Article

Treatment Retention and Follow-Up Outcomes in the Drug Abuse Treatment Outcome Study (DATOS)

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Abstract

Clients in the national Drug Abuse Treatment Outcome Study reported significant overall improvements in drug use and related measures during a 12-month follow-up period. A quasi-experimental design was used to examine the relationship of treatment duration with outcomes in each of the 3 major modalities represented. Client subsamples with longer retention in long-term residential programs and in outpatient methadone treatment had significantly better outcomes than those with shorter lengths of stay (results were inconclusive for outpatient drug-free programs because of sample limitations). This study used several methodological enhancements and showed general continuity of findings on retention effects from previous national evaluations of treatment effectiveness. It supports the need for more careful study of treatment process in relation to outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

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... The Drug Abuse Treatment Outcome Study (DATOS) hodnotila výsledky léèby 10 010 klientù, kteøí v letech 1991-1993 zahájili léèbu v 96 léèebných centrech v 11 mìstech v USA (Gossop, 2004;Simpson, Joe, Broome et al., 1997;Simpson, Joe, & Brown, 1997). Data byla sbírána 1 a 3 mìsíce po zahájení léèby a 12 mìsícù po jejím ukonèení. ...
... Rovnì dalí autoøi poukazují na sníení rizikového chování uivatelù drog po léèbì v terapeutické komunitì (napø. Hubbard et al., 1989;Simpson, Joe, & Brown, 1997;Wilson, 1978 ...
... Výsledky léèby uivatelù drog ukazují na významné sníení kriminálního chování po léèbì (Ball & Alan, 1991;Gossop et al., 2005;Hubbard et al., 1989;NIDA, 2002;Rawlings, 2001;Simpson, Joe, & Brown, 1997). U klientù sledovaných ve studii NTORS se po léèbì podstatnì sníila drogová i nedrogová kriminalita . ...
... Timely access to evidence-based SUD treatment is critical to improving health. Shorter waiting times have been shown to increase likelihood of attendance in substance use treatment (Claus & Kindleberger, 2002;Festinger, Lamb, Kountz, Kirby, & Marlowe, 1995;Simpson, Joe, & Brown, 1997;Stasiewicz & Stalker, 1999). Despite its importance, access to care is often limited by long waiting times (Guerrero, Fenwick, Kong, Grella, & D'Aunno, 2015;Pollini, McCall, Mehta, Vlahov, & Strathdee, 2006;Stasiewicz & Stalker, 1999), which are associated with adverse events including overdose (Pollini et al., 2006). ...
... The full performance contract approach is described here, although this paper focuses only on the waiting time measure, which is conceptually different from retention. The incentivized measures included two measures of waiting time and two retention measures which have been shown to be linked to improved outcomes (Simpson et al., 1997). The contract also incentivized units of service delivered for all outpatient addiction treatment services, not just state contracted units. ...
Article
Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005–2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008–2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial.
... Both research and clinical experience have shown that patients frequently drop-out having never obtained the therapeutic gains of treatment. Multiple studies have found that time spent in treatment is one of the most important predictors of patient outcomes and that longer durations in treatment have more positive outcomes (Bao et al., 2009;Degenhardt et al., 2011;Oliver et al., 2010;Simpson, 1981;Simpson, Joe, & Brown, 1997;Soyka, Zingg, Koller, & Kuefner, 2008;Villafranca, McKellar, Trafton, & Humphreys, 2006). While recommended duration of treatment varies, 12 months is generally considered a minimum length of treatment to obtain positive benefits (NIDA, 2018). ...
... Finally, it is well documented in the literature that time spent in treatment (operationalized in this study as number of prior treatment episodes) is one of the most important predictors of patient success (Bao et al., 2009;Degenhardt et al., 2011;Oliver et al., 2010;Simpson, 1981;Simpson, Joe, & Brown, 1997;Soyka, Zingg, Koller, & Kuefner, 2008;Villafranca, McKellar, Trafton, & Humphreys, 2006). These studies suggest that retention in treatment may be more important than engagement and that patients who maintain some form of attendance to treatment tend to have better outcomes than patients who leave early. ...
Article
Background Over the past 25 years, the United States has experienced an opioid epidemic that has cost hundreds of thousands of lives and which now constitutes as the worst drug overdose epidemic in U.S. history. Increases in opioid use and abuse have been found among men and women, most age groups, and all income levels (CDC, 2017). Methadone Maintenance Treatment (MMT) is one the most effective forms of treatment for opioid addiction, and has been found to reduce substance use, the risk of HIV, overdose, and criminal behaviors (Joseph et al., 2000; Mattick, Breen, Kimber, & Davoli, 2009). Both clinical experience and research show that MMT programs suffer from low retention and patient engagement in treatment and that patients are particularly vulnerable to disengagement or withdrawal during the early stages of treatment (Baxter et al., 2013). To address this problem, Thomas Jefferson University Hospital Narcotic Addiction Rehabilitation Program (TJUH NARP) utilized funds from Governor Wolf’s administration to implement a program entitled the Center of Excellence (COE) to provide patients with increased support during the early stages of treatment. This support occurred in the form of one-on-one support from a Certified Recovery Specialist (CRS) who provided counselling, case management, and care coordination. As MMT treatment providers develop new programs such as the COE to address the problem of patient engagement and retention, it is critical that researchers assess their efficacy. In light of this, this dissertation has two specific aims. First, to examine the efficacy of COE program in improving patient retention, engagement in treatment, and opioid use. Second, to identify predictors of outcome within and across the conditions. Methods A case comparison study was conducted in which a control (N=57) and a treatment group (N=57) were compared regarding patient attendance, engagement, and opioid use. The control group consisted of a group admitted a year prior to the implementation of the COE while the treatment group received the supportive services of the COE. Data was collected from clinical documentation in the TJUH database. A convenience sample was used that consisted of all patients admitted during a specific time frame and who met criteria. Patient outcomes were analyzed through T-tests and chi-squared tests. Findings Patients within the treatment group had lower opioid use in months 1-3 (P=.02). This group also experienced lower attendance during month 1 (P=.04), month 2 (P=.05), month 3 (P=.02), and month 4 (P=.03). No other significant differences were found between groups regarding patient retention, engagement, or opioid use. However, while not significant, the treatment group had trends towards higher average medication doses (P=.13) and IOP attendance (P=.12). When outcomes were analyzed across conditions, patient admitted via transfer were found to have higher methadone doses on average when compared to patients admitted via self-referral (P=.01). Discussion The finding of reduced opioid use among the treatment group in months 1-3, as well as trends towards higher dosing and treatment attendance, suggests that the COE met with success in improving patient outcomes. At the same time, the lack of significant findings regarding patient attendance and engagement, as well as the treatment group’s lower attendance during months 1-4, suggests that the COE program implemented at TJUH NARP may not be entirely successful in meeting its goals. The significance of referral method challenges the efficacy of self-referral routes of entry into outpatient MMT. While further research is needed, these findings suggest that patients may benefit from inpatient stabilization prior to admittance into outpatient MMT.
... It is certainly true that many people enter such programmes and achieve durable abstinence and recovery as a result, but it is equally the case that many fail to achieve benefit. The evidence for this comes both large scale longitudinal studies in the United States and in the United Kingdom ( Simpson, Joe & Brown 1997, Gossop et al. 1999), and from local outcome studies such as that of Clouds House by Georgakis (1995). Georgakis showed that for a cohort admitted over a six month period, a third maintained continuous abstinence for a period averaging 30 months after the treatment episode, together with a range of other benefits including improved quality of life and well-being, and a third failed to respond to the programme, typically dropping out before completing and returning to their addiction in short order. ...
... Following on from earlier work, Simpson and colleagues established that in DATOS, as in earlier studies, there was a robust relationship between retention in treatment and good outcomes (Simpson, Joe & Brown 1997). However, it was found that there was great diversity in the programmes within each modality in terms of who was treated, their success in engaging and retaining clients, and the services delivered. ...
Thesis
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This research addresses the question ‘How does transformative change occur in rehabilitation programmes, and how is it facilitated or constrained by contextual factors?’ The study, carried out in three community-based intensive rehabilitation projects for alcohol and drug dependent people, is designed to specify and explain change mechanisms, understood as the processes through which programme resources influence the intentional actions of participants. A critical realist theoretical frame is used, drawing on the work of Margaret Archer and John Greenwood. The study consisted of two phases: in Phase 1, fourteen client interviews and eight counsellor interviews were carried out in two treatment programmes, and these were analysed abductively to produce a set of tentative contexts, mechanisms and outcomes. Phase 2 consisted of ten theory-driven interviews (Pawson 1996) with clients in a third programme, designed to elaborate the emerging theory. An explanatory model was produced, in contexts- mechanisms-outcomes form. This showed that the institutional context of active warmth and acceptance, combined with a clear, predictable and transparent structure, allowed participants to build trust, bond with the peer group and become ready to accept and process respectful challenges to their perspective or their interpersonal behaviour. This facilitated a change in the clients’ internal conversation (Archer 2000), permitting new emotional responses and the formation of new attachments, values and commitments. The programme was seen as a place which facilitated the development of a revised personal and social identity. The study contributes to the understanding of these programmes by clarifying how participants change or fail to change. It responds to recent calls for more useful forms of evidence, to complement the sparse and equivocal experimental evidence base. The study findings have the potential to improve counsellor training and programme development.
... For years, dropout has been recognized as a key factor affecting SUD treatment effectiveness [3][4][5][6][7][8]. Treatment participation and retention are consistently related to beneficial post-discharge outcomes [10][11][12][13][14][15], whereas participants who drop out of treatment prematurely often produce high front-end costs without benefiting from the full course of intervention. High dropout can therefore reduce both the efficiency and effectiveness of a treatment program [12,16]. ...
... Treatment participation and retention are consistently related to beneficial post-discharge outcomes [10][11][12][13][14][15], whereas participants who drop out of treatment prematurely often produce high front-end costs without benefiting from the full course of intervention. High dropout can therefore reduce both the efficiency and effectiveness of a treatment program [12,16]. ...
Article
Full-text available
Background and aims: Relapse rates for psychosocial substance use disorder (SUD) treatments are high, and dropout is a robust predictor of relapse. This study aimed to estimate average dropout rates of in-person psychosocial SUD treatment and to assess predictors of dropout. Design: A comprehensive meta-analysis of dropout rates of studies of in-person psychosocial SUD treatment. Studies included RCTs and cohort studies. Setting: Studies conducted anywhere in the world that examined SUD treatment and were published 1969 to 2016, inclusive. Participants/cases: 151 studies, 338 study arms, and 299 dropout rates including 26,243 participants. Measurements: Databases were searched for studies of SUD treatment that included an in-person psychosocial component. Meta-analyses and meta-regressions were conducted to estimate dropout rates and identify predictors of dropout, including 22 participant characteristics, two facilitator characteristics, and 15 treatment characteristics. Pooled estimates were calculated with random-effects analyses accounting for the hierarchical structure of study arms nested within studies. Findings: The average dropout rate across all studies and study arms was 30.4% (95% CI=27.2-33.8, and 95% PI=6.25-74.15) with substantial heterogeneity (I2 =93.7%, p<0.0001). Studies including a higher percentage of African Americans and lower-income individuals were associated with higher dropout rates. At intake, a greater percentage of heroin use days and cigarettes/day were associated with lower dropout rates, whereas heavier cocaine use was associated with higher dropout rates. Programs characterized by more treatment sessions and greater average session length were associated with higher dropout rates. Dropout rates were highest for studies targeting cocaine, methamphetamines, and major stimulants (broadly defined), and lowest for studies targeting alcohol, tobacco, and heroin, though there were few studies on methamphetamines, major stimulants, and heroin. Facilitator characteristics were not significantly associated with dropout. Conclusions: On average around 30% of participants drop out of in-person psychosocial substance use disorder treatment studies but there is wide variability. Drop-out rates vary with substance being treated, characteristics of the treatment and the treated population.
... Since cortisol was previously associated with craving and consolidation processes, we suggest that modifications in the cortisol levels could be associated with premature discharge, fact that we observed frequently among crack cocaine users (Barnaby & Gibson, 2008). Studies point out that one of the predictors of successful addiction outcomes and clinical improvement in substance abuse is a longer duration of treatment (Hubbard, Craddock, & Anderson, 2003;Simpson, Joe, & Brown, 1997). Hospitalization days are associated with treatment retention, since patients who spend more time in hospital are more likely to evolve and have a more significant clinical improvement (Simpson et al., 1997). ...
... Studies point out that one of the predictors of successful addiction outcomes and clinical improvement in substance abuse is a longer duration of treatment (Hubbard, Craddock, & Anderson, 2003;Simpson, Joe, & Brown, 1997). Hospitalization days are associated with treatment retention, since patients who spend more time in hospital are more likely to evolve and have a more significant clinical improvement (Simpson et al., 1997). Furthermore, previous studies showed that presence of SUD together with positive family history for addiction could increase cortisol levels (Dai, Thavundayil, Santella, & Gianoulakis, 2007). ...
Article
Background: Dysregulation of the hypothalamic-pituitaryadrenal (HPA) axis has been associated with craving and early relapse among individuals with substance use disorders. However, no association has been postulated regarding treatment retention and prognosis in crack cocaine users. Objective: Our aim was to investigate the association between morning salivary cortisol levels and treatment retention in crack cocaine users. Methods: 44 male crack cocaine users were recruited from a detoxification unit. Saliva collection was performed in the morning of the second treatment day. Substance use profile was assessed using the Addiction Severity Index. Results: The median length of stay in inpatient treatment was 7 days (IQR 3-16). Treatment retention was associated with cortisol levels (r = -0.324; p = 0.032), especially in the group with positive family history. Moreover, treatment retention was correlated with age (r = 0.333, p = 0.027), and number of days of tobacco use (r = 0.332, p = 0.028) and crack use (r = 0.327, p = 0.031). A Cox regression model was performed and showed that inpatients with above normal cortisol levels (≥0.69 µg/dL) presented a worse prognostic related to treatment retention (HR = 2.39, CI95% 1.1-5.1, p = 0.024). Conclusion: Several factors could contribute to increased cortisol levels in these patients, e.g. craving, dysregulation of the HPA axis, chronic drug use, stress due to confinement, and substance abstinence. Nevertheless, our findings could guide further studies about new biomarkers in crack cocaine use disorder, since HPA axis dysregulation at the time of treatment admittance may be a prognostic marker for treatment retention.
... Studies in many countries demonstrate the clinical effectiveness of methadone maintenance treatment (MMT) to promote individual recovery, to slow HIV transmission, and to reduce overdose death, drug injection, HIV risk behavior and HIV sero-conversion (Des Jarlais & Semaan, 2008;Faggiano, Vigna-Taglianti, Versino, & Lemma, 2003;Newman & Whitehill, 1979;Simpson, Joe, & Brown, 1997;Strain, Bigelow, Liebson, & Stitzer, 1999). A 2009 Cochrane review of randomized controlled trials found that methadone was significantly more effective than non-pharmacological approaches in retaining patients in treatment and in reducing heroin use (Mattick, Breen, Kimber, & Davoli, 2009). ...
Article
The nation's methadone maintenance treatment (MMT) programs play a central role in addressing the current opioid epidemic. Considerable evidence documents the treatment effectiveness of MMT and, in turn, the importance of adequate dosing to MMT's effectiveness. Yet, as recently as 2011, 41% of patients received doses below the level of 80 mg/day. Using survey data from a nationally representative sample of MMT programs in 2011 and 2017, we examine (1) the extent to which the nation's MMT programs are meeting evidence-based standards for methadone dose level and (2) characteristics of MMT programs that are associated with variation in performance. Our results show that 43% of MMT patients receive <80 mg/day in 2017, and 23% of methadone maintenance patients receive daily doses below 60 mg. Results from multivariate regression analysis of the 2017 survey data show that private for-profit and public organizations significantly under-dosed patients compared to private nonprofit providers. Under-dosing also was more common in programs that serve high proportions of African-American patients. These results are concerning because MMT remains the medication of choice for vulnerable patients with the most severe opioid use disorders, and for-profit providers treat a growing proportion of MMT patients.
... First, I exclude PSPs whose treatment during their PRCS stint before the passage of Proposition 47 involved medication-assisted treatment (MAT). This group is expected to have different treatment trajectories because a successful episode is expected to last much longer than other modalities (Simpson, Joe, & Brown, 1997). Individuals in MAT also have disproportionately more treatment episodes and a longer treatment career compared to other modalities . ...
... Individual months were summed to calculate the total number of months patients were engaged over study enrollment and classified into three categories: low engagement (0-3 months), moderate engagement (4-7 months) and high engagement (8-12 months). Given the known challenges inherent in engaging this patient population (Neighbors et al., 2013;Raven et al., 2011), feasible engagement was specified as moderate to high engagement of at least 50% of enrolled patients, which was based on prior research recommending treatment durations of at least 90 days (Grella, Hser, Joshi, & Anglin, 1999;Simpson, Joe, & Brown, 1997). ...
Article
Although care management approaches have potential to improve clinical outcomes and reduce healthcare costs, little is known about the feasibility of these interventions in patients with complex substance use disorders (SUDs), which are characterized by psychosocial, psychological and/or medical needs and high acute healthcare utilization. We assessed the feasibility of recruitment, treatment engagement, compliance with follow-up assessments, and patients’ use of a care management model (CMM) at one medical center. This pilot study enrolled patients with complex SUDs and high healthcare utilization in a prospective, 1-year open trial of a CMM adapted for specific needs of this patient population. Patients completed baseline assessment, monthly assessments of treatment progress and follow-up assessments at 6- and 12-months. Patients’ use of CMM services were abstracted from medical records. Of 33 eligible patients approached, 23 (69.6%) men enrolled in the study. Approximately 59.1% of patients attended a CMM visit in ≥8 of 12 months enrolled. Patients completed monthly assessments in 4.9 (SD = 3.1) of 12 months enrolled, and 68.2% and 41.0% completed 6- and 12-month follow-up assessments, respectively. The most common CMM service delivered was care coordination/case management, followed by supportive counseling, motivational interviewing, and medication management. Recruitment and engagement results suggest that use of CMM for complex SUDs and high healthcare utilization is feasible. More robust outreach services may be needed to increase engagement among those who did not engage or lost contact with the CMM team. Additional research is needed to evaluate if CMM enhances retention, improves outcomes and reduces acute healthcare utilization of patients with complex SUDs.
... Another study using a sample of 249 treatment staff in the United States revealed that higher staff turnover was associated with better client treatment outcomes (i.e., less involvement in illegal activity and lower social risk; Garner, Hunter, Modisette, Ihnes, & Godley, 2012); the authors suggested that a high turnover would allow for effective utilization of staff reshuffling, particularly for those who were more willing or able to implement treatment innovation, which led to more positive outcomes. In addition, some old but important studies (Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997;Simpson, Joe, & Brown, 1997) using the U.S. national-sample data also revealed that treatment modalities (e.g., outpatient methadone, long-term residential, outpatient, and short-term inpatient programs) might impact treatment outcome and longer treatment programs (at least 3 months) tended to yield better treatment outcomes than did shorter programs. However, there is a lack of research investigating the difference on treatment engagement between different treatment modalities, which again suggests a great research need on factors influencing substance treatment engagement. ...
Article
There is a call for drawing on client voice to provide a rich, nuanced understanding of factors influencing substance treatment engagement as to maximizing treatment benefits. We interviewed 60 clients in a short-term inpatient substance treatment program and examined facilitators and barriers to treatment engagement. Thematic analysis yielded four themes, including perceived treatment needs, trust and counselor rapport, peer inspiration, and organizational factors. Perceived treatment needs serve as both a facilitator and a barrier wherein the acknowledgment of needs led to greater treatment engagement whereas a lack of perceived needs hindered treatment engagement. The establishment of trust and counselor rapport and peer inspiration facilitated treatment engagement. Clients rated several organizational factors including a lack of treatment provision, gender-responsive treatment and infrastructure, and ineffective communication with nonclinical staff as barriers to treatment engagement. Clinical implications include enhancing treatment motivation and counselor rapport, establishing gender-responsive treatment programs, and providing trainings for staff.
... Dosage can include the number, frequency, intensity, and duration of treatment services (Crites & Taxman, 2013). Individuals who have been in treatment longer generally experience less recidivism (Bourgon & Armstrong, 2005;Landenberger & Lipsey, 2005;Simpson et al., 1997;Vanderplasschen et al., 2007), and higher risk individuals tend to have better outcomes than lower risk individuals, especially for programs with higher intensity of services (Bourgon & Armstrong, 2005;Kopta et al., 1994;National Institute of Corrections, 2005;Takahashi & Kroner, 2013;Thanner & Taxman, 2003). Examining how the program is delivered in terms of frequency, number of sessions, and length of time details the dosage of the program. ...
Article
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Background Fidelity assessment tools can assess whether a program embraces a core set of principles and performs well. A quality fidelity tool with valid scales can be a feedback loop to identify areas that need further work to improve the program. Using data collected from 1816 correctional and reentry programs in the United States in the construction sample and 761 programs in the confirmation sample, this study examined the internal consistency of the Risk-Need-Responsivity (RNR) Program Tool, an online resource to capture information about structural features of a program. Results The study reports on reliability statistics and factor analyses to highlight individual subscales. Six scales emerged and had acceptable to excellent levels of internal consistency. These scales are staffing, reward-and-sanction, clinical standards for programs, coaching, program duration, and risk-need assessment. Conclusions This article discusses fidelity scales from the RNR Program Tool and provides guidance on the importance of tool development processes to ensure accurate, valid, and reliable scales. The purpose of the RNR Program Tool is to create a modern, online tool integrating both the empirical (research) literature on effective practices and clinical standards on quality programming. This process minimizes the need for consultants by giving program administrators the ability to gather information on their programs, score them, and receive instant and targeted feedback with recommendations for improvement to assess their programs against empirical standards in the field. Furthermore, it provides a standardized tool that administrators can use to examine what type of individuals fare better in their programs. The provided targeted feedback can give the programs the ability to seek technical assistance or guidance in specific areas that can strategically strengthen their program.
... These findings are echoed in reviews of studies involving general community samples [62]. Treatment adherence appears to be a significant component for the success of OAT in reducing HIV-risk behaviors [62], consistent with the broader literature which reports that adherence to substance abuse treatment is key in producing positive treatment outcomes [63]. While the present study did not find support for the use of prerelease buprenorphine to reduce HIV-risk behaviors, the parent study found that participants who initiated buprenorphine in prison had a higher mean number of days receiving buprenorphine treatment in the community, suggesting that prison-initiated buprenorphine may improve treatment adherence in the community. ...
Article
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Background: It has been estimated that approximately 15% of people who are incarcerated in the US have histories of opioid use disorder. Relapse to opioid use after release from prison poses a serious risk of HIV infection. Prison-initiated buprenorphine may help to reduce HIV infection given the association between opioid use and HIV-risk behaviors. Methods: The present study is a secondary analysis of longitudinal data gathered from a randomized controlled trial of buprenorphine-naloxone for people who were incarcerated (N = 211) between 2008 and 2012. It compares the impact of assignment to initiate buprenorphine in prison (N = 106 randomized, N = 104 analyzed) versus in the community (N = 107 randomized, N = 107 analyzed) and whether or not participants entered community treatment on the frequency of HIV-risk behaviors in the 12 months following release from prison. Data were analyzed hierarchically and for each outcome variable, a multilevel, over-dispersed Poisson model was fit to the data. Outcome variables were the number of times the following behaviors occurred in the last 30 days: (1) having sex without a condom (2) injecting drugs (3) using unsterilized needles, and (4) sharing injection paraphernalia. Results: Participants assigned to begin buprenorphine in the community experienced a greater decrease in injection drug use over time compared to participants assigned to begin buprenorphine in prison. There were no significant associations between treatment assignment or community treatment entry and instances of having sex without a condom, sharing injection paraphernalia, or using unsterilized needles. Conclusions: Overall, the present study did not find support for the initiation of buprenorphine in prison (as opposed to the community) as a means to reduce incidences of HIV-risk behaviors. Avenues for future research in the nexus of HIV-risk reduction, criminal justice, and pharmacotherapy are discussed. Trial registration This study was supported by the National Institute on Drug Abuse (NIDA), Buprenorphine for Prisoners (PI: Kinlock; R01DA021579). ClinicalTrials.gov identifier: NCT00574067.
... Available SUD treatments typically exhibit limited success with most patients not achieving long-term abstinence (23)(24)(25)(26). Medications for opioid use disorder (OUD) include the agonist treatments methadone and buprenorphine, and the opioid antagonist naltrexone (27). ...
Article
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Background Observational data and preliminary studies suggest serotonin 2A agonist psychedelics may hold potential in treating a variety of substance use disorders (SUDs), including opioid use disorder (OUD).AimsThe study aim was to describe and analyze self-reported cases in which naturalistic psychedelic use was followed by cessation or reduction in other substance use.Methods An anonymous online survey of individuals reporting cessation or reduction in cannabis, opioid, or stimulant use following psychedelic use in non-clinical settings.ResultsFour hundred forty-four respondents, mostly in the USA (67%) completed the survey. Participants reported 4.5 years of problematic substance use on average before the psychedelic experience to which they attributed a reduction in drug consumption, with 79% meeting retrospective criteria for severe SUD. Most reported taking a moderate or high dose of LSD (43%) or psilocybin-containing mushrooms (29%), followed by significant reduction in drug consumption. Before the psychedelic experience 96% met SUD criteria, whereas only 27% met SUD criteria afterward. Participants rated their psychedelic experience as highly meaningful and insightful, with 28% endorsing psychedelic-associated changes in life priorities or values as facilitating reduced substance misuse. Greater psychedelic dose, insight, mystical-type effects, and personal meaning of experiences were associated with greater reduction in drug consumption.Conclusions While these cross-sectional and self-report methods cannot determine whether psychedelics caused changes in drug use, results suggest the potential that psychedelics cause reductions in problematic substance use, and support additional clinical research on psychedelic-assisted treatment for SUD.
... Alcoholism treatment programmes are also economically efficient if the patient remained sober up to 12 months (7,8). On the other hand, to the best of our knowledge, few studies researched prognostic factors for stabile abstinence and long-term benefits (more than five years) of treatment due to complexity of factors influencing the outcomes (9)(10)(11), or the studies used very specific populations (e.g. adolescents, young adults, specific co-morbid conditions) (e.g. ...
Article
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Introduction Using the modified Theory of Planned Behaviour (mTPB), different indicators of therapeutic success were studied to understand pro-abstinence behavioural orientation during an 18-year after-care period following a 3-month intensive alcoholism treatment. The indicators were: perceived needs satisfaction (NS), normative differential (ND), perceived alcohol utility (UT), beliefs about treatment programme benefits (BE) and behavioural intentions (BI). Methods The sample of 167 patients who consecutively started an intensive alcoholism treatment programme has been followed-up for 18 years, using standardised ailed instruments at the end of the treatment, and in the years 4-5, 9 and 18 of follow-up. The last data collection was completed by 32 subjects in 2010. The analysis followed the standard explore-analyse-explore approach. After the initial descriptive exploration of data, multivariate analysis of variance (MANOVA) in SPSS statistical package was set to explore between-groups and within-groups differences over time. Results At the between-group level, BI remained stable at the same level as at the end of the treatment programme, whereas BE and UT robustly changed over time and levelled off after 10 years of follow-up. NS and ND show a trend of pro-abstinent orientation and level off after 10 years of follow-up, although the trend is not significant. The same results were confirmed by the within-subject level. Conclusions Studied constructs stabilised after ten years of follow-up, apart from BI. The latter suggests that BI level needed for completion of an intensive treatment programme suffices for the maintenance of abstinence when accompanied by the change in perception of alcohol usefulness.
... Greater engagement is associated with retention of participants and positive change in a key outcome of the intervention [19]. There are evidences, which have shown positive outcomes among participants who stayed longer in the program as compared to those with shorter lengths of stay [20,21]. A systematic review of patient engagement in healthcare research too supported the idea of focusing on participant's engagement. ...
... 13 Attrition from OUD treatment (pharmacological, behavioral, or both) is another major barrier to successful outcomes with an estimated 30% attrition rate within the first month and an attrition rates of 50% or higher within the first 3 months. [14][15][16][17][18] Studies have shown an association between actively engaging patients in their treatment and improved retention and successful recovery. 19,20 Prescription digital therapeutics (PDTs) are software-based disease treatments that deliver evidence-based treatment that is evaluated for safety and effectiveness in randomized clinical trials (RCTs), and authorized by the U.S. Food and Drug Administration (FDA) to treat disease with approved directions for use (label). ...
Article
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Abstract Objectives: To evaluate patient engagement and usage of a prescription digital therapeutic (PDT) and associated outcomes of opioid use and treatment retention in a large real-world dataset of patients with opioid use disorder (OUD) treated with buprenorphine MOUD. PDTs are software-based disease treatments evaluated for safety and effectiveness in randomized clinical trials (RCTs) and authorized by the U.S. Food and Drug Administration (FDA) to treat disease with approved directions for use (label). Methods: A real-world observational evaluation of an all-comer population of patients who redeemed a 12-week prescription for the reSET-O PDT. Engagement and therapeutic use data were collected and analyzed on a population level. Substance use was evaluated as a composite of self-reports recorded with reSET-O and urine drug screens. Results: Data from 3,144 individuals with OUD were evaluated. 45.5% were between ages 30 and 39 years. 80% completed at least 8 of 67 possible therapeutic modules, 66% completed half of all modules, and 49% completed all modules. Abstinence during the last 4 weeks of treatment was calculated with two imputation methodologies: 66% abstinent using “missing data excluded (patients with no data as positive),” and 91% abstinent with “missing data removed (patients with no data excluded).” 91% of patients met the responder's definition of ≥80% of self-report or UDS negative. 74.2% of patients were retained through the last 4 weeks of treatment. Subgroup analysis of patients using reSET-O appropriately (4 or more modules per week for the first 4 weeks) showed 88.1% abstinence using “missing data excluded (patients with no data as positive,” and retention at weeks 9-12 of 85.8%. Conclusions: Results demonstrate that reSET-O is readily and broadly used by patients with OUD and that high real-world engagement with the therapeutic is positively associated with abstinence and retention in treatment. ReSET-O is a potentially valuable adjunct to buprenorphine MOUD therapy for patients with OUD.
... Alcoholism treatment programmes are also economically efficient if the patient remained sober up to 12 months (7,8). On the other hand, to the best of our knowledge, few studies researched prognostic factors for stabile abstinence and long-term benefits (more than five years) of treatment due to complexity of factors influencing the outcomes (9)(10)(11), or the studies used very specific populations (e.g. adolescents, young adults, specific co-morbid conditions) (e.g. ...
Article
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Introduction Using the modified Theory of Planned Behaviour (mTPB), different indicators of therapeutic success were studied to understand pro-abstinence behavioural orientation during an 18-year after-care period following a 3-month intensive alcoholism treatment. The indicators were: perceived needs satisfaction (NS), normative differential (ND), perceived alcohol utility (UT), beliefs about treatment programme benefits (BE) and behavioural intentions (BI). Methods The sample of 167 patients who consecutively started an intensive alcoholism treatment programme has been followed-up for 18 years, using standardised ailed instruments at the end of the treatment, and in the years 4-5, 9 and 18 of follow-up. The last data collection was completed by 32 subjects in 2010. The analysis followed the standard explore-analyse-explore approach. After the initial descriptive exploration of data, multivariate analysis of variance (MANOVA) in SPSS statistical package was set to explore between-groups and within-groups differences over time. Results At the between-group level, BI remained stable at the same level as at the end of the treatment programme, whereas BE and UT robustly changed over time and levelled off after 10 years of follow-up. NS and ND show a trend of pro-abstinent orientation and level off after 10 years of follow-up, although the trend is not significant. The same results were confirmed by the within-subject level. Conclusions Studied constructs stabilised after ten years of follow-up, apart from BI. The latter suggests that BI level needed for completion of an intensive treatment programme suffices for the maintenance of abstinence when accompanied by the change in perception of alcohol usefulness.
... En av de viktigste behandlingsmålsettingene, enten det dreier seg om poliklinisk behandling eller døgnbehandling, er å beholde klientene så lenge i behandling at intervensjonene får sjanse til å virke. Forskning viser at fullføring av behandling, eller tid i behandling, er en av de viktigste indikatorene for et positivt utfall (O' Brian & McLellan 1996;Simpson et al. 1997a;Ravndal & Vaglum 1998;Gossop et al. 1999). En prospektiv studie av stoffmisbrukere i behandling i Norge vensjonene som oftest var langt mindre omfattende, ville en høyere fullføringsprosent vaert å forvente. ...
Article
Aim This is the first prospective treatment study of a wide spectrum of treatment programmes for drug abusers in Norway. The aim of this article is to describe client characteristics, treatment compliance and to what extent client characteristics may predict treatment completion. ■ Methods and Data 482 clients who entered 20 programmes during the period 1998–2000 were investigated according to four different treatment types: residential treatment, youth collectives, outpatient psychiatric youth teams, and outpatient maintenance treatment. The following instruments were used: EuropASI, MCMI-II, SCL-25. ■ Results Clients who were recruited to the four types of treatment had partly different backgrounds, the differences being primarily related to age. Clients in the youth collectives, in which compulsory treatment was partly used, completed treatment most often (55%). The retention rate in outpatient maintenance treatment was 66%. The negative predictors for completion of inpatient treatment were personality disorder, three or more previous inpatients stays and 11 or more years with use of syringes, while being 40 years or more was a positive predictor. ■ Conclusions Treatment alone is limited in affecting the psychosocial problems of drug abusers irrespective of the best referral policy and treatment programmes. Maintaining motivation for a change of lifestyle outside of treatment is a political challenge that not only the treatment field should be responsible for.
... Completion of a treatment episode is critical to recovery; however, completing treatment is a major challenge for women (Brorson et al., 2013). Compared with residential patients who successfully meet their treatment goals and complete a treatment episode, noncompleters are generally challenged by continued substance use relapses (Brorson et al., 2013;Evans et al., 2009); criminal activity (Hser et al., 2004;Simpson et al., 1997); and other economic, social, and health consequences (National Institute on Drug Abuse, 2004;ONDCP, 2004). Yet prior research on mandated treatment has provided limited information on the effects on women's residential treatment completion due to: (a) predominantly male samples in studies of CJ-mandated treatment, along with a single focus on criminal recidivism and lack of investigation of any modality of SUD treatment completion (Mitchel et al., 2012;Wilson et al., 2006); (b) few studies of CPS-mandated treatment and its effects on any modality of treatment completion (Marlowe & Carey, 2012); and (c) no studies on SUD treatment completion (including residential) comparisons among women who CJ or CPS has mandated and those not mandated. ...
Article
Background Court-mandated substance use disorder (SUD) treatment, compared to nonmandated treatment, has been associated with increased retention and completion. However, due to limitations of previous studies, whether child protective services (CPS) and criminal justice (CJ) mandated treatment improve treatment completion and retention among women in residential treatment remains unclear. Purpose This study investigated differences in treatment completion and progress based on three clinical discharge outcomes (i.e., completer, noncompleter with significant progress, and noncompleter without significant progress). We hypothesized that women mandated by (1) CJ will have a better treatment discharge outcome (i.e., treatment completer and noncompleter with satisfactory progress) compared to women who are CPS mandated; (2) CPS will have a better treatment discharge outcome (i.e., treatment completer and noncompleter with satisfactory progress) compared to nonmandated women. Methods Study staff conducted multinomial logistic regression analyses on data for a diverse sample of 161 women mandated or nonmandated (CJ: N = 71, CPS: N = 66, nonmandated: N = 24) into residential SUD treatment to determine each group’s clinically defined treatment discharge outcomes while controlling for covariates. Results Multinomial logistic regression analyses revealed that being mandated by the CJ system predicted being a treatment completer compared to those who were CPS mandated (RR = 9.88, p = .009). The study found no differences in discharge status of completer without satisfactory progress between those who were CPS mandated and those who were CJ mandated or nonmandated. For women mandated by the CPS system compared to nonmandated women, the risk of being a treatment completer relative to noncompleters with satisfactory progress was not significant (RR = 1.08, p = .897). Analyses showed that being mandated by the CJ system predicted an improved clinically defined discharge outcome of treatment completer compared to women who were nonmandated to treatment (RR = 10.74, p = .016). In several of the models, drug and alcohol craving was associated with increased odds of being a noncompleter of treatment without satisfactory progress Conclusions This study demonstrates that improved treatment completion and discharge status cannot be assumed based solely on being mandated by the CJ or CPS systems. As evidenced by variability in treatment discharge outcomes within and among referral groups, the paper suggests directions for future research.
... It has been well documented that health service availability and access are an important determinant of treatment utilization in the general population, which may increase positive health outcomes for PWUDs [118][119][120][121]. More importantly, for people with OUD, ongoing treatment utilization and retention among methadone-maintained patients are especially important because continued medication is often required to achieve and sustain treatment gains [50,[122][123][124][125]. Despite evidence-based research demonstrating the effectiveness of such programs, however, expanded access to these much-needed services has still not been realized [125][126][127][128]. ...
Article
Nonmedical opioid (NMO) use has been linked to significant increases in rates of NMO morbidity and mortality in non-urban areas. While there has been a great deal of empirical evidence suggesting that physical features of built environments represent strong predictors of drug use and mental health outcomes in urban settings, there is a dearth of research assessing the physical, built environment features of non-urban settings in order to predict risk for NMO overdose outcomes. Likewise, there is strong extant literature suggesting that social characteristics of environments also predict NMO overdoses and other NMO use outcomes, but limited research that considers the combined effects of both physical and social characteristics of environments on NMO outcomes. As a result, important gaps in the scientific literature currently limit our understanding of how both physical and social features of environments shape risk for NMO overdose in rural and suburban settings and therefore limit our ability to intervene effectively. In order to foster a more holistic understanding of environmental features predicting the emerging epidemic of NMO overdose, this article presents a novel, expanded theoretical framework that conceptualizes "socio-built environments" as comprised of (a) environmental characteristics that are applicable to both non-urban and urban settings and (b) not only traditional features of environments as conceptualized by the extant built environment framework, but also social features of environments. This novel framework can help improve our ability to identify settings at highest risk for high rates of NMO overdose, in order to improve resource allocation, targeting, and implementation for interventions such as opioid treatment services, mental health services, and care and harm reduction services for people who use drugs.
... Junto con establecer de manera convincente que el tratamiento para los TUS funciona, los estudios DARP, TOPS y DATOS infromaron que, a diferencia de lo que ocurre comúnmente en psicoterapia (en que se informa una curva negativamente acelerada de mejoría con cada nueva sesión), los efectos positivos del tratamiento de drogas comienzan a observarse únicamente después de pasado un "umbral" de permanencia en el programa (tres meses para los programas residenciales y ambulatorios basados en la abstinencia, y un año para los programas de mantenimiento con entrega de metadona). Es decir, los usuarios que abandonan el tratamiento previo a que se cumpla el respectivo umbral de retención, no experimentan beneficio alguno por su participación en el tratamiento (Simpson, 1981;Simpson, Joe, Broome et alii, 1997;Simpson, Joe y Brown, 1997). ...
Article
Texas Christian University Model for Assessment and Treatment of Substance Use Disorders. This article aims to present a critical review of the literature regarding the Texas Christian University (TCU) Model in the field of assessment and treatment of substance use disorders (SUD). First, the background that prompted the development of the TCU Model is summarized. Subsequently, the central aspects of the model are detailed, including an assessment of empirical research that supports it. Then, the assessment tools developed within the model are described, with a focus on the psychometric properties of the instruments. Finally, the intervention strategies that constitute the TCU Treatment System are presented, emphasizing the evidence supporting the utilization of those interventions. The last three sections end up with a critical analysis in which the positive and negative aspects of the model, the assessment tools, and the associated interventions are presented.
... Seventy-nine percent of the participants in the intervention group successfully completed the treatment, demonstrating the feasibility of providing a TC-oriented day treatment program to women with AUD in South Korea. Completion rates are important in that they correlate with the post-treatment chances of recovery [36]. Yet, TCs have historically suffered from high drop-out rates [8]. ...
Article
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Background The prevalence of alcohol use disorder (AUD) among women in South Korea has been rising, causing public health problems. Yet women’s treatment needs are mostly unmet in South Korea due to the lack of women-focused treatment programs. This study evaluated the feasibility, acceptability, and clinical outcomes of a therapeutic community (TC)-oriented day treatment program for Korean women with AUD on alcohol abstinence self-efficacy, forgiveness, and spirituality. Methods The current study employed a quasi-experimental, non-equivalent control group design with a pretest and posttest. Participants were assigned to 6-month TC-oriented day treatment program (n = 19) or usual treatment (n = 21). Feasibility (treatment completion rate) and acceptability (overall program satisfaction) were assessed. Alcohol abstinence was measured as a clinical outcome at baseline, 3 months, and 6 months. Repeated measures using Alcohol Abstinence Self-Efficacy (AASE), Enright Forgiveness Inventory-Korea (EFI-K), and Spiritual Assessment Scale (SAS) were also obtained from both conditions at those three time points. Results Fifteen participants (78.9%) in the intervention group successfully completed the program. The overall program satisfaction ratings were very high (4.9 ± 0.2). Continuous abstinence rates at 6 months were significantly higher in the treatment group (78.9%) than in the control group (9.5%). Results of the two-way repeated measures ANOVA indicated that statistically significant two-way (group × time) interaction effects were found for the intervention group on AASE, EFI-K, and SAS but not for the control group on any of the outcomes. Conclusion The current study demonstrated the feasibility and acceptability of implementing a TC-oriented intensive day treatment program to promote recovery in Korean women with AUD. This intervention merits further investigation as a potential strategy to help address alcohol abstinence self-efficacy, forgiveness and spirituality. Trial registration : KCT0006386 (Cris.nih.go.kr).
... However, most treatment programs will last no less than seven to ten days, and it will continue for as long as the patient requires the treatment and support that is provided; the average length of programs was 90 days. This is in line with findings of Condelli and Hubbard (1994); Simpson et al. (1997) which show that those populations who remain in treatment for at least 3 months have more favorable outcomes, a critical retention threshold of at least 90 days has been established for residential programs. ...
Article
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Drug addiction is a complex illness. It is characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. Counsellors therefore need to study and develop multi-faceted drug intervention models that are "drug specific" to the addiction at hand. One size does not fit all. This paper looks at the various approaches to rehabilitation used to enhance recovery of alcoholics and drug abusers in registered inpatient rehabilitation centres in Kenya. A descriptive study that used a qualitative approach was carried out. The study focused on all the residential drug rehabilitation centres in and around Nairobi. The Study Sample included the counselors directly dealing with the treatment of clients in these centres. A two level questionnaire was used to establish the treatment models used in the various in patient drug rehabilitation centres from the respondents, using a qualitative key informant interview. Data was analysed and presented using descriptive and inferential statistics. The study found out that various models of treatment were used for treatment of clients admitted in drug rehabilitation centres in Nairobi. The commonly used models included the 12 step program of the Minnesota model, Therapeutic community model, Medical model and in most places a mixture of the various models.
... These studies found consistent decrease in drug use 1-year post-treatment as well as within a 5-year period. The studies focused on changes in use of single drugs, mainly heroin, and pointed at the completion and the temporal length of treatment as predictors for reduced drug use [8], [9]. ...
Article
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Aim: To examine temporal changes in opiate and stimulant use among patients in substance abuse treatment over a ten-year observation period and to explore the role of contextual factors, mental health disorders and psychosocial factors on these changes. Methods: A cohort of 481 patients was prospectively interviewed at admission to treatment and after 1, 2, 7 and 10 years. The sample was recruited from 20 facilities in the Greater Oslo region, Norway. Results: The majority of patients were poly-drug users and 80% had used both opiates and stimulants the last 30 days prior to treatment admission. Last-month use of heroin, other opiates, cocaine and amphetamines declined from 80% to 34% at the end of the observation period. The most substantial reduction was observed between baseline and one-year follow-up. Use of heroin decreased the most from 62% to 16% after 10 years (a reduction of 74%), and the reduction continued from one-year follow-up throughout the observation period. The most important multivariate risk factors for sustained use of these drugs were male gender, having one or both biological parents with severe alcohol or drug problems, having an antisocial personality disorder, and living together with a person who abuses alcohol or drugs. Employment was associated with reduced risk of drug use at 7-year follow-up. Conclusions: There was a substantial reduction in opiate and stimulant use from baseline to all follow-up assessments, most greatly for heroin. Findings regarding sustained use could suggest familial transmission and the challenges of preventive strategies and treatment efforts in an intergenerational context. Co-occurrence between drug abuse and mental health problems highlights the need of highly specialized competence in SUD treatment.
... Even when patients have access to treatment, dropout rates are high (30% over one month and 50% or higher at three months and beyond) [19][20][21][22][23]. This is why healthcare strategies to improve access and adherence to OUD treatment are of paramount importance to patients and payers. ...
Article
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The lack of adequate treatment for many patients with opioid use disorder (OUD) has led to high medical costs ($90B in 2020). An analysis of the cost-effectiveness (cost-utility) of reSET-O, the first and only FDA-approved prescription digital therapeutic (PDT) for the treatment of OUD, is needed to inform value assessments and healthcare decision making. To evaluate the cost-utility of reSET-O in conjunction with treatment-as usual (TAU) compared to TAU alone. A third-party payer-perspective decision analytic model evaluated the cost-effectiveness of reSET-O + TAU relative to TAU (i.e., oral buprenorphine, face-to-face counseling, and contingency management [immediate rewards for negative drug tests logged]) alone over 12 weeks. Clinical effectiveness data (retention in therapy and health state utilities) were obtained from the peer-reviewed literature, while resource utilization and cost data were obtained from a published claims data analyses. Over 12 weeks, the addition of reSET-O to TAU resulted in a gain of 0.003 quality-adjusted life years (QALYs), and $1,014 lower costs, resulting in economic dominance vs. TAU. reSET-O + TAU’s was economically dominant (less costly, more effective) vs. TAU alone over 12 weeks, a result that was driven by a reduction in medical costs after initiation of reSET-O observed in a recent real-world claims analysis.
... Several studies have shown that longer time spent in treatment was associated with better outcomes in terms of decreased substance use, improved employability, and reduced criminal activity (Condelli & Hubbard, 1994;Gossop, Marsden, Stewart, & Rolfe, 1999;Simpson, 1981;Simpson, Joe & Brown, 1997) as well as a reduction in post-treatment readmission rates (Moos, Pettit & Gruber, 1995) and relapse rates (Brecht et al., 2014). A review of 20 studies evaluating the efficacy of various aftercare and support models noted that three 12-month-long models obtained positive results whereas the shorter ones were more heterogeneous (McKay, 2009), thereby indicating that that longer planned treatment could have a considerable effect on their efficacy. ...
Article
Rationale The reconceptualization of substance use disorders (SUD) as a chronic phenomenon calls for a paradigm shift in service provision, particularly by way of long-term treatment and support. Studies that have evaluated the efficacy of long-term treatment models seem to indicate that they are an improvement on more standard short-term treatments, even though these studies do not take the durations into consideration. Objective Measure the efficacy of SUD treatments and support lasting 18 months or more regarding their ability to decrease substance use as compared to shorter treatments. Methods A meta-analysis based on a systematic literature review was conducted. Eight databases were consulted for peer-reviewed studies. Certain variables were coded as moderators: intervention length, participant characteristics, and treatment characteristics. Results The main results suggest that the people who received a planned long-term treatment or support had a 23.9 % greater chance of abstaining or consuming moderately than did people who received a shorter standard treatment (OR = 1.347 [CI 95 % = 1.087–1.668], p < .006, adjusted OR = 1.460 [CI 95 % = 1.145–1.861]). None of the moderation analyses revealed any variation in the efficacy of the long-term treatments and support. Conclusions The reconceptualization of the SUD as a chronic disorder among people with this problem leads us to reconsider both the length of the services provided and the paradigms underlying their organization.
... The current study examines the LOCADTR's predictive validity for recommendations to outpatient treatment among patients who were placed in the recommended LOC (concordant) or were placed in more resource-intensive LOCs (i.e., discordant from the tool recommendation). Our outcome of interest is continuous engagement in treatment, reflected in the length of an episode that continues across LOCs, which has been associated with improved client outcomes (e.g., mortality, substance use, acute care utilization) (Broome et al., 1999;Hubbard et al., 1997;Hubbard et al., 2003;Martin et al., 2019;Proctor & Herschman, 2014;Simpson, Joe, Broome, et al., 1997;Simpson, Joe, & Brown, 1997;Zhang et al., 2003). We focused on clients for whom the LOCADTR recommended the outpatient LOC and compared treatment engagement length for clients who entered the LOCADTRrecommended outpatient LOC (i.e., concordant) versus entering a discordant LOC: inpatient or outpatient rehabilitation. ...
Article
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Background The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate level of care for individuals seeking addiction treatment. However, research has not studied its predictive validity. We examined the predictive validity of the LOCADTR recommendation for outpatient treatment by determining whether those who entered an LOC concordant with the LOCADTR recommendation differed in continuous engagement in treatment compared to those who entered a discordant LOC. Methods The study combined data from two NYS administrative sources, the LOCADTR database and a treatment registry. The study examined characteristics of the clients who entered concordant and discordant LOCs as well as tested for differences in continuous engagement of clients who entered discordant care compared to a propensity score-matched comparison group of clients who entered the concordant LOC. Results Among clients for whom the LOCADTR recommended the outpatient LOC, concordant clients who entered the outpatient LOC were more likely to be retained in care than discordant clients who entered the inpatient LOC (aOR = 0.53; 95% CI = 0.36, 0.77). We did not observe statistical differences in continuous engagement among clients who were recommended for outpatient and entered that LOC versus those who entered the outpatient rehabilitation LOC instead (aOR = 1.08; 95% CI = 0.90, 1.30). Conclusion This study provides support for predictive validity of recommendations stemming from the LOCADTR. Clients, treatment providers, and payers benefited from a tool that provides clear guidance and predictively valid recommendations for treatment placement. The study found that clients were more likely to be retained in treatment for 6 months or longer if admitted to outpatient care, as recommended by the LOCADTR algorithm, rather than to inpatient treatment. One factor accounting for the longer engagement in outpatient care is the low level of continuity of care among patients being discharged from inpatient treatment.
... Studies on cognitive behavior therapy (CBT) for substance-use disorder demonstrate that length of treatment can vary greatly. However, some correlational studies indicate a positive relationship between longer duration and positive outcome (Simpson, Joe, & Brown, 1997). Without existing guidelines for the treatment of MD, and given the pioneering nature of the planned treatment, a relatively longer CBT duration was chosen. ...
Article
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This paper describes the course of psychotherapeutic treatment of a 25-year-old man presenting with maladaptive daydreaming (MD), from analysis of the underlying rationale through the treatment process to the outcomes. MD, a condition marked by highly absorptive daydreaming , consumed many hours of his day and produced distress, dysfunc-tion, and excessive Internet use. Ontological analysis resulted in classifying MD characteristics under several categories: as a dissociative disorder of absorption, as a behavioral addiction, and as an obsessive-compulsive spectrum disorder producing significant attention deficits. The therapy plan was derived from evidence-based treatment modalities for conditions elucidated in the ontological analysis and included cognitive behavioral interventions as well as mindfulness meditation. Therapy was provided for a predetermined period of six months. MD and relevant indices were measured before and after therapy, as well as at a two-month follow-up. The data show that the client was able to reduce his daydreaming time by over 50% and his time spent on the Internet by over 70%. He reported an improvement of over 70% in his work and social adjustment. Nevertheless, his maladaptive daydreaming scale score and his self-assessed pleasure derived from daydreaming showed more modest gains. I discuss this discrepancy and suggest future research directions.
... According to international and Nordic research, the treatment completion rate is about 20-50% (Lopez-Goni et al., 2008;Ravndal et al., 2005;Simpson et al., 1997) and dropout ranges from 17-57% in residential SUD treatment (Andersson et al., 2018;Deane et al., 2012;Samuel et al., 2011). Positive treatment outcomes are one of the most consistent factors associated with treatment completion (Ball et al., 2006;Beynon et al., 2008;Dalsbø et al., 2010;Hser et al., 2004;Meier et al., 2005;Ravndal et al., 2005;Zhang et al., 2003). ...
Article
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The underlying mechanisms of drop out in residential substance use disorder (SUD) treatment were investigated from the users’ perspective to identify what impacts their drop-out. A survey-based design was used in this study of patients who had decided to drop-out from residential SUD treatment with a therapeutic community approach. The survey included items such as patient satisfaction, psychological burden, and treatment-related factors such as staff competence. We found a high psychological burden among the dropout population. Patients who had considered dropout before leaving treatment reported significantly more difficulty from program-related treatment factors. The patients reported confidence in staff competence. A need for increased access to staff was reported, especially among those actively considering drop-out. Our results suggest that dropping out might not be an impulsive act but a result of prior consideration and decision-making. The study has important clinical implications for social and health services to consider to reduce dropout.
... Overall retention in treatment constitutes a broadly accepted indicator which is used to evaluate the quality of OAT [9][10][11]. Retention in OAT significantly reduces the risk of all-cause mortality and overdose mortality for those dependent on opioids, whereas poor retention and dropping out of treatment has been shown to increase mortality risk [12]. ...
Article
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Background Retention in care is a prerequisite for successful recovery, especially for a chronic condition like opioid dependence. Though retention varies greatly depending on the different substitution medication and treatment model, treatment retention is used as an indicator of treatment quality and effectiveness of care on a system and individual level. To monitor the overall quality of the Austrian opioid agonist treatment (OAT) system and to monitor patient satisfaction within the system, a new online-based registry called “eSuchmittel” was introduced in Austria at the beginning of 2011. The objective of this study is to analyze retention rates within the Austrian treatment system and to identify patient characteristics associated with retention, using data collected by the substitution registry. Methods The complete Austrian sample of 4778 registered patients starting treatment between 1.1.2011 to 31.12.2012 were included in the prospective cohort study using data from the Austrian substitution registry. For the statistical analysis, multivariate Cox Regression and Kaplan–Meier survival analysis were used to evaluate retention in treatment. Results The retention rate of the total cohort after two years was around 61%. Retention rates were significantly lower for men (exp(B) = .806, 95% CI 0.714–0.908) and significantly higher for patients aged 30 and older (exp(B) = 1.155, 95% CI 1.044–1.279), among patients located in Vienna (exp(B) = 1.439, 95% CI 1.273–1.626) and among patients prescribed oral slow-release morphine (SROM) (exp(B) = 2.141, 95% CI 1.885–2.430). Conclusions Average retention in the Austrian system is high in comparison to international retention rates. Nationally, SROM demonstrates higher treatment retention when compared to other available substitution medications. Sociodemographic and regional indicators also contribute to higher retention in care. A systematic monitoring of retention rates within a national registry is an important tool helping to evaluate the quality of care. In this study, the Austrian OAT system proves very high retention in care, an important success criterion.
... Een aantal elementen kunnen de effectiviteit van deze behandeling beïnvloeden. (Inter)nationale studies tonen aan dat de kans op een positieve afronding van een behandeling recht evenredig verloopt met de retentie of de duur van de behandeling (Simpson, Joe & Brown, 1997). Het volgen van een nazorgbehandeling versterkt deze positieve resultaten. ...
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Introduction Malaysia started to provide Methadone Maintenance Treatment to opioid dependence patients in government facilities since 2005. The implementation of this program was as part of the National Harm Reduction Program. This study was conducted to evaluate the Methadone Maintenance Program in Malaysia over a 10 year period (2005-2014) from various perspectives: patients, staffs and infrastructures. Methodology A cross sectional two stage systematic stratified random sampling study using retrospective record and questionnaires, conducted in 103 Ministry of Health’s health clinics and hospitals from October 2014-December 2014. Result The response rate was 93.5% with 3254 respondents selected. They were mainly male, the Malays with a mean age of 39.6 years old, 37.3 % (n=1234) were still on treatment, 17.1% had transferred out, 29.1% had defaulted, 8.6% had died and 7.6% were terminated. The mean duration on MMT was 3.8 years; the mean current methadone dose was 54.8 mg, 60% had takeaway dose, 5.1% required split dose mainly due to drug interactions with HAART and Rifampicin and 29.1% had constipation. Their cardiovascular risks were sedentary life and smoking. For mental health problems, 23.3% had symptoms of depression, 33.2% had symptoms of anxiety while 16.2% have symptoms of stress. For alcohol use, prevalence of current drinker was 8.8% and ever drinker was 9.5%. There were significant improvement in quality of life in all four domains, employment, health status and social functioning; reduction in HIV, Hepatitis B & C transmission, crime, incarceration, drug use and HIV risk. MMT was perceived by patients positively. Staff attitude needs improvement. The overall infrastructure was adequate. Conclusions & Recommendations MMT program in Malaysia was found to be effective, hence, must be expanded. There are areas for improvement that need rectification. Keywords : Malaysia, Methadone Treatment Outcome Study (MyTOS).
Article
A system known as fair hearings is a due process opportunity for patients who are involuntarily discharged from methadone maintenance treatment to challenge the discharge recommendation. We know very little about the processes and outcomes of fair hearings. For this study, we used a mixed methods approach to retrospectively analyze 73 fair hearing reports from a California methadone maintenance treatment program between 2000 and 2014. The aims of the study were to identify the factors involved in involuntary discharge from methadone maintenance, describe the factors involved when fair hearing outcomes decided in favor of the clinic, and describe the factors involved when fair hearing outcomes decided in favor of the patient. We found that patient attendance at the fair hearing meeting was significantly related to the fair hearing ruling in favor of the patient. We grouped the main reasons for discharge recommendations into five categories: 1) suspected diversion, 2) behavioral/interpersonal, 3) repeated, unexcused absences, 4) co-occurring substance use, and 5) multiple sources of opioids. For each category, we describe the circumstances involved in an outcome favoring the patient or the clinic using excerpts from fair hearing reports as examples.
Article
Addictive disorders have a strong psychosocial component in their etiogenesis, and hence psychosocial approaches form a significant part of management planning with a role in prevention, treatment, relapse prevention and long term rehabilitation. Due to a number of myths and misconceptions associated with addictive disorders, there is often strong resistance from the patients as well as the families towards treatment. The disorder is often perceived as a bad habit and hence not requiring treatment. It is very important to break this barrier to bring the patient and the family in treatment engagement. This article summarizes the need for psychosocial management of the addictive disorders, dealing with treatment resistance building therapeutic alliance, and improving the long term outcome. © 2018 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow.
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Objectives: Retention in methadone maintenance treatment is instrumental in achieving better treatment outcomes. In this study, we compared 2 medication-assisted treatment (MAT) clinics in Dar es Salaam, Tanzania with respect to patient characteristics, outcomes, and factors that predict 12-month treatment retention. Methods: This retrospective registry-based cohort study utilized data collected for routine clinical and program monitoring at 2 sites, Mwananyamala and Muhimbili MAT clinics. Cumulative retention in treatment was calculated using life tables. The analysis of treatment retention predictor variables used both Kaplan-Meier and Cox proportional hazard analyses. Results: We examined the socio-demographic and program-related characteristics of 362 (181 from each clinic) patients. Twelve-month treatment retention was higher at Mwananyamala (73%) than Muhimbili (64%) MAT clinic, but the difference was not significant. In both clinics, a higher methadone dose (>60 mg) significantly predicted treatment retention (P < 0.05). Being employed and traveling an average short distance (<5 km) from home to clinic significantly increased the likelihood of remaining in treatment in Muhimbili MAT clinic (P < 0.05) only. Conclusions: A methadone dose of 60 mg and above was associated with longer retention in treatment. At 1 clinic in a denser and more central location, employment and a short travel distance from home to clinic were associated with longer tenure in treatment. These findings have potential implications for clinical practice, research, and scaling up MAT services in Tanzania.
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This Practice Note describes the implementation of a partnership between child welfare and substance use providers in New York City, with the aim of supporting cross-systems collaboration and improving outcomes for dually involved families. Specifically, this report focuses on improving both coordination and communication between a preventive child welfare service provider (Montefiore Family Treatment & Rehabilitation Program), an outpatient substance abuse treatment provider (Montefiore Division of Substance Abuse), and the local department of social services (New York City Administration for Children’s Services). This article identifies general challenges with collaboration, describes how this collaboration was created and implemented in New York City, and provides guidance for other entities that are attempting to create similar collaborations.
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In this study we test the efficacy of Moment-by-Moment in Women's Recovery (MMWR), a mindfulness-based intervention adapted to support women with substance use disorder (SUD) while in residential treatment. We use a parallel-group randomized controlled trial with a time-matched psychoeducation control to test MMWR effects on residential treatment retention. We used clinical staff-determined residential site discharge status and discharge date from the SUD treatment site record to determine retention. We tested for study group differences in retention defined as time to treatment non-completion without improvement (i.e., patient left treatment before completion of the treatment plan and made little or no progress toward achieving treatment goals based on clinical team determination), as well as differences in self-report of study intervention mechanisms of action (i.e., mindfulness, perceived stress, distress tolerance, emotion regulation, distress, affect, and drug and alcohol craving). The analytic timeframe for the survival analysis was from study intervention start date to 150 days later. The sample (N = 200) was female, majority amphetamine/methamphetamine users (76%), Hispanic (58%), with a history of incarceration (62%). By the 150-day analytic endpoint, the sample had 74 (37%) treatment Completers, 42 (21%) still In-residence, 26 (13%) Non-completers with satisfactory progress, and 58 (29%) Non-completers without satisfactory progress. Survival analysis of the intent-to-treat sample showed the risk of non-completion without improvement was lower in MMWR as compared to the control group (adjusted hazard ratio = 0.42, 95% CI: 0.16-1.08, p = .07). Both groups improved on select self-reported mechanism measure scores at immediate post-intervention, but only in the MMWR group did class attendance (dosage) have a large-size correlation with improved mindfulness (r = .61, p < .01), distress tolerance (r = 0.55, p < .01) and positive affect (r = 0.52, p < .01) scores. The hazard ratio for retention was of medium-to-large effect size, suggesting the clinical relevance of adding MMWR to an all-women's, ethnoracially diverse, SUD residential treatment center. An extended curriculum may be helpful considering the protective benefits of class attendance on psychological health indicators.
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Objectives Longer retention in treatment is associated with positive outcomes. For women, who suffer worse drug-related problems than men, social technologies, which are more readily adopted by women, may offer promise. This naturalistic study examined whether a smartphone-based relapse-prevention system, A-CHESS (Addiction-Comprehensive Health Enhancement Support System), could improve retention for women with substance use disorders in an impoverished rural setting. Methods A total of 98 women, age 18 to 40, in southeastern Kentucky and mandated to treatment, received A-CHESS with intensive outpatient treatment for 6 months. For comparison, data were obtained for a similar but non-equivalent group of 100 same-age women also mandated to treatment in the same clinics during the period. Electronic medical record data on length-of-stay and treatment service use for both groups were analyzed, with A-CHESS use data, to determine whether those using A-CHESS showed better retention than those without. Results Women with A-CHESS averaged 780 service units compared with 343 for the comparison group. For those with discharge dates prior to the study’s end, A-CHESS patients stayed in treatment a mean of 410 vs 262 days for the comparison group. Conclusions Given associations between retention and positive outcomes, mobile health technology such as A-CHESS may help improve outcomes among women, especially in settings where access to in-person services is difficult. The findings, based on a non-equivalent comparison, suggest the need for further exploration with rigorous experimental designs to determine whether and to what degree access to a smartphone with A-CHESS may extend and support recovery for women.
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HIV prevention for women with substance use disorders is a public health priority. To identify characteristics associated with sexual risk among women in outpatient substance abuse treatment we categorized 809 screened women into three groups: (1) sexually inactive, (2) sexually active with consistent condom use, and (3) sexually active with inconsistent condom use. Multinomial logistic regression analyses were used to examine demographics, substance use and treatment characteristics, and regional HIV seroprevalence as predictors of sexual risk behavior. Younger age and attending psychosocial (PS) treatment were significantly associated with being at higher HIV risk. HIV prevention should be tailored to address HIV risk in younger women in PS treatment.
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Introduction Fentanyl is a potent synthetic opioid that has contributed to increasing overdose deaths in the United States in recent years. Concern over safety and efficacy of agonist treatment for fentanyl use may limit access to treatment. This study sought to address these potential concerns in a naturalistic setting. Objectives Measure 12-month treatment outcomes for methadone maintenance treatment (MMT) in a fentanyl endemic area. Outcomes Primary: 1) Treatment retention; 2) sustained remission (defined as 3 consecutive negative screens); 3) return to use; 4) methadone dosage required; and 5) number of days to achieve remission. Secondary: Mortality. Methods A naturalistic follow-up study and retrospective review of consecutive patients newly admitted to a single methadone maintenance treatment program in Rhode Island. Results We observed 154 unique intake events (representing 151 patients). Eighty percent (n = 121) tested positive for fentanyl at intake. Seventy-five percent of patients achieved remission within the 12-month study period. One-year retention was 53% for fentanyl-exposed individuals and 47% for those not exposed. The majority (99%) of patients who remained in treatment at 12 months achieved remission. We saw prolonged, sustained remission in 44% of patients exposed to fentanyl at intake and 47% of those who were not. Dose and time to remission were similar. Unfortunately, 4 patients died after leaving MMT prematurely. Conclusions This study suggests MMT is safe despite repeated exposure to fentanyl while taking methadone. Remission is achievable, and MMT is protective against death among fentanyl-exposed patients while in treatment.
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Controlled studies provide little empirical evidence to inform clinical recommendations for the optimal duration (i.e., “dosage”) of psychosocial treatment for substance use disorders (SUDs). The current study prospectively examined the relationships among treatment dosage, participant adherence to the treatment regimen, and treatment outcomes in a population of adults with stimulant use disorder (cocaine and/or methamphetamine). The study randomly assigned eighty-five participants to receive either 4 weeks or 16 weeks of standardized outpatient treatment. The treatment consisted of cognitive behavioral therapy (CBT) and content covered was identical for each condition; only the planned duration of participation differed. Although both groups reduced stimulant use over time, participants in the 16-week condition were significantly more likely than those in the 4-week condition to provide stimulantnegative urine specimens 26 and 52 weeks following randomization. Participant adherence to treatment correlated significantly with drug-use outcomes: we observed a greater likelihood of stimulant-negative urine tests among those who completed treatment, irrespective of group assignment. Both the number of sessions attended and the percentage of prescribed sessions attended were associated with reductions in stimulant-use frequency 26 and 52 weeks after admission.
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Background The American Society of Addiction Medicine (ASAM) criteria were developed to provide a systematic, evidence-based, and transparent approach to addiction treatment assessment and level-of-care recommendations. In 2017, California began a Medicaid demonstration that required that providers in participating counties to adopt ASAM-based intake assessments and level-of-care criteria. We hypothesized that ASAM implementation would increase the proportion of patients retained in addiction treatment and successfully completing their treatment plan. Methods We implemented a comparative interrupted time series analysis with 407,792 treatment episodes by Medicaid beneficiaries in specialty addiction treatment settings from 2015 to mid-2019. We compared the change in retention rates and successful completion rates in counties that adopted ASAM-based assessments relative to counties that did not adopt ASAM-based assessments and used only clinical judgment for level-of-care decisions. Treatment retention was defined as staying in addiction treatment for at least 30 days. Successful completion of the treatment plan was determined by the patient’s clinician. Results After one year, ASAM implementation was associated with a 9% increase in 30-day retention among treatment episodes that started in a residential setting, but no change in retention among episodes starting in outpatient settings. We found no statistically significant association between ASAM adoption and successful treatment completion. Conclusions Implementation of ASAM-based assessment may lead to improved retention for individuals who begin treatment in residential treatment, which may be encouraging to the many state Medicaid programs that are adopting ASAM-based criteria. More research is needed to clarify the mechanism by which ASAM leads to improved outcomes and to clarify how to maximize the potential benefits of ASAM, such as through patient-centered implementation.
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Purpose To evaluate real-world prescription digital therapeutic (PDT) use and associated clinical outcomes among patients with opioid use disorder (OUD). Patients and methods A real-world observational evaluation of patients who filled either a 12- or 24-week (refill) prescription for the reSET-O® PDT. The PDT content consists of 67 interactive lessons unlocked in sequence during use as well as the chance to earn rewards for progress and/or negative urine screens. Engagement/retention data (ongoing engagement in weeks 9-12, or 21-24) were collected via the PDT and analyzed with descriptive statistics. Substance use was evaluated as a composite of patient self-reports and urine drug screens (UDS). Missing UDS data were assumed to be positive. A regression analyses of hospital encounters for 12- vs. 24-week prescriptions controlling for covariates was conducted. Results In a cohort of 3,817 individuals with OUD who completed a 12-week PDT prescription, a cohort of 643 was prescribed a second 12-week “refill” prescription, for a total treatment time of 24 weeks. Mean age of the 24-week cohort was 39 years, 56.7% female. At 24 weeks of total treatment: abstinence in the last 4 weeks of treatment was 86% in an analysis in which patients with no data are assumed to be positive for illicit opioids. Over 91% of patients were retained in treatment. An analysis of matched insurance claims showed that those treated for 24 weeks had a 27% decrease in unique hospital encounters compared to those who got the first 12-week prescription only. Conclusions These data present real-world evidence that a second prescription (24 weeks) of a PDT for OUD is associated with improved outcomes, high levels of retention, and fewer hospital encounters compared to a single prescription for a PDT.
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Given the potential benefits of SUD treatment compliance and the continuing problems associated with waiting for treatment, it is critical to establish an understanding of the factors that influence the cause and duration of waiting time for treatment services.The 2018 US Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set-Admissions (TEDS-D) were used for this analysis. Prevalence odds ratios from the multivariate logistic regression analyses were used to determine associations between sociodemographic attributes and waiting times prior to SUD admission treatment. Compared to African Americans, the odds of waiting 1–7 days to enter treatment were highest among Alaskan Natives (OR = 1.637, 95% CI: 1.243–2.156). The odds of waiting more than 1 week to enter treatment were 1.690 times higher (95% CI: 1.299–2.197) among Blacks/African Americans after adjusting for race, marital status, employment, and biological sex; there was a statistically significant association between the level of educational attainment and waiting 1–7 days to enter treatment.This study shows that among adults seeking admission into a SUD treatment program, waiting times varies across different sociodemographic attributes especially race as non-Hispanic blacks had a shorter wait time compared to other races.
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BACKGROUND Opioid dependence affects several neurocognitive domains, which can negatively affect the treatment outcome. OBJECTIVE Examining the relationship between neurocognitive functions and short-term treatment retention in subjects on buprenorphine-naloxone-based agonist treatment. METHODS We recruited 56 subjects (aged between 18 and 45 years) registered between March 2017 and December 2017. We excluded subjects dependent on other substances (except cannabis and tobacco), along with medical and other psychiatric comorbidities. During the first week of the agonist treatment, we assessed executive function, decision-making, attention, psychomotor speed, and working memory with the Wisconsin card sorting test (WCST), Iowa gambling test (IGT), and Trail making and verbal and visual N-back tests. Treatment retention was assessed after 12 weeks. RESULTS The mean age of the subjects was 26 (±5.9) years. Twenty-eight (50%) subjects were retained in the treatment. Neurocognitive functions at the treatment entry did not differ between subjects retained in the treatment and those who dropped out. A higher severity and lower duration of dependence and use were associated with higher treatment discontinuation. The regression model, with the cognitive functions and significant clinical variables, could explain 38% variance for treatment retention. CONCLUSION Neurocognitive functions at the treatment entry did not predict retention in opioid agonist treatment. • There is some evidence of baseline cognitive functions predicting treatment retention in substance use disorders • We wanted to test it in a group of patients on buprenorphine (naloxone)-based agonist management • Relevant clinical and demographic variables were controlled for • Executive functions, decision-making, attention, psychomotor speed, and working memory at the treatment entry did not predict retention at the end of three months • Longer duration of opioid use (and dependence) was associated with better treatment retention
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Examined measures of motivation for drug use change and treatment with respect to psychometric properties and prediction of early dropouts from methadone maintenance. Three scales developed by D. D. Simpson (1992) were used to obtain personal assessments: Drug Use Problems, Desire for Help, and Treatment Readiness. Data were collected at intake from 311 methadone maintenance clients admitted to 3 outpatient treatment agencies, of which 24% dropped out of treatment within 60 days. The scales were found to be reliable. Social stability (marital status, employment, and fewer prior arrests), previous treatment experience, expectations for reducing future drug use, higher methadone dose level, and higher motivation were identified as significant predictors of treatment retention beyond 60 days. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Objective. —To examine whether the addition of counseling, medical care, and psychosocial services improves the efficacy of methadone hydrochloride therapy in the rehabilitation of opiate-dependent patients.Design. —Random assignment to one of three treatment groups for a 6-month clinical trial: (1) minimum methadone services (MMS)—methadone alone (a minimum of 60 mg/d) with no other services; (2) standard methadone services (SMS) —same dose of methadone plus counseling; or (3) enhanced methadone services (EMS)—same dose of methadone plus counseling and on-site medical/psychiatric, employment, and family therapy.Setting. —The methadone maintenance program of the Philadelphia (Pa) Veterans Affairs Medical Center.Subjects. —Ninety-two male intravenous opiate users in methadone maintenance treatment.Results. —While methadone treatment alone (MMS) was associated with reductions in opiate use, 69% of these subjects had to be "protectively transferred" from the trial because of unremitting use of opiates or cocaine, or medical/ psychiatric emergencies. This was significantly different from the 41% of SMS subjects and 19% of EMS subjects who met the criteria. End-of-treatment data (at 24 weeks) showed minimal improvements among the 10 MMS patients who completed the trial. The SMS group showed significantly more and larger improvements than did the MMS group; and the EMS group showed significantly better outcomes than did the SMS group. Minimum methadone services subjects who had been "protectively transferred" to standard care showed significant reductions in opiate and cocaine use within 4 weeks.Conclusions. —Methadone alone (even in substantial doses) may only be effective for a minority of eligible patients. The addition of basic counseling was associated with major increases in efficacy; and the addition of on-site professional services was even more effective.(JAMA. 1993;269:1953-1959)
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Considerable heterogeneity in patterns of addiction and treatment career histories was observed among the 10,010 clients participating in the Drug Abuse Treatment Outcome Study (DATOS). For half of the clients, DATOS was their first treatment episode; for the other half, their mean number of prior treatment episodes was 3.5. Type of treatment and cumulative length of treatment exposure reflected the interaction of clients' drug use patterns and the historical availability of different treatment approaches. Regression analyses showed that a higher level of prior treatment use was associated with more severe addiction career characteristics, injection drug use, and criminal activities. Effective and cost-effective approaches to treatment need to include more strategic interventions that consider clients' diverse treatment histories. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Examined treatment satisfaction (TS) in relation to treatment outcomes (i.e., tenure and relapse for opioid use) and client and treatment variables in 532 methadone maintenance clients in a data system by M. Allison et al (1982). Satisfaction data were limited to the 1st 3 mo in treatment. Most Ss stated that the treatment had helped them to some degree with their drug problem or that they were at least somewhat satisfied with treatment. About three-quarters of the clients felt that the treatment had helped them at least somewhat with other nondrug problems. Overall, results suggested that TS measured early in treatment does not have strong direct effects on during-treatment-outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Stays of 3 months or longer in drug abuse treatment generally predict better follow-up outcomes. In a national sample of community-based programs that participated in the Drug Abuse Treatment Outcome Study, median lengths of stay were 3 months for clients in long-term residential and outpatient drug-free treatments and 1 year for clients in outpatient methadone treatment. However, individual programs within each of these modalities differed widely in how long they kept their clients in treatment as well as their service delivery. Programs treating individuals with heavier cocaine and alcohol use and more psychological dysfunction usually had shorter retention rates. Nonetheless, even after statistically controlling for these client differences, some programs were more effective than others in engaging and retaining clients. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The Drug Abuse Treatment Outcome Study (DATOS) collected 1-year follow-up outcomes for 2,966 clients in outpatient methadone (OMT), long-term residential (LTR), outpatient drug-free (ODF), and short-term inpatient (STI) programs in 1991-1993. LTR, STI, and ODF clients reported 50% less weekly or daily cocaine use in the follow-up year than in the preadmission year. Reductions were greater (p < .01) for clients treated for 3 months or more. Clients still in OMT reported less weekly or daily heroin use than clients who left OMT. Multivariate analysis confirmed that 6 months or more in ODF and LTR and enrollment in OMT were associated with the reductions. Reductions of 50% in illegal activity and 10% increases in full-time employment for LTR clients were related (p < .01) to treatment stays of 6 months or longer. The results replicated findings from 1979-1981 for heroin use in OMT and illegal activity and employment for LTR but not for illegal activity in OMT and ODF.
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A general framework for studying drug abuse treatment process factors is presented, and components are then used to predict relapse to opioid use during treatment in methadone maintenance. Major domains of the treatment process research framework include client variables at entry, program characteristics, treatment events, and client outcomes. The analyses rely on the use of proportional hazards models to identify significant outcome predictors in a sample of 590 methadone maintenance clients from 21 clinics in the Research Triangle Institute/Treatment Outcome Prospective Study (RTI/TOPS) data system who remained in treatment at least 3 months. The analyses were performed on the total sample and separately on clients from three groups of clinics classified on the basis of the distribution of client relapse rates and tenure in treatment. Relapse rates were related to dosage level, client monitoring with urinalyses, and methadone take-home privileges in some clinics, and hence, these time-varying treatment events were important factors in treatment outcomes. Even at entry to treatment, some measures were found to be related to how the client later performed during treatment. Finally, it was also found that the particular area of professional speciality of the staff making client diagnosis at intake and preparing treatment plans was associated with client outcomes.
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Research found that therapeutic communities and other types of residential programs are effective in reducing drug use, unemployment, and criminal behavior and that length of time spent in treatment is an important predictor of client outcomes from programs. Studies vary considerably, however, in terms of the amount of time they found clients need to stay in treatment to produce those outcomes. Data collected for the Treatment Outcome Prospective Study (TOPS) were analyzed to explore the relationship between time spent in treatment and client outcomes from therapeutic communities and other types of residential drug treatment programs. The analysis took into account client characteristics and whether clients received drug treatment during the follow-up year. The results indicate there is a stronger relationship between time spent in treatment and client outcomes from therapeutic communities than was suggested in earlier analysis of TOPS data.
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There have been few studies of treatments for substance dependence among private programs. The present study compared the patient populations, treatment services provided and six-month outcomes of employed, insured patients referred by an employee assistance program to four private treatment programs (two inpatient and two outpatient). Subjects were alcohol and/or cocaine dependent males referred from a single employer. Ninety-four percent were successfully contacted at six-month follow-up, with confirmatory urinalysis and breathalyzer samples taken. Three results were obtained. First, there were significant and pervasive improvements shown in the total sample at follow-up. Fifty-nine percent were completely abstinent, 82% were working and only 8% required re-treatment. Second, there were significant differences among the programs in levels of improvement and six-month outcomes. Finally, the differences in efficacy were related to the differences in the nature and amount of treatment services provided.
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This study summarizes historical changes among clients entering drug treatment in their sociodemographic characteristics and important pretreatment behaviors, such as work activity, criminal behavior, drug use, prior drug treatment, and health insurance. Data are drawn from three major studies of drug abuse treatment clients: the Drug Abuse Reporting Program (DARP), 1969-1972; the Treatment Outcome Prospective Study (TOPS), 1979-1981; and the Drug Abuse Treatment Outcome Study (DATOS), 1991-1993. The mix of drug treatment clients and their interaction with the drug treatment system changed substantially over the past three decades. Because data items are most directly comparable between TOPS and DATOS, the focus of this paper is on changes within the past decade. The most conspicuous change is in types and numbers of drugs used by clients entering treatment. Multiple drug use declined since the late 1970s, while reports of cocaine use since TOPS more than doubled among clients in the long-term residential and outpatient treatment modalities, and increased 1 1/2 times among methadone clients. Other differences in treatment populations include decreases in clients' working full-time and in reports of suicidal ideation and attempts and predatory crime. Data from such studies as DARP, TOPS, and DATOS are valuable in historical, contextual, policy, and evaluative frameworks. The changing nature of the drug treatment client population--from sociodemographics to drug use and multiple treatment problem severities--highlights the complexity of issues and difficulties encountered by those attempting to treat clients or plan treatment strategies.
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Longer length of stay (LOS) in substance abuse treatment, a standard measure of treatment success, conflicts with pressures from managed care. To maintain LOS as an outcome, we identified, for four modalities, LOS categories such that program completion rates were relatively constant within category and differed among categories. We validated the cutoffs by showing that future utilization over a 2-year period by clients differed by category. Clients in the long-LOS category used the system in a way consistent with more successful treatment. Thus, rather than using increase in LOS as an outcome, one can use increase in the percentage of clients reaching the long-LOS category. Categories were developed and utilization analyzed for discharges from publicly funded Boston treatment programs between 1/92 and 12/94 from the following modalities: short-term residential (5,462 discharges), long-term residential (5,086 discharges), outpatient (13,656 discharges), and detox (19,965 discharges).