Substance Abuse Treatment Units Research Articles

An Institutional Analysis of HIV Prevention Efforts by the Nation's Outpatient Drug Abuse Treatment Units

Drawing from an institutional-theory perspective on innovations in organizations, this paper examines the use of human immunodeficiency virus (HIV) prevention practices by the nation's outpatient substance abuse treatment units during a critical period from 1988 to 1995. An institutional perspective argues that organizations adopt new practices not only for technical reasons, but also because external actors actively promote or model the use of particular practices. We examine the extent to which treatment units use several practices to prevent HIV infection among their clients and among drug-users not in treatment. Results from random-effects regression analyses of national survey data show that treatment units significantly increased their use of HIV prevention practices from 1988 to 1995. Further, the results show that treatment units' use of prevention practices was related to clients' risk for HIV infection, unit resources available to support these practices, and organizational support for the practices. Implications are discussed for an institutional view of organizational innovation as well as for research on HIV prevention.

Managed care and technical efficiency in outpatient substance abuse treatment units.

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.

Organizational factors related to AIDS/HIV education in outpatient substance abuse treatment units.

The association of HIV and AIDS with intravenous drug use is well documented. Given this, substance abuse treatment providers must figure prominently in any effective national response to HIV/AIDS. The strategies employed by human service managers to address AIDS may be important in explaining how substance abuse treatment units implement policies and programs concerning AIDS-related prevention services. This paper utilizes data from the National Drug Abuse Treatment System Survey to examine how strategic activities concerning AIDS/HIV undertaken by outpatient substance abuse treatment unit managers impacted the provision of preventive AIDS-related services to clients. Results of multiple regression analysis indicate collaboration with other human service organizations and environmental scanning activities are important variables in explaining variation among substance abuse treatment units in the provision of AIDS prevention education to clients. Based on these findings, implications for future research and policy concerning AIDS prevention within the context of substance abuse treatment are made.

Auricular Acupuncture as an Adjunctive Treatment for Cocaine Addiction: A Pilot Study

The authors conducted a single-blind study of auricular acupuncture in 36 cocaine-dependent inpatient veterans on a substance abuse treatment unit to determine whether the treatment could help reduce craving, increase treatment retention, and prevent relapse. Acupuncture was given on a predetermined schedule to both treatment and control groups, with status assessed regularly by independent, blinded raters. The study failed to show a significant difference between treatment and control groups. However, the study patients, as a whole, did remain in treatment longer than a retrospectively analyzed group who received no acupuncture.

Auricular Acupuncture as an Adjunctive Treatment for Cocaine Addiction: A Pilot Study

The authors conducted a single-blind study of auricular acupuncture in 36 cocaine-dependent inpatient veterans on a substance abuse treatment unit to determine whether the treatment could help reduce craving, increase treatment retention, and prevent relapse. Acupuncture was given on a predetermined schedule to both treatment and control groups, with status assessed regularly by independent, blinded raters. The study failed to show a significant difference between treatment and control groups. However, the study patients, as a whole, did remain in treatment longer than a retrospectively analyzed group who received no acupuncture.

Managed care penetration in outpatient substance abuse treatment units.

The authors present the first nationally representative data on managed care penetration in the outpatient substance abuse treatment (OSAT) sector. Thirty-eight percent of all OSAT units were involved in some form of managed care in 1995, with 22 percent of their client base covered by managed care. There is also variation in managed care penetration and activity across different types of treatment units. Private for-profit units are involved in managed care to a greater extent than are public and private, not-for-profit organizations. Units affiliated with a hospital have greater participation and penetration than other units. Smaller OSAT facilities have a disproportionately large percentage of their client base in managed care arrangements. Finally, private managed care arrangements are more prevalent, more evenly distributed across organizational types, and represented in larger numbers than are public sources of managed care.

Outcomes of inpatients treated on a VA psychiatric unit and a substance abuse treatment unit.

The utility of the Treatment Outcome Profile (TOP) for measuring the effectiveness of acute inpatient psychiatric and substance abuse treatment was tested, including its internal reliability, validity, and sensitivity to treatment gains. The relationship between patients' satisfaction with services and treatment gains in quality of life, symptoms, and level of functioning was explored. A pre-post research design was used with consecutive admissions to an inpatient psychiatric unit (N = 66) and a substance abuse treatment unit (N = 88) at a VA medical center. At admission and at discharge, the TOP, a self-report instrument assessing quality of life, symptoms, level of functioning, and patient satisfaction with services (at discharge only) was completed. Multivariate analysis of variance and univariate analysis of variance were used to test differences in scores between admission and discharge. Patients demonstrated significant treatment gains. Overall, compared with patients on the substance abuse unit, those receiving psychiatric treatment were more impaired at admission and had lower levels of self-reported therapeutic gain at discharge. Improvement for both groups occurred in quality of life, symptoms, and level of functioning. Both groups reported high levels of patient satisfaction, comparable with levels in other service industries. A high positive correlation (alpha = .61) was found between patient satisfaction and overall self-reported treatment gain. The results indicate that it is important to compare treatment effectiveness as well as costs when seeking less costly alternatives to inpatient care. The TOP is a valid and sensitive outcome measurement tool. Patient satisfaction is an important outcome variable and positively related to treatment gains in quality of life, symptoms, and level of functioning.

Supervisor Ideology and Organizational Response

Distinct practice ideologies or ideologies of care are deemed to influence greatly the selection of intervention methods and the mix of services adopted by the providers. Examined here is the relation between clinical supervisor ideology and variation among human service organizations in their provision of HIV/AIDS prevention services. Data were drawn from a 1990 national, representative sample of outpatient substance abuse treatment (OSAT) units. The study affirms that ideology is central to both means and ends in HSOs, helping to define the organization's mission and goals, and establishing guidelines for practice and procedures. Future research on the relationship between ideology and HIV/AIDS education can benefit from efforts to develop alternative strategies for measuring ideologies of care among both managers and staff in substance abuse settings.

Variation in Outpatient Substance Abuse Treatment Units with High Concentrations of Latino Versus White Clients: Client Factors, Treatment Experiences, and Treatment Outcomes

Research on Latinos receiving substance abuse care lacks detail in terms of client characteristics, treatment services, and the effectiveness of treatment. This study uses data from a large, recent, nationally representative sample of outpatient substance abuse treatment units to examine differences in client characteristics, treatment services, and outcomes. The study examines differences between units with 20% or more Latino clients and treatment units with 90% or more White clients. Results show that units with high concentrations of Latinos treat clients who are significantly poorer, more prone to abuse drugs than alcohol, more prone to turn to crime to support their habit, more likely to be ordered to treatment by the courts, and at a higher risk for HIV/AIDS; these clients have poorer treatment outcomes. Treatment and policy implications for units treating high concentrations of Latino clients and culturally sensitive substance abuse treatment are discussed.

Patient Predictors of Irregular Discharge From Inpatient Substance Abuse Treatment

The authors conducted a controlled cohort study to determine the characteristics of patients irregularly discharged from inpatient substance-abuse treatment and to derive and validate an instrument to predict such early discharge. The sample was 220 subjects (110 consecutive patients who were discharged early and 110 matched control patients) admitted to a voluntary substance abuse treatment unit of a general hospital. Structured chart audits were used to collect demographic and clinical data. Hierarchical logistic regression identified only three predictors of irregular discharge: predominant heroin use, failure to complete high school, and age younger than 30 years. These three items were used to derive and validate an instrument for predicting completion of treatment. Readily available information on age, education, and psychoactive substance history is useful in identifying the risk of early discharge from inpatient substance abuse treatment.

Irregular discharges from a dual diagnosis unit.

Irregular discharges, previously studied on psychiatric or substance abuse treatment units, are a particular problem for dual diagnosis units. We examined demographic and clinical variables for their association with irregular discharge from an acute dual diagnosis inpatient unit, retrospectively reviewing 316 consecutive admissions. One hundred and nineteen patients (37.7%) were irregularly discharged (61 AMA, 31 administrative, 27 elopements), staying an average of 18.8 days compared with 51.4 days for those regularly discharged (p < .001). Younger age (p = .007) and discharge diagnosis of antisocial personality disorder (p < .001) were associated with irregular discharge; the attending psychiatrist was also significant (p = .016). Demographic variables (sex, ethnicity, marital status, religion, employment, education, living circumstances), Axis I diagnosis, and type and number of substances abused were not predictive of discharge type. Patients irregularly discharged within the first week (40% of irregular discharges) were significantly less likely to have known legal involvement (p = .006). No significant temporal clustering of irregular discharges was found on a daily, weekly, or monthly basis, nor was a seasonal pattern detected. These findings are generally consistent with several pre-DSM-III studies on nondual diagnosis units, but more specifically highlight the diagnosis of antisocial personality. Regarding program completion, they suggest that risk factors for irregular discharge (substance abuse, antisocial personality, characteristics of the doctor-patient relationship, problems of younger patients) have not been adequately addressed simply by creating dual diagnosis units. Further programming study appears warranted to address the problem of patient retention on dual diagnosis units.

Electroencephalographic Sleep And Mood During Cocaine Withdrawal

We report on nine patients between the ages of 21 and 39 years who were admitted to an inpatient substance abuse treatment unit for cocaine treatment. The patients' sleep was studied in the laboratory for 4 nights during the first week, and 2 nights during the second and third weeks of their hospitalization. Daily mood ratings, cocaine craving scores and sleep logs were also recorded on each patient. During the first week of withdrawal, these patients had a markedly shortened REM latency, an increased REM sleep percentage, a very high REM density and a long total sleep period time. During the third week, REM latencies were very short and total percentage of REM sleep was increased. By week three of withdrawal the sleep continuity pattern was similar to that found in chronic insomnia, with a long sleep latency, an abnormally increased total time awake after sleep onset and a poor sleep efficiency. The subjects' ratings of cocaine craving, total POMS scores and depression fell precipitously after the first week of withdrawal and were at sub-clinical levels by week three of withdrawal.

Self-reports by alcohol and drug abuse inpatients: factors affecting reliability and validity.

The reliability and validity of self-report data regarding substance abuse has often been questioned. To determine how best to enhance the veracity of self-report, three factors which might affect self-report veracity were examined: alcohol status at time of interview; level of cognitive functioning; and method of self-report data collection. Subjects were 234 admissions to an inpatient substance abuse treatment unit. Self-report data were collected via both personal interview on the day of admission and and questionnaire within the first week of stay. Self-reports concerned use of alcohol, cocaine, and marijuana in the days preceding admission. Test-retest reliability for the questionnaire data produced reliability coefficients of 0.88, 0.91, and 0.88, for alcohol, cocaine, and marijuana, respectively. Variation in inter-test interval had virtually no effect upon reliability coefficients. Interview data were compared to toxicologic analyses of blood and urine samples collected on admission. Overall, this comparison showed self-reports to be valid, with a 97% agreement between verbal report and laboratory data for alcohol, 93% for cocaine, and 84% for marijuana. The comparison of interview data with questionnaire responses also showed self-reports to be valid: 90% agreement for alcohol, 93% for cocaine, and 81% for marijuana. Level of cognitive function did not influence the validity of self-reports for any of the three substances. Recent consumption of alcohol also had no statistically significant effect on the validity of self-reported marijuana use, regardless of the operational form of validity tested. However, BAC-negative subjects produced a significantly greater validity coefficient for self-reported cocaine use (kappa = 0.87) than did BAC-positive patients (kappa = 0.43), when interview data were compared with toxicologic measures. A similar finding was not uncovered when interview and questionnaire data were compared. An interaction between admission alcohol status and cognitive function was uncovered for cocaine self-reports when interview data was compared with toxicologic measures. The rate of agreement for alcohol-negative subjects is quite high for both cognitively impaired and unimpaired subjects (M = 93% and M = 94%, respectively) as well as for alcohol-positive, cognitively unimpaired subjects (M = 94%), but not for alcohol-positive, cognitively impaired subjects (M = 67%). Results are discussed in terms of threats to the validity of self-report and strategies for the optimization of response accuracy.

Persistent Urinary Benzoylecgonine Following Cocaine Use

The authors examine the utility of a fluorescence polarization immunoassay (the ADx Cocaine Metabolite Assay) for the determination of benzoylecgonine in 41 patients (28 women and 13 men) admitted to an inpatient substance abuse treatment unit following recent cocaine use. The assay remained positive (i.e., exceeded 300 ng/ml) in urine for a mean of 84.4 hours from the last reported use. There was no difference by gender or route of administration either for grams used or hours of positivity. Cocaine use in the week prior to admission was the only significant predictor of hours of positivity; age, gender, and weight did not contribute significantly to the variance. The implications of these findings for both cocaine pharmacokinetics and for treatment of cocaine abuse are discussed.

Yale substance abuse treatment unit psychotherapy research battery: Kathleen Carroll. Yale University School of Medicine, New Haven, CT

Yale substance abuse treatment unit psychotherapy research battery: Kathleen Carroll. Yale University School of Medicine, New Haven, CT

Patients who use drugs during inpatient substance abuse treatment

Drug use by patients during inpatient substance abuse treatment is frequently a cause of premature hospital discharge. The authors examined the histories of patients who used drugs while in inpatient substance abuse treatment, the methods used to detect drug use, and the temporal relationship of drug use episodes. The authors reviewed the charts of patients admitted consecutively to an inpatient substance abuse treatment unit between 1981 and 1988. Of 729 patients, 42 were found to have used drugs while receiving inpatient treatment. The diagnoses and clinical histories of these 42 patients were compared with those of all other patients. Methods of detection and circumstances of drug use were recorded, and drug use episodes were plotted on a time line that was examined for temporal clustering. Significantly more of the patients who used drugs during inpatient substance abuse treatment had primarily used heroin or methadone before treatment. Random urine screens, self-report, and staff observation together detected approximately 85% of the patients who used drugs during treatment. Episodes of drug use did cluster in time, but within clusters the hospital stays of the patients who used drugs did not necessarily overlap. Temporal clustering of drug use episodes may occur because drug use by one patient heralds drug availability and stimulates craving in other inpatients. Clinicians should be aware that one episode of drug use may be followed by others. Multiple detection methods, including random comprehensive urine screens, should be used to test for drug use on inpatient units.

Evaluation of patients treated for pathological gambling in a combined alcohol, substance abuse and pathological gambling treatment unit using the Addiction Severity Index

Seventy-two pathological gambling patients were followed-up after treatment in a combined alcohol, substance abuse and compulsive gambling treatment program. The Addiction Severity Index (modified for use with pathological gamblers) was used to evaluate the effectiveness of treatment. Patients reduced their intake of alcohol, other drugs and their gambling as well as improved in legal, family/social, and psychological functioning. There was a trend for improvement in medical condition and no net change in employment functioning. The study supports the idea that combined treatment is an effective way of dealing with patients whose gambling problems are discovered when they enter treatment for another addiction, as well as for patients whose initial complaints include pathological gambling, with or without additional problems.

Buprenorphine: Beyond Methadone?

This month's guest authors are affiliated with the substance abuse treatment and treatment research unit of the Connecticut Mental Health Center and the department of psychiatry at Yale University School of Medicine, where Dr. Rosen is instructor and Dr. Kosten is associate professor. They discuss a promising new treatment that may reduce abuse of cocaine by drug addicts who use intravenous heroin and may indirectly reduce risk-taking behavior associated with transmission of the human immunodeficiency virus.

Ratings of behavior problems in adolescents hospitalized for substance abuse

Abstract The usefulness of the Devereux Adolescent Behavior Rating Scale (DAB) for assessing behavior problems in adolescents hospitalized for substance abuse was demonstrated using a sample of 404 adolescents admitted to inpatient substance abuse treatment units. Adolescents admitted to these units displayed multiple behavioral difficulties, which require consideration in any treatment planning. From the 15 original DAB scales, four broad‐band scales measuring acting out behaviors, psychotic behaviors, attention seeking/expressive behaviors, and inner turmoil/frailty, were developed to improve its usefulness. Age and gender differences on these four broad‐band scales are discussed in terms of their clinical implications and suggestions are given for further use of and research with the DAB.

Predictors of rehospitalization in a male alcoholic population.

The aim of this study was to determine demographic and psychological predictors of rehospitalization in a group of 238 alcoholic patients followed 6 months after hospital discharge. The relationship of the person's perception of the treatment environment and whether treatment was completed or not was also studied in regard to readmission. At the time of admission to an inpatient Substance Abuse Treatment Unit, patients gave demographic and medical, social, and vocational histories. They also completed a battery of psychological tests which measured symptoms, mood, and motivation. One week after admission they rated their perception of the treatment unit in regards to 12 dimensions of ward atmosphere. Of the 200 patients available for follow-up, 125 completed the 30 to 50 d treatment and 75 did not. Thirty percent of the patients were readmitted within 6 months. Patients with more stable life histories in terms of employment and family background were less often readmitted. Being depressed, angry, inert, and thoughtful (preoccupied) was associated with relapse. In addition, patients who had a low need to succeed at the time of admission were less prone to remain in the community. Perception of the treatment ward as more autonomous was related to longer community tenure. Whether or not treatment was completed was not associated significantly with readmission. Since hospitalization is costly both socially and economically, identifying predictors which distinguish those individuals prone to relapse may lead to the establishment of different goals for these patients within alcohol treatment programs.