Substance Abuse Treatment Programs Research Articles

A Comparison of Treatment Outcomes for Individuals with Substance Use Disorder Alone and Individuals with Probable Dual Diagnosis

The co-occurrence of substance use and mental health problems, often referred to as dual diagnosis (DD), is increasingly recognised as commonplace within substance abuse treatment programs. Two-hundred and thirty-four individuals from 9 Australian Salvation Army drug and alcohol rehabilitation programs completed a 3-month post-discharge telephone follow-up. Using a cut-off score from the Psychiatric Subscale of the Addiction Severity Index (5th ed.), 66.7% were classified as likely to have DD and 33.3% as substance use disorder only (SUD). Both groups reported comparable and decreased substance use levels at follow-up, yet DD individuals perceived less improvement in substance use problems. Comparable improvements were reported in the areas of: symptom distress and recovery from symptoms. This was despite greater scope for improvement in individuals with DD. Duration of treatment and access to post treatment services were also assessed. Understanding factors effecting treatment outcomes is imperative for the implementation of effective, evidence based treatment programs.

Nonviolent Communication Training and Empathy in Male Parolees

The purpose of this study was to determine the impact of a behavioral intervention, nonviolent communication (NVC), on the development of empathic coping and communication skills in a sample of male parolees enrolled in substance abuse treatment (SAT; N = 30). At the end of the 8-week intervention, results revealed a significant increase (p = .01) in participants' empathy levels. Findings also revealed the acceptability and utility of NVC training to men on parole. Results suggest that NVC training may (a) be a useful addition to substance abuse treatment programs for parolees, (b) be effective in addressing problematic coping and communication styles resulting from incarceration and criminal behavior, and (c) assist paroled individuals in building and sustaining positive social support networks.

Design and methodological considerations of an effectiveness trial of a computer-assisted intervention: An example from the NIDA Clinical Trials Network

Computer-assisted interventions hold the promise of minimizing two problems that are ubiquitous in substance abuse treatment: the lack of ready access to treatment and the challenges to providing empirically-supported treatments. Reviews of research on computer-assisted treatments for mental health and substance abuse report promising findings, but study quality and methodological limitations remain an issue. In addition, relatively few computer-assisted treatments have been tested among illicit substance users. This manuscript describes the methodological considerations of a multi-site effectiveness trial conducted within the National Institute on Drug Abuse's (NIDA's) National Drug Abuse Treatment Clinical Trials Network (CTN). The study is evaluating a web-based version of the Community Reinforcement Approach, in addition to prize-based contingency management, among 500 participants enrolled in 10 outpatient substance abuse treatment programs. Several potential effectiveness trial designs were considered and the rationale for the choice of design in this study is described. The study uses a randomized controlled design (with independent treatment arm allocation), intention-to-treat primary outcome analysis, biological markers for the primary outcome of abstinence, long-term follow-up assessments, precise measurement of intervention dose, and a cost-effectiveness analysis. Input from community providers during protocol development highlighted potential concerns and helped to address issues of practicality and feasibility. Collaboration between providers and investigators supports the utility of infrastructures that enhance research partnerships to facilitate effectiveness trials and dissemination of promising, technologically innovative treatments. Outcomes from this study will further the empirical knowledge base on the effectiveness and cost-effectiveness of computer-assisted treatment in clinical treatment settings.

Typologies of Prescription Opioid Use in a Large Sample of Adults Assessed for Substance Abuse Treatment

BackgroundAs a population, non-medical prescription opioid users are not well-defined. We aimed to derive and describe typologies of prescription opioid use and nonmedical use using latent class analysis in an adult population being assessed for substance abuse treatment.MethodsLatent class analysis was applied to data from 26,314 unique respondents, aged 18-70, self-reporting past month use of a prescription opioid out of a total of 138,928 cases (18.9%) collected by the Addiction Severity Index-Multimedia Version (ASI-MV®), a national database for near real-time prescription opioid abuse surveillance. Data were obtained from November 2005 through December 2009. Substance abuse treatment, criminal justice, and public assistance programs in the United States submitted data to the ASI-MV database (n = 538). Six indicators of the latent classes derived from responses to the ASI-MV, a version of the ASI modified to collect prescription opioid abuse and chronic pain experience. The latent class analysis included respondent home ZIP code random effects to account for nesting of respondents within ZIP code.ResultsA four-class adjusted latent class model fit best and defined clinically interpretable and relevant subgroups: Use as prescribed, Prescribed misusers, Medically healthy abusers, and Illicit users. Classes varied on key variables, including race/ethnicity, gender, concurrent substance abuse, duration of prescription opioid abuse, mental health problems, and ASI composite scores. Three of the four classes (81% of respondents) exhibited high potential risk for fatal opioid overdose; 18.4% exhibited risk factors for blood-borne infections.ConclusionsMultiple and distinct profiles of prescription opioid use were detected, suggesting a range of use typologies at differing risk for adverse events. Results may help clinicians and policy makers better focus overdose and blood-borne infection prevention efforts and intervention strategies for prescription opioid abuse reduction.

Substance Abuse Treatment in United States Prisons: A Social Work Perspective

A literature review was completed to explore the existing, scholarly articles concerning substance abuse treatment programs offered in different U.S. prisons. The theoretical perspectives that were applied in the treatment of inmates were analyzed, and recommendations were given about how to expand upon completed work with these individuals. Upon examination, it was discovered that the primary theories and models used in various types of substance abuse treatment are biopsychosocial, systems, and assets-based community development models. Strategies and interventions were also developed based on the knowledge presented in the articles, and implications for social work practice were considered in the process.

A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs

The purpose of this study was to examine the effects of feedback provided to counselors on the outcomes of patients treated at community-based substance abuse treatment programs. A version of the Outcome Questionnaire (OQ-45), adapted to include drug and alcohol use, was administered to patients (N = 304) in 3 substance abuse treatment clinics. Phase I of the study consisted only of administration of the assessment instruments. Phase II consisted of providing feedback reports to counselors based on the adapted OQ-45 at every treatment session up to Session 12. Patients who were found to not be progressing at an expectable rate (i.e., “offtrack”) were administered a questionnaire that was used as a second feedback report for counselors. For offtrack patients, feedback compared with no feedback led to significant linear reductions in alcohol use throughout treatment and also in OQ-45 total scores and drug use from the point of the second feedback instrument to Session 12. The effect for improving mental health functioning was evident at only 1 of the 3 clinics. These results suggest that a feedback system adapted to the treatment of substance use problems is a promising approach that should be tested in a larger randomized trial.

Hepatitis B virus and hepatitis C virus services offered by substance abuse treatment programs in the United States

Although substance abuse treatment programs are important contact points for providing health services for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, availability of services in these programs has not been well characterized. This study evaluated the spectrum of HBV and HCV services offered by substance abuse treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Our survey of substance abuse treatment program administrators covered availability of testing for HBV and HCV; hepatitis A virus (HAV) and HBV immunization; and HCV medical and nonmedical services. There were also questions covering clarity of guidelines for HBV and HCV testing and HAV and HBV immunization. Differences between methadone and nonmethadone programs were examined. Despite the importance of substance abuse in sustaining the hepatitis epidemics, few programs offer comprehensive HBV and HCV testing or HCV health care services. Interventions to improve access to hepatitis services for substance-abusing patients are needed.

Mortality among substance‐using mothers in California: a 10‐year prospective study

To examine mortality rates and causes of death among a cohort of substance-using mothers and to identify risk factors that predict mortality. This is a prospective study of a cohort of 4447 substance-using mothers (pregnant or parenting) who were enrolled during 2000-02 in 40 drug abuse treatment programs across California. All mothers were assessed at baseline using the Addiction Severity Index. Mortality data were obtained from the National Death Index and causes of death were coded using ICD-10. Standardized mortality ratios (SMR) were calculated relative to women in the general population adjusted for age. Proportional hazard (Cox) regression was used to identify risk factors predicting death. At the end of 2010, 194 deaths were confirmed, corresponding to a crude mortality rate of 4.47 per 1000 person-years and SMR of 8.4 (95% confidence interval: 7.2-9.6). Drug overdose (28.8%), cardiovascular disease (10%), and alcohol or drug disorders (8.9%) were the leading causes of death. Baseline factors associated with higher mortality included older age, being white (relative to African American or Hispanic), heroin, alcohol, cocaine or marijuana (relative to methamphetamine) as the primary drug problem, drug injection and greater severity of employment, medical/health and psychiatric problems. Substance-using mothers have 8.4 times the mortality than that observed among US women of similar age. Greater severity of employment, medical/health and psychiatric problems contributed to the elevated mortality.

Changes in sexual activity following substance dependence treatment

Individuals who abuse alcohol and other drugs are at increased risk for HIV/AIDS, although time of greatest risk is unclear. Although many studies have documented decreased sexual risk behaviours following substance abuse treatment, some evidence indicates that sexual risk behaviours may actually increase with sobriety. In this study, individuals involved in a substance abuse treatment programme were asked about their sexual activity for the month prior to treatment and 6 months after treatment. Results showed higher levels of sexual activity, including risky sexual activity, 6 months after discharge from treatment. This increase was found for individuals regardless of whether they were abstaining from substance use at follow-up, with highest levels of sexual activity and risky sexual activity reported by those still consuming alcohol or other drugs. These findings support the need for inclusion of HIV/AIDS prevention and educational programmes during substance abuse treatment.

Predictors of Retention of Women Offenders in a Community-Based Residential Substance Abuse Treatment Program

Substance abuse is a major contributing factor to women being incarcerated in the United States, and substance abuse is a critical factor in the high recidivism rates of women offenders (50–70% within one year). Understanding factors that enhance and deter women from retention in substance abuse treatment will facilitate tailored interventions to improve treatment outcomes. This prospective study examined the relationship of substance use characteristics, childhood trauma, current trauma-related symptoms, motivation to treatment, and socio-demographic characteristics, in predicting the retention of women offenders in an urban, residential substance abuse program as they re-enter the community from incarceration. All women were interviewed within the first week of admission to the residential program using the following measures: the Addiction Severity Index (ASI), the Childhood Trauma Questionnaire (CTQ), and the Trauma Symptom Inventory (TSI), and socio-demographic characteristics. Length of stay was tra...

Evidence-Based Practices, Attitudes, and Beliefs in Substance Abuse Treatment Programs Serving American Indians and Alaska Natives: A Qualitative Study

Substance abuse disproportionately impacts American Indian/Alaska Native (AI/AN) communities in the United States. For the increasing numbers of AI/AN individuals who enter and receive treatment for their alcohol or other drug problem it is imperative that the service they receive be effective. This study used qualitative methodology to examine attitudes toward evidence-based practices, also known as evidence-based treatments (EBTs) in minority-serving substance abuse treatment programs in the San Francisco Bay area. Twenty-two interviews were conducted in the study, of which seven were with program directors and substance abuse counselors at two urban AI/AN focused sites. These clinics were more likely than other minority-focused programs to have experience with research and knowledge about adapting EBTs. Only in the AI/AN specific sites did an issue arise concerning visibility, that is, undercounting AI/AN people in national and state databases. Similar to other minority-focused programs, these clinics described mistrust, fear of exploitation from the research community, and negative attitudes towards EBTs. The underutilization of EBTs in substance abuse programs is prevalent and detrimental to the health of patients who would benefit from their use. Future research should explore how to use this research involvement and experience with adaptation to increase the adoption of EBTs in AI/AN serving clinics.

Shame Resilience: A Strategy for Empowering Women in Treatment for Substance Abuse

Shame resilience theory (SRT) proposes that a woman who experiences shame can reduce the sense of feeling trapped, isolated, and powerless by implementing specific strategies and processes that increase awareness and understanding about shame and the sociocultural expectations that trigger it. SRT also promotes reaching out to others who can offer empathy and support and building skills in conveying what she feels and needs. This article reports on a pilot study of Connections, a 12-week psychoeducational curriculum based on SRT and piloted with 19 women from predominantly Hispanic backgrounds in 3 residential substance abuse treatment programs in central California. The results indicate statistically significant differences on measures of general health, depressive symptoms, internalized shame, self-conscious affect, and shame resilience.

American Indian Culture as Substance Abuse Treatment: Pursuing Evidence for a Local Intervention

Contemporary tribal commitments to traditional cultural reclamation and revitalization find continued expression by recent generational cohorts of American Indians who, when it comes to matters of recovery, healing, and wellness in the context of substance abuse, routinely assert that “our culture is our treatment.” And yet, empirical investigations of this culture-as-treatment hypothesis—namely, that a (post)colonial return to indigenous cultural orientations and practices is sufficient for effecting abstinence and recovery from substance use disorders for many American Indians—have yet to appear in the scientific literature. Preliminary activities of a research partnership dedicated to the empirical exploration of this hypothesis for reducing Native American substance use disorders are summarized. Specifically, collaboration between a university-based research psychologist and a reservation-based substance abuse treatment program staff has thus far resulted in a detailed blueprint for a radically alternative, culturally-grounded intervention developed for reservation residents. This proposed alternative intervention—a seasonal cultural immersion camp designed to approximate the day-to-day experiences of prereservation ancestors—was designed for eventual implementation and evaluation with adult clients referred for residential treatment on the Blackfeet Indian reservation. It is anticipated that the proposed intervention will eventually afford empirical evaluation of the culture-as-treatment hypothesis.

Community Providers' Impression of HIV Prevention Intervention Research in NIDA's Clinical Trials Network.

Research-based approaches to HIV risk reduction are available but not readily adopted by community-based treatment programs. This exploratory survey study assessed staff (N=116) attitudes as a function of direct research participation, treatment program type, and study performance within seven methadone maintenance and eight psychosocial outpatient substance abuse treatment programs that participated in the NIDA Clinical Trials Network HIV risk reduction trials. Clinical staff who directly participated in the research reported intervention components as useful and were more likely to report perceived increases in HIV testing/referrals compared to staff who did not directly participate. However, those directly involved reported less positive attitudes about clinical impact and research impression. Results suggest a positive influence of research participation on awareness of program services, but also the need to address practical and professional issues related to research collaboration. Effectiveness trials offer a valuable opportunity to assess provider-level factors associated with adoption and implementation.

The Substance Abuse Counseling Workforce: Education, Preparation, and Certification

ABSTRACT The National Drug Abuse Treatment Clinical Trials Network (CTN) is an alliance of drug abuse treatment programs and research centers testing new interventions and implementation factors for treating alcohol and drug use disorders. A workforce survey distributed to those providing direct services in 295 treatment units in the CTN obtained responses from 1750 individuals with a job title of counselor (n = 1395) or counselor supervisor (n = 355). A secondary analysis compares and describes both groups. Supervisors were more likely to be licensed or certified. Master's degrees were more common among counselors in outpatient and methadone programs. Counselors in residential settings tended to be on the job fewer years. Finally, higher education was associated with greater familiarity with and acceptance of evidence-based practices.

Substance Abuse Treatment for Women who are Under Correctional Supervision in the Community: A Systematic Review of Qualitative Findings

This systematic review was conducted to more fully analyze qualitative research findings relating to community-based court-supervised substance abuse treatment for women and to make recommendations regarding treatment enhancement. Five reports of qualitative research met the inclusion criteria. Findings from these reports were extracted and analyzed using constant comparative methods. Women who are referred to court-sanctioned substance abuse treatment programs may initially be reluctant to participate. Once engaged, however, they advocate for a full complement of well-financed comprehensive services. To optimize treatment effectiveness, women recommend gender-specific programs in which ambivalence is diminished, hope is instilled, and care is individualized.

Drunk versus drugged: How different are the drivers?

BackgroundDriving under the influence (DUI) of drugs is increasing in the U.S., but little is known about the differences based on their patterns of use and abuse of alcohol and other drugs. MethodsThis paper uses a large dataset to study patients admitted to Texas substance abuse treatment programs with one or more past-year DUI arrests. t-Tests are used for comparisons between normally distributed continuous data and chi square for categorical data. ResultsFirst-time DUI offenders not only differ from those reporting more than one past-year DUI, but they differ among themselves in terms of demographics, treatment participation, substance use problems, and mental health disorders. Those with primary problems with methamphetamine, crack cocaine, powder cocaine, other opiates, sedatives, and heroin reported more days of problems and more daily use than those with problems with alcohol, while offenders with primary problems with cannabis were less impaired. ConclusionsThe most impaired clients were less likely to be referred to treatment from the justice system, and the differences in drug and alcohol offenders show the need to tailor approaches with education and treatment programs. More attention should be given to the needs of drivers impaired through use of prescription drugs such as the opiates and sedatives, as well as female drivers, and the role of acculturation should be recognized in programs for Hispanic drivers. In addition, specific programs should be targeted to young cannabis abusers and underage offenders. All first-time DUI arrestees should be assessed for their levels of impairment.

Access to a running wheel inhibits the acquisition of cocaine self-administration

Physical activity decreases cocaine self-administration in laboratory animals and is associated with positive outcomes in substance abuse treatment programs; however, less is known about its efficacy in preventing the establishment of regular patterns of substance use in drug-naive individuals. The purpose of the present study was to examine the effects of access to a running wheel on the acquisition of cocaine self-administration in experimentally naive rats. Male, Long–Evans rats were obtained at weaning and assigned to sedentary (no wheel) or exercising (access to wheel) conditions immediately upon arrival. After six weeks, rats were surgically implanted with intravenous catheters and placed in operant conditioning chambers for 2h/day for 15 consecutive days. Each session began with a noncontingent priming infusion of cocaine, followed by a free-operant period in which each response on the active lever produced an infusion of cocaine on a fixed ratio (FR1) schedule of reinforcement. For days 1–5, responding was reinforced with 0.25mg/kg/infusion cocaine; for days 6–15, responding was reinforced with 0.75mg/kg/infusion cocaine. In addition, all rats were calorically restricted during days 11–15 to 85% to 95% of their free-feeding body weight. Compared to sedentary rats, exercising rats acquired cocaine self-administration at a significantly slower rate and emitted significantly fewer active lever presses during the 15days of behavioral testing. These data indicate that access to a running wheel inhibits the acquisition of cocaine self-administration, and that physical activity may be an effective intervention in substance abuse prevention programs.

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.

Zero-Inflated and Hurdle Models of Count Data with Extra Zeros: Examples from an HIV-Risk Reduction Intervention Trial

Background: In clinical trials of behavioral health interventions, outcome variables often take the form of counts, such as days using substances or episodes of unprotected sex. Classically, count data follow a Poisson distribution; however, in practice such data often display greater heterogeneity in the form of excess zeros (zero-inflation) or greater spread in the values (overdispersion) or both. Greater sample heterogeneity may be especially common in community-based effectiveness trials, where broad eligibility criteria are implemented to achieve a generalizable sample. Objectives: This article reviews the characteristics of Poisson model and the related models that have been developed to handle overdispersion (negative binomial (NB) model) or zero-inflation (zero-inflated Poisson (ZIP) and Poisson hurdle (PH) models) or both (zero-inflated negative binomial (ZINB) and negative binomial hurdle (NBH) models). Methods: All six models were used to model the effect of an HIV-risk reduction intervention on the count of unprotected sexual occasions (USOs), using data from a previously completed clinical trial among female patients (N = 515) participating in community-based substance abuse treatment (Tross et al. Effectiveness of HIV/AIDS sexual risk reduction groups for women in substance abuse treatment programs: Results of NIDA Clinical Trials Network Trial. J Acquir Immune Defic Syndr 2008; 48(5):581–589). Goodness of fit and the estimates of treatment effect derived from each model were compared. Results: The ZINB model provided the best fit, yielding a medium-sized effect of intervention. Conclusions and Scientific Significance: This article illustrates the consequences of applying models with different distribution assumptions on the data. If a model used does not closely fit the shape of the data distribution, the estimate of the effect of the intervention may be biased, either over- or underestimating the intervention effect.