Treatment Entry Research Articles

Coerced addiction treatment: Client perspectives and the implications of their neglect

Recent work has criticized the evidence base for the effectiveness of addiction treatment under social controls and coercion, suggesting that the development of sound policies and treatment practices has been hampered by numerous limitations of the research conducted to date. Implicit assumptions of the effectiveness of coerced treatment are evident in the organization and evolution of treatment, legal, and social service systems, as well as in related legislative practices. This review builds upon previous work by focusing in greater detail on the potential value of incorporating client perspectives on coercion and the implications for interpreting and applying existing research findings. Reviewing the existing empirical and theoretical literature, a case is made for greater accuracy in representing coercive experiences and events in research, so as to better align the measured concepts with actual processes of treatment entry and admission. Attention is given to studies of the effectiveness of treatment under social controls or pressures, the connections to coercion and decision-making, and theoretical perspectives on motivation and behaviour change, including Self-Determination Theory in particular. This synthesis of the available research on coerced addiction treatment suggests that it remains largely unclear to what extent many of the commonly employed methods for getting people into treatment may be detrimental to the treatment process and longer-term outcomes. The impact of coercion upon individual clients, treatment systems, and population health has not been adequately dealt with by addiction researchers to date.

Comparing Outcomes of ‘Voluntary’ and ‘Quasi-Compulsory’ Treatment of Substance Dependence in Europe

Aim: This study evaluates quasi-compulsory drug treatment (QCT) arrangements for substance-dependent offenders receiving treatment instead of imprisonment in comparison to voluntary treatment within five European countries. Methods: Participants were interviewed with the European Addiction Severity Index, the ASI-crime module, questions on perception of pressure and self-efficacy, and the Readiness-to-Change Questionnaire at treatment entry and after 6, 12, and 18 months. Results: Reductions in substance use and crime as well as improvements in health and social integration were observed in QCT and voluntary treatment groups. After controlling for various factors, subjects in the QCT and the comparison group showed similar reductions in substance use and crime over time. Study retention was comparable in both groups. Conclusion: QCT is as effective as voluntary treatment provided in the same services in reducing substance use and crime.

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AbstractStudy Finds Link Between Controlling Drug Use and Treatment Entry in IDUsEvidence‐Based Alcohol and Drug Intervention Effective, Easy to ImplementWorkplace Drug Testing Helps Maintain Long‐Term Cocaine AbstinenceReview: Substance Use Treatment Leads to Reductions in Partner ViolenceStudy: Combination Nicotine Therapy More Effective Than MonotherapyField Should Be Unified, Not Divided, by NIDA‐NIAAA Merger Discussion

Inmate Prerelease Assessment (IPASS) Aftercare Placement Recommendation as a Predictor of Rural Inmate's 12-step Attendance and Treatment Entry Postrelease

The purpose of this study is to use the Criminal Justice Drug Abuse Treatment Studies' (CJ-DATS) Inmate Prerelease Assessment (IPASS), which recommends either intensive or nonintensive treatment after release, to predict rural offenders' 12-step attendance and treatment entry within six months of release from prison. IPASS scores indicated that 52% of rural offenders needed intensive treatment upon community re-entry. In bivariate analyses, rural offenders with an intensive aftercare placement recommendation were significantly younger, more likely to have been employed more months in the year prior to incarceration, to have ever injected drugs, and to have ever received outpatient substance abuse treatment. The variables which were significant at the bivariate level were entered into two logistic multivariate models predicting 12-step attendance and treatment entry within six months of being released from prison. Age and having ever injected drugs were positive predictors of having attended a 12-step meeting, while the number of months legally employed was negatively related to 12-step attendance. In the treatment entry model, age increased the odds of entering formal treatment while having ever injected a drug decreased the odds. IPASS aftercare placement recommendation was not significant in either of the multivariate models. Findings from this study suggest that offenders re-entering rural communities may receive limited community-based continued care and future studies should explore geographic-specific treatment barriers. Implications for rural substance abuse treatment are provided.

An Outcome Evaluation of a Treatment Readiness Group Program for Probationers with Substance Use Problems

From 2003 to 2008, Treatment Alternatives for Safe Communities of Illinois (TASC) implemented the Reducing Risk: Outreach and Pretreatment for Probationers program (RROPP) in Cook County (Chicago), Illinois. The goal of RROPP was to reduce probationers' further penetration into the criminal justice system by increasing participation in substance abuse treatment. To achieve this goal, TASC incorporated evidence-based practices for enhancing the effectiveness of pretreatment services. An outcome evaluation assessed the extent to which RROPP's proposed goals were achieved. The evaluation also obtained useful information regarding lessons learned in the implementation of pretreatment services for probationers. Participation in TRGs was related positively to treatment entry, length of stay in first treatment episode, and completion of first treatment episode.

Suicide attempt in first-episode psychosis: A 7.4 year follow-up study

Background Individuals with first-episode psychosis demonstrate high rates of suicide attempt (SA). Aims 1) To examine the prevalence of, and risk factors for, SA in a first-episode psychosis (FEP) cohort over a 7.4 year follow-up period. 2) To investigate differences between single versus multiple suicide attempters. Methods This study reports baseline and follow-up data from a naturalistic, prospective follow-up of 413 FEP patients treated at a specialist early psychosis centre. Assessments were conducted at treatment entry, initial symptom remission or stabilization, and long term follow-up. Binary logistic regression models were used to assess unadjusted and adjusted associations between early illness and sociodemographic characteristics and two outcome measures: any SA during follow-up; and multiple SAs. Results Follow-up data were available for 282 participants. Sixty-one (21.6%) made a suicide attempt over the follow-up period, including 12 successful suicides. The following baseline risk factors increased the risk of any SA: history of self-harm (OR = 4.27; p < 0.001), suicidal tendencies (OR = 2.30; p = 0.022), being depressed for > 50% of the initial psychotic episode (OR = 2.49; p = 0.045), and hopelessness (OR = 2.03; p = 0.030). History of problem alcohol use increased the risk of multiple SAs (OR = 4.43; 95% CI (1.05–18.7); p = 0.043). Discussion The prevalence of suicide attempt in this study exceeds reports from short-term FEP studies but is comparable to longer term follow-up studies, indicating that risk remains elevated for at least 7 years following commencement of treatment. The key predictor of future suicide attempt was previous self-harm, indicating that interventions for self-harm are required.

Racial and Ethnic Differences in Substance Abuse Service Needs, Utilization, and Outcomes in California

This study examined differences in service needs and treatment utilization, retention, and outcomes between African-American, Hispanic, and white substance abusers in community-based treatment programs. Data were collected from 2,401 African Americans, 3,222 Hispanics, and 7,980 whites who were admitted to 43 drug treatment programs across California from 2000 to 2001. The Addiction Severity Index (ASI) was administered at intake to assess clients' problem severity in a number of domains (alcohol use, drug use, employment, family and social relationships, legal, medical, and psychological), and treatment retention and arrest data were obtained from administrative records. A subsample was followed up at three months to assess service utilization (N=2,145) and again at nine months to readminister the ASI (N=2,566). All three groups had similar severity levels of drug and legal problems upon treatment entry. Upon entry to treatment, white clients had the highest severity levels of alcohol, family, and psychiatric problems and African Americans had the highest severity levels of employment problems compared with the other two groups. Treatment retention did not differ between the three groups, but whites received a greater number of alcohol treatment services than did African Americans or Hispanics, and African Americans received a greater number of employment services than did Hispanic and white clients. All three groups showed significant improvement in all outcome domains except for medical outcomes. At the nine-month follow-up, whites had worse outcomes in the alcohol domain compared with the other two groups, and whites had worse outcomes in the legal domain compared with Hispanics. Compared with whites, African Americans were significantly less likely to be charged with driving under the influence in the year after treatment admission. All three groups improved after treatment, although benefits from treatment can be further enhanced if services underscore different facets of the psychosocial problems of each racial and ethnic group.

Racial and Ethnic Differences in Substance Abuse Service Needs, Utilization, and Outcomes in California

Racial and Ethnic Differences in Substance Abuse Service Needs, Utilization, and Outcomes in California

Employment Services Utilization and Outcomes among Substance Abusing Offenders Participating in California’s Proposition 36 Drug Treatment Initiative

California drug treatment programs may use funds to address barriers to work faced by Proposition 36 offenders, most of whom are not working at treatment entry, but employment services utilization and related behavioral outcomes have never been studied. This study examined primary data collected on 1,453 offenders by 30 programs during 2004 to explore the characteristics, employment services utilization, and outcomes of those who did and did not receive employment services while in drug treatment. One-year outcomes were mostly similar across groups, however, increases in the proportion of offenders employed, receiving income from employment and family or friends, and being paid for work were significantly greater among the received-employment-services group, and a greater proportion of this group also completed drug treatment. Employment services utilization was less likely for persons recruited from outpatient settings and more likely with greater severity of family/social problems and desire for services. Odds of employment one-year post-treatment entry were higher for those of Hispanic race/ethnicity (vs. White) and for those with treatment completion/longer retention but lower for those who were older, lived in specific counties, had greater employment problem severity at intake, and received other income-related services. Strategies for improving employment services utilization and outcomes among Proposition 36 offenders are discussed.

Beyond screening: assessment of perinatal depression in a perinatal care setting

Although screening for perinatal depression substantially improves detection, screening alone does not improve treatment entry or outcome. This paper summarizes a pilot evaluation of the feasibility and patient acceptance of on-site diagnostic assessment in perinatal care settings for women who screen positive for perinatal depressive symptoms. The model included screening, assessment by the perinatal care provider, an algorithm to guide decisions, guidelines for evidence-based antidepressant treatment, support through phone and webbased consultation, and quality monitoring to track and remedy "missed opportunities" for screening and assessment. A mean of 17.1% of women screened were identified as having depressive symptoms in need of further assessment. Of those identified, a mean of 72.0% received a diagnostic assessment on site. A mean of 1.4% of patients refused on-site diagnostic assessment. It is feasible to incorporate assessment for depression into perinatal care. This paves the way for better engagement in treatment, and better clinical outcomes.

Facilitating outpatient treatment entry following detoxification for injection drug use: A multisite test of three interventions.

A multisite, randomized trial within the National Drug Abuse Treatment Clinical Trials Network (CTN) was conducted to test 3 interventions to enhance treatment initiation following detoxification: (a) a single session, therapeutic alliance intervention (TA) added to usual treatment; (b) a 2-session, counseling and education, HIV/HCV risk reduction intervention (C&E), added to usual treatment; and (c) treatment as usual (TAU) only. Injection drug users (n=632) enrolled in residential detoxification at 8 community treatment programs were randomized to 1 of the 3 study conditions. TA participants reported entering outpatient treatment sooner and in greater numbers than TAU participants. Reported treatment entry for C&E fell between TA and TAU with no significant differences between C&E and the other conditions. There were no differences among the interventions in retention, as measured by weeks of outpatient treatment for all participants who reported treatment entry. Alliance building interventions appear to be effective in facilitating transfer from detoxification to outpatient treatment, but additional treatment engagement interventions may be necessary to improve retention.

Service System Involvement and Delinquent Offending at System of Care Entry

This study examines correlates of delinquent offending among 2,554 youths presenting to community-based treatment in Center for Mental Health Services-funded systems of care. Variables in five key domains, including demographics, family risk, child clinical risk, school, and service system involvement, were examined in relation to severity of offending at treatment entry for early/middle (11-15 years) versus late (16-18 years) adolescents. Significant correlates of offending severity were identified in all domains except family risk for the 11 to 15 year olds and in demographics and child clinical risk for the 16 to 18 year olds. Service system involvement was a unique correlate of delinquency in the younger group. Findings add to other studies showing that correlates of offending appear to differ across stages of adolescence; specifically, school and service system involvement may be less important for older adolescents than for younger adolescents. Service system involvement should be included in longitudinal studies of risk for adolescent offending.

Improving substance abuse treatment enrollment in community syringe exchangers

The present study evaluated the effectiveness of an intervention combining motivational enhancement and treatment readiness groups, with and without monetary incentives for attendance and treatment enrollment, on enhancing rates of substance abuse treatment entry among new registrants at the Baltimore Needle Exchange Program (BNEP). Opioid-dependent study participants (n = 281) referred by the BNEP were assigned randomly to one of three referral interventions: (i) eight individual motivational enhancement sessions and 16 treatment readiness group sessions (motivated referral condition--MRC); (ii) the MRC intervention with monetary incentives for attending sessions and enrolling in treatment--MRC+I); or (iii) a standard referral condition which directed participants back to the BNEP for referral (standard referral-SRC). Participants were followed for 4 months. MRC+I participants were more likely to enroll in any type of treatment than MRC or SRC participants (52.1% versus 31.9% versus 35.5%; chi(2) = 9.12, P = 0.01), and more likely to enroll in treatment including methadone than MRC or SRC participants (40.4% versus 20.2% versus 16.1%; chi(2) = 16.65, P < 0.001). MRC+I participants also reported less heroin and injection use than MRC and SRC participants. Syringe exchange sites can be effective platforms to motivate opioid users to enroll in substance abuse treatment and ultimately reduce drug use and number of drug injections.

Neurocognitive profiles of people with comorbid depression and alcohol use: Implications for psychological interventions

Depression and alcohol use disorders frequently co-occur and are highly prevalent. Both conditions are known to impair cognitive functioning, yet research into the role of these impairments in response to Cognitive Behaviour Therapy (CBT) is limited. The purpose of the present study was to examine the relationship between baseline neuropsychological performance, severity of depressive symptoms and alcohol use disorders. Participants with current depression and hazardous alcohol use were functioning in the average range on all neuropsychological measures prior to treatment entry. Baseline measures of drinking severity and a range of cognitive functions were inversely correlated. After controlling for other baseline variables, superior baseline cognitive functioning predicted greater reductions in depression severity after 17 weeks. These predictive effects occurred across both brief and extended interventions. Findings suggest that improvement in depression following psychological treatment is enhanced by greater fluid reasoning ability and is predicted by executive functioning, regardless of the treatment length or problem focus.

Effects of opioid use on treatment entry, completion, and outcomes for a rehabilitative program for fibromyalgia patients

Effects of opioid use on treatment entry, completion, and outcomes for a rehabilitative program for fibromyalgia patients

Events as Precipitators to Treatment: Important for Both Well-Integrated and Marginalized Alcohol and Drug Users of a Swedish Treatment System

“Women and Men in Swedish Alcohol and Drug Treatment” studies how people with alcohol and drug problems come to treatment. The focus is on different alcohol- and drug-related life events in the year prior to treatment and whether or not these events contributed to treatment entry. The importance of these events is also studied in relation to level of marginalization. The representative cross-sectional sample includes 1865 clients (71% men) interviewed inperson when entering inpatient and outpatient treatment facilities. Most respondents reported events in the year prior to treatment and these were also perceived as contributors to treatment. Events related to significant others and health workers seem to be of greatest importance for treatment entry. These events happen to a lot of the problematic alcohol and drug users and are viewed as strong contributing factors by the respondents. More marginalized people and misusers with more severe addiction problems experience more events. A curvilinear relationship (somewhat U-shaped) was found between level of marginalization and events as contributors to treatment: the least marginalized people are most likely to report events as contributors, people in between are the least likely and the most marginalized people are likely to report events as contributors to treatment, given that they have experienced the event.

Changes in the Episodic Memory and Executive Functions of Abstinent and Relapsed Alcoholics Over a 6‐Month Period

It is still unclear whether episodic memory and executive functions capacities can return to normal in abstinent patients over a 6-month period. Furthermore, the role of interim drinking in cognitive recovery is still not well known. Finally, further research is required to specify the predictive value of cognitive abilities at initial testing in the treatment outcome (abstinence or relapse). The aims of the present study were therefore to measure changes in episodic memory and executive functions over a 6-month period in abstinent and relapsed alcoholics and to ascertain whether neuropsychological results at treatment entry can predict treatment outcome at follow-up. Fifty-four alcoholic patients and 54 matched control subjects performed baseline neuropsychological tasks assessing episodic memory, executive functions, the slave systems of working memory and attentional abilities. At the follow-up session (i.e., 6 months later), episodic memory and 3 executive functions (inhibition, flexibility, and updating) were re-examined in the alcoholic patients. Results showed that over the 6-month interval, the abstainers' episodic memory and executive performances had returned to normal, whereas the relapsers performed lower than before in the flexibility task. Episodic memory and executive functions recovery was correlated, in abstainers, with drinking history and age respectively. Finally, there was no significant difference regarding neuropsychological scores at baseline between abstainers and relapsers. Over the 6-month interval, abstainers normalized episodic memory and executive performances whereas relapsers obtained executive results which were more severely impaired, emphasizing the influence of interim drinking on cognitive changes. Episodic memory, executive functions, the slave systems of working memory and attentional abilities did not appear to be reliable predictors of treatment outcome over a 6-month interval.

Alterations in Brain Serotonin Synthesis in Male Alcoholics Measured Using Positron Emission Tomography

A consistent association between low endogenous 5HT function and high alcohol preference has been observed, and a number of serotonergic manipulations (uptake blockers, agonists) alter alcohol consumption in animals and humans. Studies have also shown an inverse relationship between alcohol use and cerebrospinal fluid levels of serotonin metabolites, suggesting that chronic alcohol consumption produces alterations in serotonin synthesis or release. The objective of the study was to characterize regional brain serotonin synthesis in nondepressed chronic alcoholics at treatment entry in comparison to normal nonalcoholic controls using PET and the tracer alpha-[(11)C]-methyl-L-tryptophan. Comparisons of the alcoholics and controls by SPM found that there were significant differences in the rate of serotonin synthesis between groups. Serotonin synthesis was significantly lower among alcoholics in Brodmann Area (BA) 9, 10, and 32. However, serotonin synthesis among the alcoholics group was significantly higher than controls at BA19 in the occipital lobe and around the transverse temporal convolution in the left superior temporal gyrus (BA41). In addition, there were correlations between regional serotonin synthesis and a quantity-frequency measure of alcohol consumption. Regions showing a significant negative correlation with QF included the bilateral rectus gyri (BA11) in the orbitofrontal area, the bilateral medial frontal area (BA6), and the right amygdala. Current alcoholism is associated with serotonergic abnormalities in brain regions that are known to be involved in planning, judgment, self-control, and emotional regulation.

The Intensive Treatment Unit: A brief inpatient detoxification facility demonstrating good postdetoxification treatment entry

Inpatient detoxification is frequently used to treat substance use disorders, despite consistent findings that drug use soon after detoxification is the norm. A number of lines of evidence suggest the most rational means of improving outcomes after detoxification is to improve postdetoxification treatment entry. This report presents outcomes from the Intensive Treatment Unit (ITU), a brief inpatient detoxification unit in Baltimore, MD, found to have good postdischarge treatment entry outcomes. The patients followed were predominantly male African Americans in early middle age who were sequentially admitted to the unit ( N = 134) and demonstrated severe social disruption and psychiatric comorbidity. More than 80% of the patients discharged from the ITU were admitted to treatment postdetoxification, with most going to long-term residential settings or recovery houses. Success was associated with seeking residential treatment, and failure was concentrated among the minority discharged with no plan for aftercare and those seeking outpatient treatments. The report explores patient and process factors associated with these outcomes and discusses the possibility that the ITU may be a model system for improving outcomes postdetoxification.

Substance use after residential treatment among individuals with co-occurring disorders: The role of anxiety/depressive symptoms and trauma exposure.

This longitudinal study examined the contribution of anxiety/depressive symptoms and lifetime and recent trauma exposure to substance use after residential substance abuse treatment among individuals with co-occurring disorders. Data were collected from adults at treatment entry and 6 and 12 months later. At treatment entry, nearly all participants reported lifetime trauma exposure, and over one third met criteria for posttraumatic stress disorder (PTSD). Over the follow-up, nearly one third of the participants were exposed to trauma. Lifetime trauma exposure and a diagnosis of PTSD at treatment entry were not associated with substance use over the follow-up. Trauma exposure and anxiety/depressive symptoms over the follow-up were associated with an increased likelihood of substance use. Gender did not moderate the association between trauma exposure and anxiety/depressive symptoms and substance use. These findings highlight the importance of monitoring for trauma exposure and symptoms of anxiety/depression to better target interventions and continuing care approaches to reduce the likelihood of posttreatment substance use in this population.