australia. The authors evaluated 121 adults recruited from inpatient and outpatient treatment facilities in Sydney, Australia. The Rating Scale Model was used in the psychometric analysis of the English version of the HRQoLDA Test. The items and persons revealed a fit between the reported data and the model. It was also demonstrated that respondents did not discriminate among the five response categories, which led to a reduction to three response categories. The adaptation of the TECVASP to the English language, renamed the HRQoLDA test, as developed with an Australian sample revealed adequate psychometric properties.

Initial abstinence status and Contingency Management treatment outcomes: Does race matter?

Initial abstinence status and Contingency Management treatment outcomes: Does race matter?

OR13-2 * PREDICTORS OF RETENTION IN METHADONE MAINTENANCE THERAPY: A PROSPECTIVE MULTI-CENTER STUDY

In the methadone maintenance therapy (MMT) as the treatment of choice in opiate dependency, retention is considered as a target. Given the paucity of data regarding factors affecting retention in MMT in Iran, we sought to determine the predictors of duration of retention. This multi-center prospective study was conducted at 7 outpatient treatment facilities in 4 cities in Iran, in 2007. 282 consecutive opiate dependent people were followed for 6 months, following their entry to MMT. Independent data were registered at baseline and included socio-demographic, social, psychological, drug related and legal data. Length of retention in MMT (0 - 6) considered as dependent variable. Predictors of length of retention were determined using a backward linear regression model. Retention was 0 months in 17.7% (n = 50), 1 months in 19.8% (n = 56), 2 months in 9.2% (n = 26), 3 months in 3.5% (n = 10), 4 months in 8.2% (n = 23), 5 months in 18.8% (n = 53) and 6 months in 22.7% (n = 64). According to the backward linear regression, the only predictors of remission were city (B=0.427, p < 0.001, CI = 0.339 - 0.514), perceived importance of distance to clinic (B = -0.008, p = 0.085, CI = -0.018 - 0.001), perceived social support (B = 0.006, p= 0.069, CI = 0.000 - 0.013), and perceived pleasure with drug use (B = 0.010, p = 0.007, CI = 0.003 - 0.017). This study shed light on factors that may serve as barriers for remaining in MMT for opiate dependence, in Iran. Some variables should be considered in programs developed by Iranian authorities to increase retention rate in MMT.

Development of forensic mental health services in Japan: working towards the reintegration of offenders with mental disorders.

BackgroundUntil the recent enactment of the Medical Treatment and Supervision Act (MTSA) in 2005, neither legislations nor facilities for mentally disordered offenders were available in Japan. The aim of the country’s forensic mental health services, based on this new law, is to improve the social reintegration of mentally disordered offenders. In order to provide optimal psychiatric care to these individuals, specialised court proceedings, treatment facilities, and concrete guidelines have been established. The aim of this study was to review the current status of the new system and to clarify future challenges for improving services.MethodsThe authors collected official statistics regarding the new system published separately by the Ministry of Health, Labour and Welfare, the Ministry of Justice, and the Supreme Court of Japan. We aggregated the data and examined the system’s current implementation status, nationwide.ResultsThere were 2,750 requests for enrolment in the MTSA system between its initiation in 2005 and 31 December 2012. Of those requests, 2,724 cases had been concluded in court. In 63.1% of the cases, an inpatient treatment order had been made; 82.4% of those inpatients were diagnosed with schizophrenia. By the end of March 2012, two patients completing treatment under the MTSA had re-committed a serious offense. While overall designated inpatient and outpatient treatment facilities have reached national targets in terms of resources and beds available, a regional gap in MTSA designated facilities remains and the number of patients under inpatient treatment order is on the increase.ConclusionsOverall, the MTSA system has been running smoothly without encountering any serious problems. However, several concerns have emerged, such as the accumulation of patients under inpatient treatment order and insufficient regional resources. To more successfully promote the reintegration of mentally disordered offenders, improvements in outpatient treatment and welfare services are crucial. In order to install effective measures to help improve the system, a nationwide database of patients being treated under order of the MTSA should be properly built and maintained.

Race/Ethnicity and Geographic Access to Medicaid Substance Use Disorder Treatment Facilities in the United States

Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees. To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure. We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population. Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid. Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect [ME], -3.1; 95% CI, -5.2% to -0.9%), rural (-9.2%; -11.1% to -7.4%), and/or uninsured (-9.5%; -13.0% to -5.9%) residents are less likely to have one of these facilities. The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.