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... Both included SRs 8,9 conducted a narrative synthesis on inpatient and outpatient programs for the treatment of SUDs. One SR by de Andrade et al. 8 included all evidence except SRs and case report study designs, and the other SR by Brooks et al. 9 included all evidence regardless of study design. Both SRs performed literature searches from multiple databases. ...
... The SR by Brooks et al. 9 included studies of patients specifically diagnosed with alcohol use disorder (AUD) and the other SR by de Andrade et al. 8 included studies involving patients with SUD. Details of patient characteristics were not fully reported in both SRs. ...
... The SR by de Andrade et al. 8 compared residential treatment (RT) programs for individuals with SUD with other treatment types including outpatient treatment, pharmacotherapy detoxification, and RT programs with different adjunctive therapies. The RT programs provided intensive care and support for individuals with severe and complex SUD (including alcohol and other drug withdrawal or maintenance management in a hospital or supervised residential facility), individual and group psychological support, mutual self-help and peer therapeutic communities, and support reintegration into the community. ...
Article
Moderate to weak evidence suggests that patients with substance use disorders who received residential treatment were more likely than outpatients to complete treatment and be considered abstinent. Comparisons between residential treatment and outpatient programs for other outcomes were unclear. Strong- to weak-quality evidence showed that residential treatment services for patients with substance use disorders was effective in improving various outcomes including substance use, social, criminal activity, and mental health outcomes. However, residential treatment was likely associated with poorest survival outcomes after discharge compared to other treatments. Managed alcohol programs in hospital settings appeared to be effective and safe in preventing and treating alcohol withdrawal syndrome in surgical patients, trauma patients, or hospitalized patients. The level of evidence was not assessed. There was evidence that managed alcohol programs in community settings improved drinking patterns, alcohol-related harm, criminal activity, mental health, and social and physical well-being. The level of evidence was not assessed. The American Society of Addiction Medicine clinical practice guideline provides recommendations for the identification and management of alcohol withdrawal in inpatient and ambulatory settings. Patients’ current signs and symptoms, levels of risk for developing severe or complicated withdrawal or complications of withdrawal, and other dimensions should be taken into consideration in the assessment process to determine the appropriate level of care. Strength of recommendations was not assessed. The Canadian Coalition for Seniors’ Mental Health recommends that patients with cannabis use disorder should be considered for residential treatment if they are unable to effectively reduce or cease their cannabis use (level of evidence: Low; strength of recommendation: Strong).
... More time spent in a therapeutic community is generally considered to elicit greater benefits (Winters and Winters, 1999). Nonetheless, evidence indicates that residential programs no longer than 28 days also elicit significant reductions in substance use behaviours (de Andrade et al., 2019). This accords with evidence suggesting that program engagement, not just the duration of treatment, are critical for positive outcomes (Davidson and Young, 2019). ...
... The comparison group were clients who spent fewer than 30 days in PALM during their last recorded admission. We dichotomised treatment duration at 30 days because, in addition to being the methodology used by prior studies on PALM (Bista et al., 2021;Nathan et al., 2020) and in other studies on residential treatment programs (de Andrade et al., 2019), it provides a useful demarcation that is easy to replicate in future studies and use in a clinical setting. ...
... Adolescents who engage in both behaviours may benefit the most from treatment that addresses a range of individual factors as well as attention to the broader socio-environmental factors, such as education and employment opportunities, that are associated with alcohol and other drug use and crime. Addressing these factors and providing life opportunities is the intention of therapeutic community programs such as PALM (de Andrade et al., 2019;Nathan et al., 2016a). This is consistent with the current study's finding that engagement in PALM was associated with a greater reduction on the rate of hospitalisation for all diagnostic categories. ...
Article
Introduction This study examines the association between treatment in a therapeutic community for adolescents with drug and alcohol problems on hospitalisation outcomes up to 15 years later for all clients, and separately for those with and without a history of criminal conviction. Method A quasi-experimental design was used to examine the linked administrative health and criminal justice records for all adolescents admitted to the Program for Adolescent Life Management (PALM) from January 2001 to December 2016 (n=3,059) in Sydney, Australia. ICD-10AM codes were used to designate hospitalisation outcomes as either physical injury, mental health problems, substance use disorders, or organic illness. The treatment and comparison groups were matched on factors associated with program retention, resulting in a final sample of 1,266 clients. We examined the rate of hospitalisation up to 15 years posttreatment for all clients and stratified by prior conviction status using Cox regression analyses. Results The treatment group had significantly lower rates of hospitalisation for a physical injury (HR=0.77 [95% CI=0.61-0.98]), mental health problem (HR=0.62 [95% CI=0.47-0.81]), substance use disorder (HR=0.59 [95% CI=0.47-0.75]), and organic illness (HR=0.71 [95% CI=0.55-0.92]). There was a significant interaction between treatment and prior criminal conviction status on rate of hospitalisation for physical injury, suggesting that the effect of treatment on physical injury was significantly greater for clients with a prior criminal conviction. Conclusions Adolescents who engage in a therapeutic community treatment program may have a long-lasting reduction in the risk of subsequent hospitalisation. This also appears to apply to those with a history of criminal conviction.
... Residential treatment services represent a higherintensity level of care for SUD and may be particularly useful for clients who experience problematic substance use with comorbid mental disorders, physical health issues, or other psychosocial complexities. A small number of studies support the effectiveness of residential treatment for SUD in adult populations [8], but less is known about residential programs that cater to young people with SUD [9]. Psychosocial interventions such as family-based therapies, cognitive behavioural therapy, motivational interviewing/motivational enhancement therapy, and third-wave cognitive behavioural therapies are effective for the treatment of young people with SUD [10]. ...
... Despite this, to the best of our knowledge, there are no studies that have evaluated integrated residential treatment for young people with SUD where DBT-based interventions form a major component of treatment. This is exemplified by the results of a recent systematic review of residential SUD treatment in which only three of the included 23 studies involved a specific focus on treating the young adult age group (i.e., 18-24 years) [8]. These studies found improved outcomes for young people in integrated programs incorporating the following psychosocial interventions: cognitive behavioural and motivational enhancement approaches [20]; unspecified individual and group evidence-based interventions based on an integrated dual diagnosis model [21]; and family-based, cognitive behavioural, and motivational enhancement approaches [22]. ...
... Specifically, designated outcomes were global psychiatric symptoms (primary outcome), as well as substance use severity and quality of life (secondary outcomes). The primary outcome was chosen on the basis of the high co-occurrence of SUD and mental disorders in adolescents [11,12], the relevance of mental health outcomes in studies of residential SUD programs [8], and the context of the residential facility studied, which is focused on providing integrated mental health treatment and a holistic approach for residents that often present with comorbid mental health and psychosocial challenges. The pragmatic design of this trial additionally allowed changes in presentation over time to be investigated, and we subsequently used the opportunity to investigate whether differences emerged in sociodemographics or psychiatric symptom severity in the young people accessing this service over a 10-year period. ...
Article
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Background Reducing substance use in youth is a global health priority. We compared two cohorts from the same 12-week residential substance use disorder (SUD) facility over a ten year period: Cohort A (2008-2009) and Cohort B (2018-2020). The essential components of the program remained the same with the primary treatment being dialectical behaviour therapy (DBT) plus residential milieu. Methods Young people in the current Cohort B (N = 100) versus historical Cohort A (N = 102) had a similar ratio of males (74 vs. 70%) but were slightly older (mean 20.6 vs. 19.5 years). Linear mixed models were used to model outcome measures (global psychiatric symptoms, substance use severity, and quality of life) longitudinally up to 12 months later. Results Baseline to end-of-treatment comparisons showed that the current Cohort B had overall higher levels of global psychiatric symptoms (d = 0.70), but both groups reduced psychiatric symptoms (Cohort A: d = 1.05; Cohort B: d = 0.61), and had comparable increases in confidence to resist substance use (d = 0.95). Longitudinal data from the current Cohort B showed significant decreases in substance use severity from baseline to 6-month follow-up (d = 1.83), which were sustained at 12-month follow-up (d = 0.94), and increases in quality of life from baseline to end-of-treatment (d = 0.83). Conclusions We demonstrate how DBT plus milieu residential care for young people continues to show positive effects in a 10-year comparison. However, youth seeking treatment today compared to 10 years ago evidenced higher acuity of psychiatric symptoms reinforcing the importance of continuous improvement of psychological treatments.
... De Andrade et al. 2019 conducted a systematic review of all studies on the effectiveness of residential treatment published between January 2013 and December 2018 [32]. They identified that despite the growing need for effective residential SUD treatment internationally, there was a lack of consensus on best practice treatment guidelines. ...
... They identified that despite the growing need for effective residential SUD treatment internationally, there was a lack of consensus on best practice treatment guidelines. In line with previous reviews, this review is of the most recent studies in the field (2013-2018) and provided some evidence that residential treatment may be effective in reducing substance use and improving mental health [32]. Furthermore, the authors found evidence that treatment may have a positive effect on social and offending outcomes. ...
... Furthermore, the authors found evidence that treatment may have a positive effect on social and offending outcomes. This research also identified an urgent need to conduct more research in this field that could address significant methodological flaws, and affirm that these flaws could be partially overcome by the use of data linkage practices to monitor outcomes [32]. Of note, there was an absence of evidence evaluating the impact of residential addiction treatment on broader health system utilization. ...
Article
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Background Indigenous communities in Canada face significant challenges with intergenerational trauma, which manifests in substance use disorders. There is consensus that connecting treatment approaches to culture, land, community, and spiritual practices is a pathway to healing trauma and substance use disorders for Indigenous peoples. Indigenous residential addiction treatment programs have been established as the primary intervention to provide healing for Indigenous peoples with substance use disorders and intergenerational trauma. However, there is limited evidence demonstrating the effectiveness of these programs. In collaboration with the Benbowopka Treatment Centre, this paper describes a study protocol which aims to evaluate the effectiveness of blending Indigenous Healing Practices and Seeking Safety for the treatment of Indigenous patients with intergenerational trauma and substance use disorders. Methods We will conduct a pre/post Quasi Experimental Community trial, to compare historical treatment outcomes for patients following the implementation of Indigenous Healing and Seeking Safety. We will conduct quantitative and qualitative analyses to understand the differences before and after the intervention is implemented. The pre- Indigenous Healing and Seeking Safety intervention study window will span from 2013 to 2016; n = 343, and the post-Indigenous Healing and Seeking Safety intervention study window from 2018 to 2020; n > 300. All participants will be enrolled in the Benbowopka residential treatment for the first time during the study periods. All data will be anonymized at the time of data entry. Propensity matching will be undertaken for patient characteristics, including sex/gender, age, and substance use type. Results and conclusions The study findings could be used to inform intergenerational trauma and substance use disorders residential treatment programming for Indigenous communities across Canada. Our work will contribute to the field of community-based intergenerational trauma and substance use disorders programming by addressing objectives that consider: (a) the patient perspective, (b) the program perspective, and (c) the community perspective. The study findings may validate an innovative approach for evaluating the effectiveness of residential addiction treatment and particularly the effective and appropriate care for Indigenous patients with intergenerational trauma and substance use disorders.
... This study sought to determine substance use and biopsychosocial outcomes at 3 months and 9 months following TC treatment across two sites. Furthermore, the length of planned TC treatment generally varies between four weeks and 12 months [4][5][6]. This study sought to determine the role of length of stay in clinical outcomes. ...
... The trial also sought to determine various biopsychosocial outcomes, extending beyond the commonly investigated substance use and dependence indicators. While a positive association between LOS and clinical improvements has been found in previous studies [17], results have often been limited by potential response bias due to high attrition rates [6,9]. The very low attrition rates in this study add more reliable support to the link between increased LOS and clinical improvements. ...
Article
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The Therapeutic Community (TC) model is considered an effective treatment for substance dependence, particularly for individuals with complex presentations. While a popular approach for this cohort across a number of countries, few studies have focussed on biopsychosocial and longer-term outcomes for this treatment modality. This study reports on substance use, dependence, and biopsychosocial outcomes up to 9 months post-exit from two TC sites. Methods: A longitudinal cohort study (n = 166) with two follow-up time points. Measures included substance use, dependence, subjective well-being, social functioning, and mental and physical health. Generalized Linear Models were employed to assess change over time. Results: At 9 months, 68% of participants reported complete 90-day drug abstinence. Alcohol frequency and quantity were reduced by over 50% at 9 months, with 32% of the sample recording 90-day abstinence at 9 months. Both alcohol and drug dependence scores were reduced by over 60%, and small to medium effect sizes were found for a range of psychosocial outcomes at 9 months follow-up, including a doubling of wellbeing scores, and a halving of psychiatric severity scores. Residents who remained in the TC for at least 9 months reported substantially better outcomes. Conclusions: With notably high study follow-up rates (over 90% at 9 months post-exit), these data demonstrate the value of the TC model in achieving substantial and sustained improvements in substance use and psychosocial outcomes for a cohort with severe substance dependence and complex presentations. Implications for optimal length of stay are discussed.
... Benefits of treatment completion or longer stays are shown to include lower levels of drug use, fewer arrests, increased employment rates and improved social engagement and psychological well-being following treatment compared with those who left the program early [12,[15][16][17][18][19]. 'Engagement' in programs, not just time in treatment, has also been identified as important in ensuring positive outcomes from residential programs [18,[20][21][22][23]. Maximising engagement and preventing drop out are therefore key priorities for the residential AOD treatment sector. ...
... However, according to Foster and colleagues (2010), adolescents in a TC in Sydney Australia wanted methods beyond the typical journaling and talk-based group sessions to reflect on their experiences, including their experiences in the program [24]. This finding, together with the increasing evidence of the need for 'engagement' to reduce treatment drop out and maximise positive outcomes from treatment [18,[20][21][22][23], led the authors of this paper to explore the role of arts-based methods as a research tool in this setting, but also as a means of 'engagement' for clients in residential treatment programs. ...
Article
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Arts-based approaches have not been widely used in the drug and alcohol treatment sector. In this study, we examined the utility of the arts-based method of Body Mapping in an Australian residential treatment centre. Two workshops were held to explore young people’s strengths and support networks in order to improve understandings of young people’s lives, identities and experiences of treatment. Semi-structured follow-up interviews were conducted and triangulated with observational notes and staff interviews. We identified four major themes: engaging through art; removing the mask; revealing strengths; and a sense of achievement. Overall, this study highlighted the value of Body Mapping as an approach to engage with young people, providing rich in-depth data about their lived experiences, including in the alcohol and other drug (AOD) treatment context.
... Compared to those who discharge from treatment prematurely, longer retention or completing treatment is a predictor of better post-treatment outcomes. Some of these outcomes include increased harm reduction, longer periods of substance abstinence, and greater social functioning (15,16). ...
... Residential treatment is recommended for individuals who are unstable and have moderate to severe substance use disorders (15,17). While longer stays in treatment (e.g., >90 days) are associated with positive outcomes for opioids, methamphetamines, and other drug use generally (16,(18)(19)(20)(21), the benefit of short-term residential treatment (e.g., 30 days or less) on the co-use of opioids and methamphetamines is unclear. ...
Article
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Objective: There is an increase in persons entering substance use treatment who co-use opioids and methamphetamines in recent years. Co-using these substances may negatively impact treatment retention in the residential setting. We explored predictors of adults completing short-term residential treatment among persons with primary opioid use disorder (OUD) who co-use either alcohol, benzodiazepines, cocaine, or methamphetamines. Methods: This study used the 2019 de-identified, publicly available Treatment Episode Dataset-Discharges. The sample included adults discharged from short-term residential treatment with primary OUD who co-used either alcohol, benzodiazepines, cocaine, or methamphetamines. The final sample size included 24,120 treatment episodes. Univariate statistics were used to describe the sample. Two logistic regression models were used to predict completing treatment. The first logistic regression model included the co-use groups as predictors and the second model added other demographic and treatment-relevant covariates. Results: A slight majority (51.4%) of the sample prematurely discharged from treatment. Compared to the other three co-use groups, the opioid and methamphetamine co-use group had the highest proportion of individuals who were women (45.0%), unemployed (62.5%), current injection drug use (76.0%), living in the Midwest (35.9%), living in the south (33.5%), and living in the west (15.5%). The opioid and methamphetamine co-use group also had the highest proportion of individuals not receiving medications for OUD (84.9%), not having a prior treatment episode (28.7%), and not completing treatment (57.4%). In the final logistic regression model, which included covariates, the opioid and alcohol (OR = 1.18, 95% CI = 1.080–1.287, p < 0.001), opioid and benzodiazepine (OR = 1.33, 95% CI = 1.213–1.455, p < 0.001), and opioid and cocaine (OR = 1.16, 95% CI = 1.075–1.240, p < 0.001) co-use groups had higher odds of completing treatment than the opioid and methamphetamine co-use group. Conclusions: Opioid and methamphetamine co-use may complicate short-term residential treatment retention. Future work should identify effective strategies to retain persons who co-use opioids and methamphetamines in treatment.
... When researching substance abuse and its harmful effects, researchers predominantly focus on certain social groups with a higher tendency towards substance taking and misuse, such as adolescents and male adults [13][14][15][16][17][18]. This is valid, as they may encounter various demanding life and social challenges, expectations, interpersonal alienation and biological impulses, all of which are relevant to the triggering of their initiation into drug experimentation as a form of self-medication. ...
... Therefore, cross-disciplinary research using different methodologies and designs is much needed to scrutinize substance abuse in respect of etiology, maintenance, consequences, abstinence and relapse. Generally speaking, empirical studies using quantitative methods are more common than research involving qualitative inquiry, analysis of secondary data and/or documentary inspection [16,39,40]. In fact, research based on a range of methods and designs is useful in enhancing our comprehension of the nature and impact of substance abuse from different perspectives. ...
Article
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Substance abuse has been a thorny public health concern throughout human history. Manifestly, prevention and treatment are the two main strategies commonly adopted to tackle the problem of substance abuse. They are in fact cross-disciplinary, and they relate to the various domains of heredity, biology, psychology, cognitive science, family, social development and cultural structures. This special issue, “Substance Abuse, Environment and Public Health,” has published empirical studies from different regions and countries globally to enhance the international exchange of latest views and findings on the etiology, processes and influences of substance abuse across different domains, through which a multilevel perspective is considered more helpful for analyzing its complex nature, courses and consequences. This in turn suggests the possible need to employ multiple responses dynamically and integratively in the prevention and treatment of substance abuse.
... Residential treatment for SUD has been shown to be effective in improving a variety of outcome domains (de Andrade et al., 2019), and some research suggests that opioid users may particularly benefit from residential treatment compared to outpatient programs (Gossop et al., 1989;Morse and MacMaster, 2015;Schuman-Olivier et al. (2014); Stahler et al., 2016). However, relapse for those with OUD is common following any type of treatment episode, and relapse following residential treatment put clients at particular risk for overdose, especially for those who do not complete treatment (Li et al., 2019;Lloyd et al., 2017;Maughan and Becker, 2019). ...
... Residential treatment will likely remain an important treatment option for individuals struggling with opioid addiction, particularly for those with co-occurring SUDs and mental health disorders, those with higher severity, and those who have not been successful in outpatient treatment (de Andrade et al., 2019;Bride et al., 2016;Eastwood et al., 2017;Galanter et al., 2016). Given our results and those of other studies (Krupitsky et al., 2011;Leslie et al., 2015;Nunes et al., 2018) showing the beneficial effect of MOUD in improving short-term residential treatment outcomes, there needs to be far greater access to, and utilization of, MOUD in short-term residential treatment facilities. ...
Article
Background This study examines whether MOUD increases treatment completion and retention in both short-term (ST) and long-term (LT) residential programs using a national dataset. Methods Data were extracted from the 2015–2017 TEDS-D (Treatment Episode Dataset-Discharge) datasets for opioid using adults in ST (n = 87,296) and LT (n = 66,623) residential treatment. Primary outcome variables were treatment completion and retention (ST: length of stay >10 days; LT: >90 days). Logistic regression estimated the effects of MOUD on the probability of treatment completion and retention separately for ST and LT residential treatment, controlling for individual background characteristics. Results Only 18% of clients in residential treatment programs had MOUD in their treatment plans. For ST residential treatment, MOUD was associated with a 40% increased likelihood of treatment completion (OR = 1.404) and 34% increased retention (OR = 1.337). For LT residential treatment, MOUD was associated with a 26% reduced likelihood of treatment completion (OR = 0.743) and no significant increase in retention. Post hoc analysis suggests insurance coverage may be influencing outcomes. Conclusions Despite MOUD being a standard of care for OUD, MOUD is particularly under-utilized in residential treatment. Further research should focus on how best to integrate MOUD within short-term residential treatment and to explore the potential viability of MOUD in long-term residential programs. Given the risk of overdose following residential treatment, for at least short-term residential programs, this setting may be advantageous for integrating psychosocial treatments with early MOUD engagement in a structured therapeutic environment as part of a long-term continuum of care recovery program.
... Residential treatment for substance use disorder (SUD) is a 24-hour, structured model of care staffed by addiction treatment and mental health professionals. 1 Residential treatment often centers on recovery models that include individual and group therapy, peer support, and psychiatric services. 2 However, there is often no standardized system for integration of primary healthcare for patients during residential treatment. Consistent access to primary care is important for women with SUD given the myriad healthcare needs of this population, including chronic diseases, substance-related complications and infections, sexual and reproductive health, preventive care, and psychiatric conditions. ...
... However, some research suggests that residential treatment leads to equal or improved outcomes for substance use, employment, social support, and psychiatric symptoms compared to outpatient treatment. 2,9 Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) also ...
Article
Residential treatment for substance use disorder (SUD) is a structured model of care centered on individual and group therapy, peer support, and psychiatric services. However, there is rarely a standardized system for integration of primary care. Consistent access to primary care is important for women with SUD given the myriad healthcare needs of this population, including chronic disease, substance-related infections, sexual and reproductive health, preventive care, and psychiatric conditions. Access to primary care can minimize the morbidity associated with substance-use related medical complications, provide longitudinal support for recovery, and reduce emergency department visits and hospitalizations. This paper explores a program of coordinated medical care at a residential treatment facility for women with histories of SUD located in Pawtucket, RI. We conclude that residential treatment is an ideal time to forge a connection to primary care services to address the multiple medical and psychiatric comorbidities that exist among patients with SUD.
... A systematic review on the topic of residential rehabilitation concluded that best practice residential care for any substance use disorder should include continuity of care postdischarge. 36 A review on group treatment for substance use disorders found that group treatment compared to no treatment had a small effect on abstinence however group treatment did not have a significant effect on the frequency of substance use or substance use disorder symptoms 37 . Additionally, with regard to opioid use disorder, it has been reported that ...
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Background: Given that fewer than 50% of countries provide Opioid Agonist Maintenance Therapies (OAMT), it is important to assess whether other substances act as a substitute for heroin in recovering heroin users who receive detoxification models of treatment. There is a dearth of prospective studies from low-and-middle-income countries evaluating these patterns of substance use. Methods: 300 heroin users from the Gauteng province of South Africa were assessed on entry into inpatient detoxification and then followed-up 3 and 9 months after leaving treatment. Treatment consisted of 1 week of detoxification followed by 6-8 weeks of psychosocial therapy. We measured the overall changes in the prevalence of heroin, alcohol and other drug use at baseline and postrehabilitation. Comparison of these outcomes at enrolment, 3 months and 9 months was performed by a Generalised Estimating Equation (GEE) with the outcome as the dependent variable, observation point as the independent variable, and participant as the repeated measure. Injecting status and treatment completion were included as covariates. We also measured the individual pathways between heroin and alcohol use in the 210 participants that were seen at all three timepoints. Results: Of the original cohort, 252 (84.0%) were re-interviewed at 3 months and 225 (75.0%) at 9 months. From baseline to 3 months, the proportion of past month heroin users decreased significantly to 65.5%; however, during this time, the proportion of past month alcohol users increased from 16.3% to 55.2% (p<0.0001). When assessing the pathways between heroin and alcohol use at an individual level, 55.4% (n-97) of those who were past month alcohol abstinent prior to rehabilitation were using alcohol at 3 months. From 3 to 9 months the proportion of heroin users increased to 72.4% (p<0.0001), and during this time, the proportion of alcohol users decreased. Conclusion: After detoxification, a significant reduction in heroin use was observed with a concomitant increase in alcohol consumption. Under these circumstances, alcohol may have acted as a substitute for heroin in the short term. The initial reduction in heroin use 3 months postrehabilitation was followed by increased consumption 6 months later. This observation supports the need for interventions to prevent, monitor and treat high levels of alcohol use in heroin users post detoxification. The provision of OAMT is a necessary consideration to address both the risk of increased alcohol intake as well as the decline in heroin abstinence rates.
... (12) Several reviews of the literature on residential settings across the continuum have found signi cant increases in recovery capital, such as increased employment and social support for individuals utilizing these services. (12)(13)(14) Other models of recovery housing also show promise. For example, annual evaluations of Recovery Kentucky, a recovery housing model located across Kentucky that offers a continuum of recovery supports for residents, have consistently reported improvements in employment and housing, as well as decreases in criminal justice involvement and alcohol and drug use. ...
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Background: Recovery support services such as recovery housing may assist individuals with increasing their access to social support, employment services, and systems of care. Lack of evidence-based practices and calls for increased oversight of these settings suggests a growing need for technical assistance and training for recovery residence owners and staff members, yet little is known about their areas of greatest technical assistance needs, and if there are differences between the needs of owners/operators of one recovery residence vs. owners/operators of multiple recovery residences. Methods: We developed and administered a survey to assess the technical assistance needs of recovery housing operators in the United States using a convenience sample of individuals who own or operate a recovery residence (N= 376). The survey was disseminated electronically via e-mail using REDCap to collect survey responses. Descriptive statistics were used to describe the survey respondents, and bivariate analyses were conducted to test for differences in TA needs by the number of residences owned by the respondent (1 vs. 2+). Thematic analysis methods were used to analyze open text survey response items focusing on challenges, resources needed to overcome challenges, and community perception of recovery residences. Results: A total of 77 owners/operators completed the survey (20% response rate), representing urban, suburban, and rural communities. Almost one-half (45%) of respondents were the owner of their residence(s), and more than half (56%) of the respondents reported that their residence was certified based on a set of national best practices for recovery housing. Differences were observed between number of owned residences; owners/operators of a single residence expressed greater interest in technical assistance on house-specific policies and linkage to established systems of care, whereas owners/operators of multiple residences were more interested in technical assistance on complex topics such as building financial sustainability, and incorporation of best practices into their recovery residences. Conclusion: As an increasing number of states move to implement voluntary certification or licensing for recovery residences, targeted training and technical assistance to owners/operators will facilitate the successful adoption of recovery residence best practices and quality standards.
... There is a substantial body of literature supporting the efficacy of face-to-face treatment modalities in helping improve addictionrelated outcomes and overall symptom burden in patients with SUDs. 47 In contrast to face-toface interventions, there are no current consensus best practice recommendations available for medical visits focused on addiction treatment via telehealth. A guide for general clinical videoconferencing in mental health was developed in collaboration with the American Psychiatric Association and the American Telemedicine Association d "Best Practices in Videoconferencing-based Telemental Health." 9 Their guide represents a model based on research evidence, expert consensus, patient needs, and available resources, and it aims to assist in providing safe and effective medical care (Table 1). ...
Article
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During the current coronavirus disease 2019 epidemic, many outpatient chemical dependency treatment programs and clinics are decreasing their number of in-person patient contacts. This has widened an already large gap between patients with substance use disorders (SUDs) who need treatment and those who have actually received treatment. For a disorder where group therapy has been the mainstay treatment option for decades, social distancing, shelter in place, and treatment discontinuation have created an urgent need for alternative approaches to addiction treatment. In an attempt to continue some care for patients in need, many medical institutions have transitioned to a virtual environment to promote safe social distancing. Although there is ample evidence to support telemedical interventions, these can be difficult to implement, especially in the SUD population. This article reviews current literature for the use of telehealth interventions in the treatment of SUDs and offers recommendations on safe and effective implementation strategies based on the current literature.
... Second, the disruption to medical and SUD services left many clients feeling completely cut off from care. Clients receiving residential services for SUD expect to receive inperson group meetings and psychosocial support, which are among the best practices for rehabilitation treatment (de Andrade et al., 2019). Although systematic reviews have identified feasibility and acceptability of telemedicine among individuals with mental illness and/or SUD (Lawes-Wickwar et al., 2018;Young, 2012), providing additional technical and social support for residents unaccustomed to using virtual care platforms may help with their adjustment (Kavoor, 2020). ...
Article
Individuals attending residential rehabilitation programs for substance misuse are particularly vulnerable to treatment disruptions spurred by the novel coronavirus disease 2019 (COVID-19) pandemic. We describe adaptations to services within a large residential rehabilitation program for under-resourced veterans, report veterans’ experiences with these changes, and outline successes and challenges encountered throughout adjustment to the pandemic. Data collected from two focus groups with nine veterans engaged in this program during the pandemic highlight experiences of inconsistent communication about residential policies, interruptions to medical and addiction services, and feelings of confinement and social isolation. Overall, these findings suggest the need for health systems to support clients in taking an active role in communications, provide additional technical and social support in transitioning to virtual health services, and offer alternative means for clients to maintain social connection during a pandemic. Understanding clients’ perspectives can inform strategies to promote continuity of care and enhanced care experiences.
... In addition, the study highlighted areas where linked data is commonly used, particularly in cross-sectorial linked data and areas where its use could be improved, however it did not mention use of longitudinal data to enhance reporting of outcomes. A systematic review conducted by Andrade, Elphinston [75], highlights the need for future research to focus on collecting better measures for outcomes data and linking data to multiple administrative databases. A systematic review conducted by da Silva, Coeli [76] examined the issue of consent for data linkage, which is one of the sources of bias in using linked data. ...
Article
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Introduction Over the past decade there has been a marked growth in the use of linked population administrative data for child protection research. This is the first systematic review of studies to report on research design and statistical methods used where population-based administrative data is integrated with longitudinal data in child protection settings. Methods The systematic review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. The electronic databases Medline (Ovid), PsycINFO, Embase, ERIC, and CINAHL were systematically searched in November 2019 to identify all the relevant studies. The protocol for this review was registered and published with Open Science Framework (Registration DOI: 10.17605/OSF.IO/96PX8 ) Results The review identified 30 studies reporting on child maltreatment, mental health, drug and alcohol abuse and education. The quality of almost all studies was strong, however the studies rated poorly on the reporting of data linkage methods. The statistical analysis methods described failed to take into account mediating factors which may have an indirect effect on the outcomes of interest and there was lack of utilisation of multi-level analysis. Conclusion We recommend reporting of data linkage processes through following recommended and standardised data linkage processes, which can be achieved through greater co-ordination among data providers and researchers.
... Substance use appeared to have a nuanced association with ACEs, being the most prevalent in the groups with high maltreatment and lowest in the group that featured only neglect. Given that a similarly high prevalence of trauma symptoms was found in the groups characterised by multiple maltreatment types, it is reasonable to hypothesise that maltreatment and trauma symptoms often underpin substance use and that addressing the underlying causes of substance abuse problems is key to long-term abstinence (de Andrade et al. 2019;de Andrade et al. 2018). Overall, by the time young people enter the youth justice system, it may well be that the vast majority have already endured a range of different traumatic events and present with significant levels of trauma symptomatology, substance use problems, and social and emotional behavioural issues. ...
... Evidence suggests that residential SUD treatment has been effective to some degree in improving behavioral health and social outcomes and that integrated treatment for these conditions also yields positive results (de Andrade et al., 2019). Nationwide, women comprise about one third of admissions to all forms of substance abuse treatment (SAMHSA, 2009). ...
Article
Purpose A trauma-informed educational support group pilot addressed traumatic stress, substance use disorders (SUDs), and child-rearing for clients who were pregnant and/or parenting young children. Methods Seeking Safety was adapted with parenting content and delivered at two intensive residential rehabilitation facilities. An explanatory sequential mixed methods approach was used to evaluate the pilot. Forty-eight participants completed starting assessments (intention-to-treat) and 31 graduates completed postgroup surveys (per protocol). Focus group sessions were completed with 19 graduates. Results Paired samples t tests of intention-to-treat data showed a statistically significant decrease in self-reported symptoms of stress and substance cravings and increases in positive behaviors and parenting self-efficacy. There were no statistically significant differences on lifestyle behaviors, parenting skill, and parenting confidence. Most participants found the intervention acceptable and felt supported to improve their parenting. Discussion Trauma-informed parenting education support in inpatient rehabilitation settings may offer an important complement to existing SUD and parenting programming.
... Reviews of the literature on residential settings across the continuum have found significant increases in recovery capital, such as increased employment and social support for individuals utilizing these services (Reif et al. 2014b;de Andrade et al. 2019;Malivert et al. 2012). Recovery residences also show promise for supporting populations who are particularly vulnerable to substance use and its consequences, including sexual minority men, victims of domestic violence, individuals with co-occurring mental disorders or who are homeless, and formerly incarcerated individuals (Edwards et al. 2018(Edwards et al. , 2017Jason, Salina, and Ram 2016;Mericle et al. 2019b;Polcin 2018;Polcin and Korcha 2017). ...
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Recovery support services such as recovery housing assist individuals with increasing their access to social support, employment services, and systems of care. Lack of evidence-based practices and calls for increased oversight of these settings suggests a growing need for technical assistance and training for recovery residence owners and staff, yet little is known about their areas of greatest need for technical assistance. We developed and administered a survey to assess the technical assistance needs of recovery housing operators in the United States using a convenience sample of individuals who own or operate a recovery residence (N = 376). A total of 77 owners/operators completed the survey (20% response rate), representing urban, suburban, and rural communities. Differences were observed between number of owned residences: owners/operators of a single residence were interested in technical assistance on house-specific policies and linkage to established systems of care, whereas owners/operators of multiple residences were interested in technical assistance on building financial sustainability and incorporation of best practices into their recovery residences. As an increasing number of states move to implement voluntary certification or licensing for recovery residences, targeted training and technical assistance to owners/operators will facilitate the successful adoption of recovery residence best practices and quality standards.
Article
Objectives: The global pandemic of coronavirus disease 2019 (Covid-19) may disproportionately affect persons in congregate settings, including those in residential substance use treatment facilities. To limit the spread of SARS-CoV-2 through congregate settings, universal testing may be necessary. We aimed to determine the point prevalence of SARS-CoV-2 in a residential treatment program setting and to understand the unique challenges of Covid-19 transmission in this setting. Methods: We performed a case series of SARS-CoV-2 rT-PCR testing via nasopharyngeal in a residential substance use treatment program for women in Boston. Staff and residents of the treatment program were tested for SARS-CoV-2. The primary outcome was SARS-CoV-2 test result. Results: A total of 31 residents and staff were tested. Twenty-seven percent (6/22) of the residents and 44% (4/9) of staff tested positive for SARS-CoV-2. All of the SARS-CoV-2 positive residents resided in the same residential unit. Two positive cases resided together with two negative cases in a 4-person room. Two other positive cases resided together in a 2-person room. One positive case resided with two negative cases in a 3-person room. One positive case resided with a negative case in a 2-person room. Based on test results, residents were cohorted by infection status and continued to participate in addiction treatment on-site. Conclusions: SARS-CoV-2 infection was common among staff and residents within a residential substance use treatment program for women in Boston. Universal SARS-CoV-2 testing in residential substance use programs can be instituted to reduce the risk of further transmission and continue addiction treatment programming when accompanied by adequate space, supplies, and staffing.
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Collective motivational interviewing (CMI) breaks new ground by extending the theory of motivational interviewing (MI) beyond the individual to include the social network. We explain the core concepts of the six-process model of CMI, which involves multiple parties in the motivational process in embodying a spirit of “neutrality.” The semi-structured manual-guided CMI was trialed in persons with substance use with the support of concerned significant others (CSOs), which demonstrated positive outcomes on motivation, social support, frequency of drug use, and adherence to long-term drug treatments. Our developed CMI approach makes a clear contribution to the theory of MI and can potentially benefit people with substance use problems with complex needs. Presently, we are refining CMI and have been applying this approach to additional clients and CSOs. We call for more studies to monitor its fidelity and wider application in populations of individuals affected by substance use disorders.
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Background: Inpatient treatment for substance use disorders is a collection of strategies ranging from short term detoxification to longer term residential treatment. How those with opioid use disorder (OUD) navigate this inpatient treatment system after an encounter for detoxification and subsequent risk of opioid-related overdose is not well understood. Methods: We used a comprehensive Massachusetts database to characterize the movement of people with OUD through inpatient care from 2013 to 2015, identifying admissions to inpatient detoxification, subsequent inpatient care, and opioid overdose while navigating treatment. We measured the person-years accumulated during each transition period to calculate rates of opioid-related overdose, and investigated how overdose differed in select populations. Results: Sixty-one percent of inpatient detoxification admissions resulted in a subsequent inpatient detoxification admission without progressing to further inpatient care. Overall, there were 287 fatal and 7337 non-fatal overdoses. Persons exiting treatment after detoxification had the greatest risk of overdose (17.3 per 100 person-years) compared to those who exited after subsequent inpatient care (ranging from 5.9 to 6.6 overdoses per 100 person-years). Non-Hispanic whites were most at risk for opioid related overdose with 16 overdoses per 100 person-years and non-Hispanic blacks had the lowest risk with 5 overdoses per 100 person-years. Conclusions: The majority of inpatient detoxification admissions do not progress to further inpatient care. Recurrent inpatient detoxification admission is common, likely signifying relapse. Rather than functioning as the first step to inpatient care, inpatient detoxification might be more effective as a venue for implementing strategies to expand addiction services or treatment such as medications for opioid use disorder.
Article
Rehabilitating substance-abusing offenders is difficult. And while correctional interventions that target problematic attitudes and cognitions have proven to be successful at reducing recidivism, the roster of attitudes and cognitions that should be targeted is often vague. This study examines the relationship between “implicit beliefs” about addiction – those beliefs that offenders might not even be aware that they hold, but that can nonetheless undermine successful treatment – and failed drug tests among a sample of offenders in a community-based treatment program. Results indicate a significant bivariate association between implicit beliefs and failed drug tests. The relationship holds up in a multivariate context, yet the patterns of magnitude and statistical significance differ depending upon how implicit beliefs are measured. The findings point to the potential importance of targeting for change offenders’ implicit beliefs and indicate that caution should be used when considering treatment models that emphasize the notion that offenders are “helpless” when it comes to their substance use addiction.
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In Australia, the terms dual diagnosis and comorbidity are commonly used, often interchangeably, to describe the experience of consumers with both mental health difficulties and difficulties with alcohol and other drug use. Consumers with comorbidity often have complex needs that require comprehensive assessment, multidisciplinary team support, and trauma‐focused management. More information about the demographics of consumers admitted with comorbidity, and the documented assessed needs, care, and interventions provided, would provide the foundations for working towards improved quality and continuity of care. Therefore, the aim of this study was to explore the documentation of inpatient assessment, care, and interventions provided to people with comorbidity. The research design was a retrospective exploratory study, and data collection involved a 12‐month healthcare record audit. Forty‐one records were screened, and 36 consumer healthcare records were identified as eligible for inclusion in the study. Most consumers (n = 34, 94%) were admitted on an involuntary basis, and 8 (22.2%) were female. Consumers had a median length of stay of almost six months. In most healthcare records, there was no documented evidence of care planning involvement by consumers or the multidisciplinary team. There was great variance in the delivery of nonpharmacological interventions. Most consumers did not receive trauma‐focused assessment or intervention, and assessment tools were often incomplete with outcome measures poorly documented. This study has demonstrated significant gaps in consumer and multidisciplinary engagement with care planning and goal setting. There was poor documentation of comprehensive assessment and nonpharmacological interventions.
Article
Innovation in addiction recovery in Scotland includes the transfer of effective models from other countries, such as San Patrignano, Italy and Basta, Sweden. Independence from Drugs and Alcohol Scotland (IFDAS) was founded to develop a new model for Scotland, based on social enterprise. Drawing on the San Patrignano programme theory, this prospective study investigates IFDAS stakeholders’ perspectives on which mechanisms should be transferred, and which require adaptation of the delivery mode, for the Scottish context. Data collection included interviews with ten stakeholders with expertise including: drugs policy, social enterprise, alcohol and drug partnership practice and therapeutic community methods. Drawing on realist principles, data were analysed using inductive and deductive approaches and synthesised using frameworks. San Patrignano mechanisms identified for transfer include: the need for motivation, recovery peer mentors, visionary leadership and social enterprise. Adaptations from Basta include: extending abstinence to alcohol and creating a smaller, semi-permeable, residential community. Further adaptations to mechanism delivery include a ‘step-wise’ model of housing and work. Scottish contextual factors shaping adaptations include: the culture of alcohol misuse, social care standards, housing regulations and socio-cultural acceptability. This study contributes to the evidence on international transfer and adaptation of complex interventions and documents stakeholders’ theory-informed decision making in the development of a new Scottish recovery model.
Article
Introduction Individuals with substance use disorder (SUD) may benefit from services and supports delivered in residential settings. Prior research in this area has primarily focused on individual-level factors that affect outcomes, with little focus on the relationship between facility-level characteristics and treatment outcomes. Methods This study incorporated facility-level features into an analysis of the effectiveness of residential settings to treat SUD. Administrative data from 2713 individuals with an index enrollment in publicly funded residential treatment in Massachusetts during 2015 were linked with facility-level survey data from 33 treatment providers. This study conducted multilevel regression analysis, adjusting for resident demographic, socioeconomic, and substance use history and severity, to test facility-level effects on treatment duration and completion, and housing and employment status at discharge. Results Residents stayed longer when they made and enforced rules (β = 30.22, p = 0.006). Residents were less likely to complete treatment as the number of non-clinical services increased (aOR = 0.918, p = 0.029), or in facilities where residents ate together family style (aOR = 0.485, p = 0.039). Being employed at discharge was more likely when house meetings were held less than once per week (aOR = 3.37, p = 0.005) and less likely when held more than once per week (aOR = 0.385, p = 0.038). Conclusion Overall, increased resident governance and fewer contingencies for successful treatment participation were associated with positive treatment outcomes. Future research should examine the internal processes of residential settings, including peer-to-peer interactions, to better understand how within-residence features affect outcomes.
Article
Background: This study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion. Methods: Data were extracted from SAMHSA's 2015-2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors. Results: After adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776). Conclusions: Access to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.
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Introduction Despite data suggesting that recovery high schools are largely effective in reducing substance use, relapse in these settings is common. The goal of the current study was to characterize factors proximal to relapse among adolescents in a local recovery high school. Method Data for this study were 200 de-identified node maps (i.e., graphical break downs of a relapse event; randomly chosen from 600 available node maps) from the charts of students at a local recovery high school in a large Midwest city (Mean Age = 16.8 ± 1.9 years, 64.1% male, 89.1% White). A four-phase process of qualitative data sorting examined features most frequently described in relapse episodes. Results The most common elements reported were using with others (n = 153, 76.5%), away from home (n = 156, 78.0%), and in response to negative affect (n = 93, 48.4%). Six relapse pathways emerged: coping (n = 30), acting out (n = 15), unexpected temptation (n = 30), planned lapse (n = 19), resistant to recovery (n = 27), and passive agency (n = 30). The pathways identified represent three critical failures in the recovery system: failure to cope, failure to guard against temptation, and failure of belief. Identifying these system failures can contribute to increased rapport and engagement, as well as planning for detailed and specific factors proximal for relapse for any given individual, both on the individual and system levels. Conclusion The use of node maps aligned with previous work, showed good face and content validity, can be used to reduce blame and increase engagement in substance use treatment among adolescents, and produced novel micro-frames with new vocabulary to accurately understand common factors associated with relapse among adolescents.
Article
Introduction There is a need for effective, inexpensive and scalable interventions in the treatment of substance use disorder (SUD). An adjunct intervention that warrants exploration is exercise. Objective To examine the acceptability of exercise as an adjunct treatment for individuals in residential treatment for SUD. The secondary objective is to guide exercise intervention development for this population. Methods After an acclimatization period where the first author spent four weeks volunteering at the treatment facility, semi-structured interviews were conducted with adult individuals (mean = 38.93, range 23–58) with SUD in residential treatment (n = 15) to assess the acceptability of exercise as an adjunct treatment. A thematic analysis was conducted using deductive and inductive methods. The interview guide and analysis were informed by the Capability, Opportunity, Motivation- Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). Results Exercise was considered an acceptable adjunct treatment for SUD. Three themes were identified as prudent for informing intervention development. Participants were 1) receptive to exercise but some lacked the knowledge and skills to participate; 2) aware of opportunities to exercise but these are often underutilized, and 3) looking ahead to life after treatment. Conclusions This study provides insight into the acceptability and receptiveness of residential SUD treatment to exercise programming. Our results provide direction for developing an exercise counselling intervention embedded within the residential treatment context.
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Introduction We examined differences in social and sociodemographic characteristics and treatment goals between people with primary alcohol use disorder (AUD) versus those with a primary drug use disorder receiving inpatient treatment for a substance use disorder (SUD). Methods A national census utilizing a cross sectional design included 56 of 60 specialized inpatient SUD treatment clinics in Norway and all patients receiving treatment on a specific date (responserate = 70%). Data on substance use, social and sociodemographic characteristics, and patient-reported treatment goals were collected. Patients were classified as having primary AUD or a drug use disorder based on the main SUD diagnosis relevant to the treatment episode. Results The analytic sample included 1093 patients. Patients with primary AUD (n = 362) were more often older, had a higher educational level and income from work, and lived in permanent housing compared with patients with a drug use disorder (n = 731). Patients with AUD were more likely to have good relationships with friends. The higher frequency of reported reduced substance use (versus quitting substance use) as the treatment goal among AUD patients disappeared when controlled for sociodemographic factors. Conclusions Knowledge about the different characteristics of inpatients with AUD versus a drug use disorder is relevant when conducting research involving the SUD treatment population and for facilitating treatment. The lower frequency of perceived support from friends among patients with a drug use disorder suggests a need for targeted efforts in (re)building supportive social relationships for inpatients being treated for SUD.
Article
While several quantitative studies exist describing the factors associated with maintaining objectives attained by people with addictions during their stay in residential therapeutic centres (RTC), few studies have examined the point of view of the residents themselves on this question. In the present study, qualitative interviews were conducted with 45 residents of an RTC in the Paris area at the end of their stay or in the 4–9 following months. Residents’ views confirmed the importance of: consolidating risk and stress management skills during their stay; adopting a holistic well-being approach; developing a truly personal health project; a treatment centre that really seems to care; peer support during and after their stay; and improving family and social networks. Obstacles included residents with rarer addictions feeling left out during group work; insufficient anticipation of the risks associated with returning to everyday life; a supportive group approach that disappears when returning to everyday life; and too great a gap between the RTC approach and the values of both the individual’s personal social network and their follow-up care professionals. In conclusion, although residents underline the therapeutic success of their stay, key questions remain concerning obstacles in recovery pathways when returning into real life situations.
Article
This article updates the evidence-based on couple and family therapy interventions for substance use disorders (SUD) since publication of the previous JMFT reviews in 2012. It first summarizes previous reviews along with findings from more recent reviews and meta-analytic studies. It then presents study design and methods criteria used to select 13 studies of couple and family therapy for level of support evaluation. Cumulative level of support designations are then determined for identified treatment approaches. Findings indicate that systemic family therapy is well-established as a standalone treatment, and behavioral family therapy and behavioral couple therapy are probably efficacious as standalone treatments and well-established as part of a multicomponent treatment. The article then suggests practice guidelines with regard to treatment modality considerations and implementation challenges. It concludes with future directions for delivering couple and family interventions in routine systems of care for SUD.
Article
Background The DSM-5 definition of alcohol use disorder (AUD) has been well validated, but information is lacking on the extent to which alcohol use, comorbidity, and impairment are associated with the 3 DSM-5-defined AUD severity levels: mild, moderate, and severe. This study examined clinical and functional characteristics as predictors (validators) of these severity levels. Methods Participants aged ≥18 years reporting current problem substance use (N = 588) were recruited between 2016 and 2019 and assessed for DSM-5 AUD and a set of potential validators: indicators of alcohol use severity (i.e., craving, binge drinking frequency, problematic use, and harmful drinking), psychiatric disorders, and functional impairment. Multinomial logistic regression models examined the association between the predictors and the 3 AUD severity levels (mild, moderate, and severe) vs the reference group, no AUD, controlling for sociodemographic characteristics and other substance use. Results All alcohol use validators were associated with a greater likelihood of all 3 AUD severity levels compared with the no-AUD group. However, psychiatric disorders were associated only with severe AUD and participants with major depression (aOR = 2.44), posttraumatic stress disorder (aOR = 1.65), borderline personality disorder (aOR = 1.99), and antisocial personality disorder (aOR = 1.78) had a greater likelihood of severe AUD than the no-AUD group. Functioning validators were also associated only with severe AUD and participants with social (aOR = 1.87), physical (aOR = 1.62), or mental (aOR = 1.84) impairment had a greater likelihood of severe AUD than the no-AUD group. Many alcohol-related, psychiatric, and functioning validators were associated with greater odds of severe AUD than mild or moderate AUD. Conclusion This study supports the criterion validity of the DSM-5 tri-categorical measure of AUD. Specifically, results fully supported the validity of severe AUD by its associations with all predictors, whereas the validity of mild and moderate AUD was supported only by alcohol use predictor variables. Findings suggest the value of using severity-specific interventions utilizing the DSM-5 AUD.
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Introduction: The recovery housing (RH) program was initiated in São Paulo with the objective of providing treatment for substance use disorders and addressing users’ housing and employment problems. The purpose of this study was to describe the model based on its first 11 months of operation, it was launched in June 2016 in Brazil. Method: We carried out a retrospective analysis of the records of all subjects treated in the RH of the Restart Program (Programa Recomeço) since its creation, from June 2016 to May 2017. Results: Sixty-nine subjects were included. Thirty-five (51%) remained in the household until the end of treatment or were reinserted in society. Thirty-four (49%) presented recurrence during their stay, of which 16 (47%) volunteered for treatment in a therapeutic community or psychiatric hospital, 8 (23.5%) chose to continue with outpatient treatment only, 6 (17.7%) returned to their families and continued to receive outpatient treatment, and 4 (11.8%) discontinued the treatment. Of the 35 subjects who completed the RH program, 28 (80%) were in employment and 7 (20%) received governmental support for permanent disability on medical or psychiatric grounds. Conclusion: RH can be an important component of integrated care and is used in several countries. Although controversial, the use of urine tests to control relapse seems to have a positive impact on adherence to treatment and maintenance of abstinence. These preliminary findings corroborate, with clear limitations, the evidence available in the literature showing that RH programs are effective for the treatment of addictions.
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Mindfulness-based relapse prevention (MBRP) is an effective treatment for substance use disorders (SUD). However, evidence is primarily based on studies of closed groups, and few studies support flexible formats of MBRP, such as rolling groups. This non-randomized, open trial evaluated the feasibility, acceptability, dose-response relations, and mechanisms of rolling admission MBRP (“Rolling MBRP”) offered as part of short-term residential treatment for SUD. Rolling MBRP was developed prior to the trial through an iterative process over several years. Participants included 109 adults (46% female, 74.3% racial/ethnic minorities, mean age = 36.40). Rolling MBRP was offered to all patients in the program 2×/week, and attendance was tracked. Outcomes were craving, self-efficacy, mental health, mindfulness, and self-compassion at discharge. Self-reported out-of-session mindfulness practice was examined as a mediator of attendance-outcome relations. Analyses involved multiple regression and mediation models. Feasibility was demonstrated by good attendance rates. Acceptability was demonstrated by high engagement in mindfulness practice and high satisfaction ratings. Total sessions attended did not predict outcomes at discharge. However, attending 2+ sessions (versus one or none) significantly predicted better mental health and higher mindfulness at discharge, and these effects were mediated by informal and formal mindfulness practice. Total sessions attended had significant indirect effects on craving, self-compassion, mindfulness, and mental health, via mindfulness practice. Results support the feasibility and acceptability of Rolling MBRP and suggest mindfulness practice may be a key mechanism driving effects of MBRP on other key mechanisms during the recovery process, such as decreased craving and improved mental health.
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Background: Program attrition is a major problem in substance use treatment. It is not clear which client and treatment variables are related to successful completion. This study aimed to identify client variables associated with Therapeutic Community (TC) completion. A secondary aim was to investigate changes in entry and exit scores on psychosocial outcome measures. Methods: Retrospective quantitative analysis of data collected from 193 Australian TC residents, over 3.5 years. Variables measured included: demographics; Depression, Anxiety, Stress Score (DASS-21) and World Health Organisation Quality of Life 8 questions (WHOQOL-8). Results: Completion rates were 30.6%. High Money WHOQOL-8 scores, suggestive of minimal financial stressors, positively predicted completion. Multivariate analyses showed that negative predictors of completion were: amphetamine being primary substance of concern, aggression, high Relationship WHOQOL-8 scores, suggestive of positive relationships, and younger or older age. Those in the program demonstrated clinically significant psychological improvement and significant improvement in all quality of life scores over time. The degree of psychometric improvement was most pronounced in those who completed the course, with the exception of depression, stress, and money problems. Conclusion: The findings provide an understanding of specific predictors of program completion which may help to identify high-risk clients and inform program improvement. Early attrition rates may be reduced by monitoring and supporting high-risk clients. Overall, psychometric improvement occurred amongst both completers and non-completers overtime but is most prominent amongst course completers, with the exception of depression, stress, and money problems. Future research could potentially focus on amphetamine users and shortened TC programs, focusing on acute psychosocial intervention.
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Background The effectiveness of an alcohol or drug treatment program is frequently measured by changes in primary outcomes such as harmful substance use. It is also important to consider the impact of treatment on secondary outcomes focusing on the consequential harm of alcohol use, including poor health, impaired quality of life, interpersonal conflict and criminality. Here, we examine the effectiveness of a comprehensive alcohol and drug treatment intervention at producing real‐world change in both substance use and secondary consequential outcomes. Methods A total of 325 participants attending a residential treatment service for harmful use of alcohol or drugs participated. The 12‐month prospective study measured outcomes at three time points: prior to treatment, at treatment‐end, and at a 3‐month follow‐up. A battery of psychometrically validated measures evaluated primary and secondary consequential outcomes. Results At treatment‐end and at follow‐up, participants who completed a therapeutic dose of treatment demonstrated improvements not only in primary outcomes (i.e., reduced substance use) but also in a wide range of secondary outcomes measured, namely improvements in physical and mental health and quality of life, and decreases in criminal activity and negative consequences related to substance use and social problems. Conclusions In evaluating treatment effectiveness, clinicians and researchers need to consider measuring consequential secondary outcomes in addition to primary outcomes related to substance use. Taken together, our findings demonstrate that a comprehensive alcohol and drug treatment program can produce real‐world positive change not only in substance use, but also in health, quality of life and reduced negative consequences of use.
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The aim of this article is to investigate changes in alcohol consumption among predominantly methamphetamine users (N = 176) in four residential therapeutic communities for addiction treatment in the Czech Republic. This is a quantitative prospective, naturalistic, cohort study that compares drinking patterns, illicit drug use, injecting, and crime prior to treatment and one year after discharge. The response rate at follow-up was 77.8% (N = 137). At the one-year follow-up the number of excessive drinkers was significantly reduced from 51.1% to 31.4%. The rate of abstinence from alcohol (33.6%) and moderate drinking (35%) at follow-up was not significantly different from the pretreatment level. At the one-year follow-up, 33.6% were consuming no alcohol, whereas 88.3% reported abstinence from methamphetamine. The authors conclude that one year after discharge from the treatment most clients were abstinent from illicit drugs. However, the number of clients who were abstinent from alcohol remains low. The implication for treatment and further research is discussed.
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This multi-center study of dual diagnosis (DD) programs involved 804 residential patients with co-occurring alcohol and mental health disorders. The Addiction Severity Index was administered at admission and at one, six, and 12 months after discharge. Repeated measures analysis showed the intoxication rate per month stabilized between months six and 12 with 68% still in remission and an 88% mean reduction from baseline (F = 519, p < .005). A comparison between patients with and without weekly relapse produced significant differences in hospitalization (odds ratio 11.3:1; 95% C.I., 5.5 to 23.2). Eight ANCOVAs used mean intoxication days per month after discharge as the outcome variable, pre-admission intoxication days per month as a covariate, and eight variables associated with relapse (e.g. depression) as factors. Patients with these factors at admission did not have significantly higher intoxication rates after discharge than patients without them. This suggests that these DD programs successfully integrated treatment of both disorders and explained their effectiveness. Co-occurring DSM IV mood disorders such as anxiety and depression as well as drug abuse involving opioids or cocaine fell between 66 and 95% at months one, six, and twelve.
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Aims: Studies consistently identify substance treatment populations as more likely to die prematurely compared with age-matched general population, with mortality risk higher out-of-treatment than in-treatment. While opioid-using pharmacotherapy cohorts have been studied extensively, less evidence exists regarding effects of other treatment types, and clients in treatment for other drugs. This paper examines mortality during and following treatment across treatment modalities. Methods: A retrospective seven-year cohort was utilised to examine mortality during and in the two years following treatment among clients from Victoria, Australia, recorded on the Alcohol and Drug Information Service database by linking with National Death Index. 18,686 clients over a 12-month period were included. Crude (CMRs) and standardised mortality rates (SMRs) were analysed in terms of treatment modality, and time in or out of treatment. Results: Higher risk of premature death was associated with residential withdrawal as the last type of treatment engagement, while mortality following counselling was significantly lower than all other treatment types in the year post-treatment. Both CMRs and SMRs were significantly higher in-treatment than post-treatment. Conclusion: Better understanding of factors contributing to elevated mortality risk for clients engaged in, and following treatment, is needed to ensure that treatment systems provide optimal outcomes during and after treatment.
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Despite limited evidence base, rehabilitation services are associated with positive outcomes in U.K. research (Best et al., 2010 Best, D., Rome, A., Hanning, K., White, W., Gossop, M., Taylor, A., & Perkins, A. (2010). Research for recovery: A review of the drugs evidence base. Edinburgh, Scotland: Scottish Government. ). The authors investigated outcomes associated following a 12-week abstinence-based treatment program. Data were collected from 145 patients using a European Version of the Addiction Severity Index (ASI-X) at intake, 6 months, and 1 year after completion. Individuals showed significantly better ASI-X scores after participating in program compared to their scores prior to the intervention. Those who completed the program had significantly better outcomes in medical and psychiatric domains at 12-month follow-up than those who dropped out before completion. Attending this abstinence-based program was associated with positive changes to physical health and social wellbeing, which were sustained 12 months after completion.
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The knowledge available on the effectiveness of treatment interventions for methamphetamine users in Europe remains scarce. The present study investigated the patterns of use and treatment outcomes of 176 clients, predominantly injecting methamphetamine users, in 4 residential therapeutic communities in the Czech Republic. Most of the clients were multiple drug users. Overall, methamphetamine users showed favorable outcomes with significant improvements in their substance misuse, injecting, health and criminal behavior at 1 year after discharge from treatment. Findings suggest that many methamphetamine users are able to complete the treatment and achieve considerable improvements.
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Background: This is the first English national study of change in criminal offending following treatment for alcohol use disorder (AUD). Methods: All adults treated for AUD by all publicly funded treatment services during April 2008-March 2009 (n=53,017), with data linked to the Police National Computer (April 2006-November 2011). Pre-treatment offender sub-populations were identified by Latent Profile Analysis. The outcome measure was the count of recordable criminal offences during two-year follow-up after admission. A mixed-effects, Poisson regression modelled outcome, adjusting for demographics and clinical information, the latent classes, and treatment exposure covariates. Results: Twenty-two percent of the cohort committed one or more offences in the two years pre-treatment (n=11,742; crude rate, 221.5 offenders per 1000). During follow-up, the number of offenders and offences fell by 23.5% and 24.0%, respectively (crude rate, 69.4 offenders per 1000). During follow-up, a lower number of offences was associated with: completing treatment (adjusted incident rate ratio [IRR] 0.82; 95% confidence interval [CI] 0.79-0.85); receiving inpatient detoxification (IRR 0.84; CI 0.80-0.89); or community pharmacological therapy (IRR 0.89; CI 0.84-0.96). Reconviction was reduced in the sub-population characterised by driving offences (n=1,140; 11.7%), but was relatively high amongst acquisitive (n=768; 58.3% reconvicted) and violent offending sub-populations (n=602; 77.6% reconvicted). Conclusions: Reduced offending was associated with successful completion of AUD treatment and receiving inpatient and pharmacological therapy, but not enrolment in psychological and residential interventions. Treatment services (particularly those providing psychological therapy and residential care) should be alert to offending, especially violent and acquisitive crime, and enhance crime reduction interventions.
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Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7]. In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA Completing a Systematic Review Is an Iterative Process The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
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Purpose – The purpose of this paper is to systematically review quantitative research since 2000 on the effectiveness of residential therapeutic communities (TCs) for the treatment of substance-use disorders with reference to substance-use, crime, mental health and social engagement outcomes. Design/methodology/approach – A systematic search with broad inclusion criteria resulted in the review of 11 studies. The studies investigated community-based TCs, as well as TCs modified for prisoners, prisoners transitioning to community living and TCs for individuals with co-occurring substance-use and mental health issues. Findings – Results were analysed by comparing the findings of the studies under investigation, of which three studies investigated within-subjects outcomes, four compared TC treatment with a no-treatment control condition and four compared TC treatment with another treatment condition. Conclusion: consistent with previous systematic reviews of TCs, outcomes varied across studies but indicated TCs are generally effective as a treatment intervention, with reductions in substance-use and criminal activity, and increased improvement in mental health and social engagement evident in a number of studies reviewed. Research limitations/implications – Variability in outcomes suggests further TC research and research syntheses focusing on a second key research question in the evaluation of complex interventions – how the intervention works – could play an important role in understanding TC effectiveness, and for whom it is effective and in what contexts. Practical implications – Although there is some variability in treatment populations included in this review, evidence reported in other studies suggests individuals with severe substance-use disorders, mental health issues, forensic involvement and trauma histories, will benefit from TC treatment. This is supported by the literature which has found a general relationship between severity of substance use and treatment intensity (Darke et al. , 2012; De Leon et al. , 2008) with outcomes further enhanced by self-selection into treatment and appropriate client-treatment matching (see De Leon, 2010; De Leon et al. , 2000, 2008). The weight of evidence gleaned from multiple sources of research, including randomised control trials and field outcome studies (De Leon, 2010) suggests TCs are an important and effective treatment for clients in improving at least some aspects of their quality of life, specifically mental health and social engagement, and in reducing harmful behaviours, including substance-use and crime. Variability in treatment setting and populations reflect the real-world setting in which TC treatment is delivered, providing a multifaceted treatment modality to a complex population in variable circumstances. Originality/value – The strength of the current study is that it provided a broad evaluation of TC effectiveness across a range of outcomes (substance-use, criminal activity, mental health and social engagement), and is therefore valuable in updating the current literature and providing context for future research in this area. It aimed to address a key question in evaluating complex interventions: whether they are effective as they are delivered. Findings suggest that TC treatment is generally effective for the populations of concern in reducing substance use and criminal activity and contributing to some improvement in mental health and social engagement outcomes.
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This study compared the effects of three drug addiction treatment methods on quality of life and mental health of drug addicts. In this study, 227 Iranian male drug addicts were selected from Mazandaran Province (northern Iran). They were randomized to be treated with methadone maintenance treatment, therapeutic community, or residential rehabilitation. The Short Form Health Survey (SF-36) and the General Health Questionnaire (GHQ) were completed by the subjects at the start and end of the study. The length of intervention and SF-36 and GHQ scores before and after treatment were compared between groups. All statistical analyses were performed in SPSS. Significant differences in quality of life and mental health scores were found between the three groups. We found that if drug addicts stay in the therapeutic community center for more than 6 months, this method will be the most effective intervention to improve quality of life and mental health of drug abusers. Evaluation of different methods drug addiction treatment is very difficult. Therefore, further studies are required to better understand the effects of therapeutic community.
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Objective: Residential treatment is a commonly used direct intervention for individuals with substance use or co-occurring mental and substance use disorders who need structured care. Treatment occurs in nonhospital, licensed residential facilities. Models vary, but all provide safe housing and medical care in a 24-hour recovery environment. This article describes residential treatment and assesses the evidence base for this service. Methods: Authors evaluated research reviews and individual studies from 1995 through 2012. They searched major databases: PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, and Social Services Abstracts. They chose from three levels of evidence (high, moderate, and low) and described the evidence of service effectiveness. Results: On the basis of eight reviews and 21 individual studies not included in prior reviews, the level of evidence for residential treatment for substance use disorders was rated as moderate. A number of randomized controlled trials were identified, but various methodological weaknesses in study designs-primarily the appropriateness of the samples and equivalence of comparison groups-decreased the level of evidence. Results for the effectiveness of residential treatment compared with other types of treatment for substance use disorders were mixed. Findings suggested either an improvement or no difference in treatment outcomes. Conclusions: Residential treatment for substance use disorders shows value and merits ongoing consideration by policy makers for inclusion as a covered benefit in public and commercially funded plans. However, research with greater specificity and consistency is needed.
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In this article, the authors outline methods for using fixed and random effects power analysis in the context of meta-analysis. Like statistical power analysis for primary studies, power analysis for meta-analysis can be done either prospectively or retrospectively and requires assumptions about parameters that are unknown. The authors provide some suggestions for thinking about these parameters, in particular for the random effects variance component. The authors also show how the typically uninformative retrospective power analysis can be made more informative. The authors then discuss the value of confidence intervals, show how they could be used in addition to or instead of retrospective power analysis, and also demonstrate that confidence intervals can convey information more effectively in some situations than power analyses alone. Finally, the authors take up the question ‘‘How many studies do you need to do a meta-analysis?’’ and show that, given the need for a conclusion, the answer is ‘‘two studies,’’ because all other synthesis techniques are less transparent and/or are less likely to be valid. For systematic reviewers who choose not to conduct a quantitative synthesis, the authors provide suggestions for both highlighting the current limitations in the research base and for displaying the characteristics and results of studies that were found to meet inclusion criteria.
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Therapeutic communities (TCs) for addictions are drug-free environments in which people with addictive problems live together in an organized and structured way to promote change toward recovery and reinsertion in society. Despite a long research tradition in TCs, the evidence base for the effectiveness of TCs is limited according to available reviews. Since most of these studies applied a selective focus, we made a comprehensive systematic review of all controlled studies that compared the effectiveness of TCs for addictions with that of a control condition. The focus of this paper is on recovery, including attention for various life domains and a longitudinal scope. We searched the following databases: ISI Web of Knowledge (WoS), PubMed, and DrugScope. Our search strategy revealed 997 hits. Eventually, 30 publications were selected for this paper, which were based on 16 original studies. Two out of three studies showed significantly better substance use and legal outcomes among TC participants, and five studies found superior employment and psychological functioning. Length of stay in treatment and participation in subsequent aftercare were consistent predictors of recovery status. We conclude that TCs can promote change regarding various outcome categories. Since recovering addicts often cycle between abstinence and relapse, a continuing care approach is advisable, including assessment of multiple and subjective outcome indicators.
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Therapeutic communities (TCs) are drug-free residential settings, focused on psychosocial rehabilitation. While TCs are considered an effective method, the bulk of the research evidence is from poorly controlled studies. The goal of this study was to evaluate TC effectiveness in terms of abstinence and to determine if there were predictive factors of abstinence. The search used Medline up to January 30, 2011 and was based on a systematic review method. Studies on retention in treatment and/or substance use were considered. Of the 321 studies retrieved from Medline, 12 met selection criteria including overall 3,271 participants from 61 TCs. On average, subjects stayed in TC a third of the planned time. The completion rate ranged from 9 to 56%. All studies showed that substance use decreased during TC, but relapse was frequent after TC. Treatment completion was the most predictive factor of abstinence at follow-up. Surprisingly, psychiatric comorbidities did not appear associated with relapse or with dropout. There was a drop in consumption after TC, but long-lasting benefits were uncertain. Further studies are needed in order to compare the efficacy of TC programs and other types of treatment settings for substance-related disorders.
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The Dual Diagnosis Capability of Addiction Treatment (DDCAT) index is used to assess the capacity of substance abuse services to work with individuals with co-occurring mental health problems. The current study aimed to: (i) examine the dual diagnosis capability of residential substance abuse programs in Australia; (ii) identify managers' perceptions regarding both priorities and confidence for change following the completion of the DDCAT; and (iii) to examine the usefulness of the DDCAT to residential substance abuse programs. The DDCAT was completed across 16 residential substance abuse units. An external researcher administered and scored the DDCAT. A Unit Manager from each site completed the Comorbidity Priorities and Confidence Survey following the completion of the DDCAT review. This survey examined the usefulness of the DDCAT, and the unit's priorities to improve its capability, and confidence to improve its DDCAT score. Across the services, program structure and staff training were the DDCAT domains that required the most improvement. While training was the highest endorsed priority area for improvement, program structure was the lowest priority. Overall the Unit Managers reported positive attitudes towards use of the DDCAT and were confident that their unit could improve their DDCAT scores. DDCAT scores of Australian residential substance abuse programs are comparable with previous published results. However, there is still substantial work required to improve the capability of these programs. Future research should examine strategies to promote sustained improvements in the capability of residential substance abuse programs.
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Several interventions for people with co-occurring severe mental illnesses and substance use disorders have emerged since the early 1980s. This paper reviews 26 controlled studies of psychosocial interventions published or reported in the last 10 years (1994-2003). Though most studies have methodological weaknesses, the cumulative evidence from experimental and quasi-experimental research supports integrating outpatient mental health and substance abuse treatments into a single, cohesive package. Effective treatments are also individualized to address personal factors and stage of motivation, e.g., engaging people in services, helping them to develop motivation, and helping them to develop skills and supports for recovery. Accumulating evidence from quasi-experimental studies also suggests that integrated residential treatment, especially long-term (one year or more) treatment, is helpful for individuals who do not respond to outpatient dual disorders interventions. Current research aims to refine and test individual components and combinations of integrated treatments.
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Therapeutic communities (TCs) are a popular treatment for the rehabilitation of drug users in the USA and Europe. To determine the effectiveness of TC versus other treatments for substance dependents, and to investigate whether effectiveness is modified by client or treatment characteristics. We searched: Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005); MEDLINE, EMBASE, Psycinfo, CINAHL, SIGLE from their inception to March 2004. Reference lists of studies were scanned. Randomised controlled trials comparing TC with other treatments, no treatment or another TC. Two authors independently inspected abstracts, the methodological quality was assessed using Drug and Alcohol CRG checklist. When possible, data were summarised using relative risks and differences in means, otherwise results are presented as reported by authors. Seven studies were included. Differences between studies precluded any pooling of data, results are summarised for each trial individually: TC versus community residence: no significant differences for treatment completion; Residential versus day TC: attrition (first two weeks), and abstinence rates at six months significantly lower in the residential treatment group; Standard TC versus enhanced abbreviated TC: number of employed higher in standard TC RR 0.78 (95% CI 0.63, 0.96). Three months versus six months programme within modified TC, and six months versus 12 months programme within standard TC: completion rate higher in the three months programme and retention rate (40 days) significantly greater with the 12 months than 6 months programme. Two trials evaluated TCs within a prison setting: one reported significantly fewer re incarcerated 12 months after release from prison in the TC group compared with no treatment, RR 0.68 (95% CI 057, 0.81). In the other, people treated in prison with TC compared with Mental Health Treatment Programmes showed significantly fewer re incarcerations RR 0.28 (95% CI 0.13, 0.63), criminal activity 0.69 (95% CI 0.52, 0.93) and alcohol and drug offences 0.62 (95% CI 0.43, 0.90) 12 months after release from prison. There is little evidence that TCs offer significant benefits in comparison with other residential treatment, or that one type of TC is better than another. Prison TC may be better than prison on it's own or Mental Health Treatment Programmes to prevent re-offending post-release for in-mates. However, methodological limitations of the studies may have introduced bias and firm conclusions cannot be drawn due to limitations of the existing evidence.
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Background: Several groups have outlined methodologies for systematic literature reviews of the effectiveness of interventions. The Effective Public Health Practice Project (EPHPP) began in 1998. Its mandate is to provide research evidence to guide and support the Ontario Ministry of Health in outlining minimum requirements for public health services in the province. Also, the project is expected to disseminate the results provincially, nationally, and internationally. Most of the reviews are relevant to public health nursing practice. Aims: This article describes four issues related to the systematic literature reviews of the effectiveness of public health nursing interventions: (1) the process of systematically reviewing the literature, (2) the development of a quality assessment instrument, (3) the results of the EPHPP to date, and (4) some results of the dissemination strategies used. Methods: The eight steps of the systematic review process including question formulation, searching and retrieving the literature, establishing relevance criteria, assessing studies for relevance, assessing relevant studies for methodological quality, data extraction and synthesis, writing the report, and dissemination are outlined. Also, the development and assessment of content and construct validity and intrarater reliability of the quality assessment questionnaire used in the process are described. Results: More than 20 systematic reviews have been completed. Content validity was ascertained by the use of a number of experts to review the questionnaire during its development. Construct validity was demonstrated through comparisons with another highly rated instrument. Intrarater reliability was established using Cohen's Kappa. Dissemination strategies used appear to be effective in that professionals report being aware of the reviews and using them in program planning/policymaking decisions. Conclusions: The EPHPP has demonstrated the ability to adapt the most current methods of systematic literature reviews of effectiveness to questions related to public health nursing. Other positive outcomes from the process include the development of a critical mass of public health researchers and practitioners who can actively participate in the process, and the work on dissemination has been successful in attracting external funds. A program of research in this area is being developed.
Article
Objective: Mindfulness Based Relapse Prevention (MBRP) has demonstrated efficacy in alleviating substance use, stress, and craving but how MBRP works for marginalized young adults has not been investigated. The current study used a novel rolling group format for MBRP as an additional intervention for young adults in residential treatment. We tested the hypothesis that MBRP (plus Treatment as usual (TAU)) would reduce stress, craving, and substance use among young adults in residential treatment relative to treatment-as-usual plus 12-step/self-help meetings (TAU only). Further, we examined whether reduced stress during treatment was a potential mechanism of change operating in MBRP. Method: Seventy-nine young adults (𝑀𝑎𝑔𝑒 = 25.3, 𝑆𝐷 = 2.7; 35% female) were randomly assigned to MBRP (n = 44) or TAU (n =35). Follow-up assessments were conducted bi-monthly for self-reported measures of stress, craving, and substance use. Results: At treatment completion young adults receiving MBRP had lower substance use (d = -.58, [-.91, -.26]), craving (d = -.58, [-1.0, -.14]), and stress (d = -.77 [-1.2, -.30]) relative to TAU condition. Reduced stress during treatment partially mediated observed outcome differences between MBRP and TAU for substance use (βindirect = -.45 [-.79, - .11]). Conclusions: Results suggest that MBRP is a useful and appropriate intervention for marginalized young adults. Further, our results suggest that the effects of MBRP on long-term substance use outcomes may be partially explained by reduced stress.
Article
Objective: Resilience has been associated with less severe psychiatric symptomatology and better treatment outcomes among individuals with posttraumatic stress disorder (PTSD) and substance use disorders (SUD). However, it remains unknown whether resilience increases during psychotherapy within the comorbid PTSD and SUD population with unique features of dual-diagnosis, including trauma cue-related cravings. We tested whether veterans seeking psychotherapy for comorbid PTSD-SUD reported increased resilience from pre- to post-treatment. We also tested whether increased resilience was associated with greater decreases in post-treatment PTSD and SUD symptoms. Method: Participants were 29 male veterans (Mage = 49.07, SD = 11.24) receiving 6-week residential day-treatment including cognitive processing therapy for PTSD and cognitive behavioral therapy for substance use disorder. Resilience, PTSD symptoms, and trauma cue-related cravings were assessed at pre- and post-treatment. Results: Veterans reported a large, significant increase in resilience at post-treatment (Mdiff = 14.24, t = -4.22, p < .001, d = 0.74). Greater increases in resilience was significantly associated with fewer PTSD symptoms (β = -0.37, p = .049, sr = -.36) and trauma-cued cravings (β = -0.39, p = .006, sr = -.38) at post-treatment when controlling for pre-treatment scores and baseline depressive symptoms. Conclusions: Results suggest evidence-based psychotherapy for comorbid PTSD and SUD may facilitate strength-based psychological growth, which may further promote sustained recovery.
Article
Background: Optimizing the effectiveness of substance use disorder (SUD) treatment is critical in low-and middle-income countries (LMICs) with limited opportunities for SUD treatment. This is the first study to identify targets for interventions to improve the quality of SUD treatment in a LMIC. Method: We explored correlates of three indicators of treatment quality (treatment engagement, completion and abstinence at treatment exit) using data from a SUD performance measurement system implemented in the Western Cape Province of South Africa. The sample included data from 1094 adult treatment episodes representing 53% of the treatment episodes in 2016. Using multivariate logistic regression analyses, we modeled socio-demographic, substance use and program correlates of treatment engagement, completion, and abstinence at treatment exit. Results: Overall, 59% of patients completed treatment (48% of patients from outpatient services). Treatment completion was associated with greater likelihood of abstinence at treatment exit. Patients were more likely to complete treatment if they engaged in treatment, were older, and had more severe drug problems (characterized by daily drug use and heroin problems) and attended programs of shorter duration. Residential treatment was associated with greater likelihood of treatment engagement, completion, and abstinence at treatment exit. Conclusion: Improving rates of outpatient treatment completion will enhance the effectiveness of South Africa's SUD treatment system. Interventions that promote engagement in treatment, particularly among younger patients; reduce program length through referral to step-down continuing care; and ensure better matching of drug problem to treatment level and type could improve rates of treatment completion.
Article
Background This was a national English observational cohort study to estimate the effectiveness of inpatient withdrawal (IW) and residential rehabilitation (RR) interventions for alcohol use disorder (AUD) using administrative data. Methods All adults commencing IW and/or RR intervention for AUD between April 1, 2014 and March 31, 2015 reported to the National Drug Treatment Monitoring System (n = 3812). The primary outcome was successful completion of treatment within 12 months of commencement, with no re-presentation (SCNR) in the subsequent six months, analysed by multi-level, mixed effects, multivariable logistic regression. Results The majority (70%, n = 2682) received IW in their index treatment journey; one-quarter (24%, n = 915) received RR; 6% (n = 215) received both. Of treatment leavers, 59% achieved the SCNR outcome (IW: 57%; RR: 64%; IW/RR: 57%). Positive outcome for IW was associated with older age, being employed, and receiving community-based treatment prior to and subsequent to IW. Patients with housing problems were less likely to achieving the outcome. Positive outcome for RR was associated with paid employment, self/family/peer referral, longer duration of RR treatment, and community-based treatment following discharge. Community-based treatment prior to entering RR, and receiving IW during the same treatment journey as RR, were associated with lower likelihood of SCNR. Conclusions In this first national effectiveness study of AUD in the English public treatment system for alcohol-use disorders, 59% of patients successfully completed treatment within 12 months and did not represent for more treatment within six months. Longer duration of treatment and provision of structured continuing care is associated with better treatment outcomes.
Article
Aims: to compare outcomes for a behavioral activation group treatment for substance use (LETS ACT), versus a time and group size matched control condition delivered in a residential treatment setting. Design: single-site two-arm parallel-group randomized clinical trial with follow-up assessment at 3, 6 and 12 months post-treatment. Setting: residential substance use treatment facility in the USA. Participants: participants were 263 adults [mean age 42.7 [11.8]; 29.3% female; 94.7% African American; 72.6% court mandated] whose insurance dictated 30-day (65.4%) or 90-day (34.6%) treatment duration. Intervention and comparator: LETS ACT (n=142) is a treatment originally developed for depression and modified for substance use. It teaches participants to increase positively reinforcing value-driven activities in order to counter depression and relapse. The control group (SC; n=121) received time and group-size matched supportive counseling. Treatment was delivered in five or eight one-hour sessions depending on patient length of stay. Measurements: percent abstinent at follow-up, percent of substance use days among those reporting use, depressive symptoms (BDI), and adverse consequences of drug use (SIP-AD). Findings: LETS ACT had significantly higher abstinence rates at 3 months (odds ratio=2.2, 95% confidence interval=1.3-3.7), 6 months (odds ratio=2.6, 95% confidence interval=1.3-5.0), and 12 months (odds ratio=2.9, 95% confidence interval=1.3-6.1) post-treatment compared with SC. LETS ACT participants reported significantly fewer adverse consequences from substance use at 12 months post-treatment (B=4.50, SE=2.17, 95% confidence interval=0.22-8.78). Treatment condition had no effect on percent substance use days among those who resumed use or on change in depressive symptoms; the latter decreased over time only in those who remained abstinent after residential treatment irrespective of condition (B=0.43, SE=0.11, 95% confidence interval=0.22-0.65). Conclusions: a behavioral activation group treatment for substance use (LETS ACT) appears to increase the likelihood of abstinence and reduce adverse consequences from substance use up to 12 months post-treatment.
Article
Aims: To identify trajectories of heroin use in Australia, predictors of trajectory group membership, and subsequent outcomes, among people with heroin dependence over 10-11-years. Design: Longitudinal cohort study. Setting: Sydney, Australia. Participants: 615 participants were recruited between 2001-2002 as part of the Australian Treatment Outcome Study (66.2% male; mean age 29). The predominance of the cohort (87.0%) was recruitment upon entry to treatment (maintenance therapies, detoxification, and residential rehabilitation), the remainder from non-treatment settings (e.g., needle and syringe programmes). This analysis focused on 428 participants for whom data on heroin use were available over 10-11-years following study entry. Measurements: Structured interviews assessed demographics, treatment history, heroin and other drug use, overdose, criminal involvement, physical health and psychopathology. Group-based trajectory modelling was used to i) identify trajectory groups based on use of heroin in each year, ii) examine predictors of group membership, and iii) examine associations between trajectory group membership and 10-11-year outcomes. Findings: Six trajectory groups were identified (BIC -1927.44 (N = 4708); -1901.07 (N = 428)). One-in-five (22.1%) were classified as having "no decrease" in heroin use, with the probability of using remaining high across the 10-11-years (>0.98 probability of use in each year). One-in-six (16.2%) were classified as demonstrating a "rapid decrease to maintained abstinence". The probability of heroin use among this group declined steeply in the first 2-3 years and continued to be low (<0.01). The remaining trajectories represented other fluctuating patterns of use. Few baseline variables were found to predict trajectory group membership, but group membership was predictive of demographic, substance use, and physical and mental health outcomes at 10-11-years. Conclusions: Long term trajectories of heroin use in Australia appear to show considerable heterogeneity over a decade of follow up, with few risks factors predicting group membership. Just over a fifth continued to use at high levels, while under a fifth become abstinent early on and remained abstinent. The remainder showed fluctuating patterns.
Article
Purpose The purpose of this paper is to analyse the clinical outcome data collected as part of an 18-week, abstinence-based residential therapeutic community (TC) programme, Higher Ground Drug Rehabilitation Trust (Higher Ground) in New Zealand. Lessons and implications for routine collection of clinical outcome data are identified. Design/methodology/approach Higher Ground collects longitudinal data on all consenting clients using a battery of validated psychometric tools, with repeated measures at up to nine points in time from first presentation through to 12-month post-discharge follow up. Data analysis covered clients who entered Higher Ground between 1 July 2012 and 2 June 2015 (n=524). Findings Clients presented with histories of addiction which often had significant negative associations with their physical and psychological health, their relationships, work, accommodation and criminal behaviour. By the time they exited the programme, clinically and statistically significant improvements were seen across multiple indicators including: substance use and abstinence; symptoms of post-traumatic stress disorder, depression, anxiety and stress; and a range of social indicators. Research limitations/implications Attrition in follow-up research is a significant challenge, with people completing the TC programme being more likely to participate than those who do not. This limits generalizability in post-discharge data. There was no control group, making causal attribution a challenge. Identifying suitable benchmarks from the literature is challenging because of the variety of outcome measures and research methodologies used. Practical implications Tracking client outcomes longitudinally using psychometric tools is potentially valuable for TCs and their funding bodies, as it provides insights into patterns of client recovery that can inform ongoing service improvements and resource allocation decisions. However, significant challenges remain. Originality/value The study demonstrates the value, and practical challenges, of collecting high-quality outcome data in a TC setting.
Article
Purpose Longer length of stay (LOS) in residential alcohol and other drug treatment has been associated with more favourable outcomes, but the optimal duration has yet to be determined for reliable change indices. Optimal durations are likely to be a function of participant and problem characteristics. The purpose of this paper is to determine whether LOS in a residential therapeutic community for alcohol and other drug treatment community independently predicts reliable change across a range of psychological recovery and well-being measures. Design/methodology/approach In total, 380 clients from Australian Salvation Army residential alcohol and other drug treatment facilities were assessed at intake and three months post-discharge using the Addiction Severity Index 5th ed., The Depression, Anxiety and Stress Scale, The Recovery Assessment Scale, the Mental Health Continuum-Short Form and The Life Engagement Test. Findings The findings confirm LOS as an independent predictor of reliable change on measures of well-being and client perceived assessment of recovery. The mean LOS that differentiated reliable change from no improvement was 37.37 days. Originality/value The finding of LOS as a predictor of reliable change and the identification of an estimated time requirement may be useful for residential drug treatment providers in modifying treatment durations.
Alcohol and substance abuse remain significant public health problems in many parts of the occidental world. Some facilities that provide treatment for such abuse often refer to themselves as "Therapeutic Communities" (TCs). However, fundamental compositional differences in TCs present unresolved issues and as such, create significant implications for research, practice, education, and substance/alcohol care policy. Accordingly, this paper examines the heterogeneity and efficacy of TCs; the treatment approaches of harm reduction and abstinence; the training of TC staff and workers; and the recommended length of stay for individuals seeking recovery.
Article
Opiate use patterns, user characteristics, and treatment response among young adults are of interest due to current high use prevalence and historical low levels of treatment engagement relative to older populations. Prior research in this population suggests that overall, young adults present at treatment with different issues. In this study the authors investigated potential differences between young adult (18-25 years of age) and older adult (26 and older) opiate users and the impact of differences relative to treatment motivation, length and outcomes. Data for this study was drawn from 760 individuals who entered voluntary, private, residential treatment. Study measures included the Addiction Severity Index (ASI), the Treatment Service Review (TSR), and University of Rhode Island Change Assessment (URICA). Interviews were conducted at program intake and 6-month post-discharge. Results indicate that older adults with a history of opiate use present at treatment with higher levels of severity for alcohol, medical, and psychological problems and young adults present at treatment with greater drug use and more legal issues. Significant improvement for both groups was noted at 6 months post treatment; there were also fewer differences between the two age groups of opiate users. Results suggest different strategies within treatment programs may provide benefit in targeting the disparate needs of younger opiate users. Overall, however, results suggest that individualized treatment within a standard, abstinence-based, residential treatment model can be effective across opiate users at different ages and with different issues, levels of severity, and impairment at intake.
Article
Background Opioid misuse and dependence rates among emerging adults have increased substantially. While office-based opioid treatments (e.g., buprenorphine/naloxone) have shown overall efficacy, discontinuation rates among emerging adults are high. Abstinence-based residential treatment may serve as a viable alternative, but has seldom been investigated in this age group Methods Emerging adults attending 12-step-oriented residential treatment (N = 292; 18-24yrs, 74% Male, 95% White) were classified into opioid dependent (OD; 25%), opioid misuse (OM; 20%), and no opiate use (NO; 55%) groups. Paired t-tests and ANOVAs tested baseline differences and whether groups differed in their during-treatment response. Longitudinal multilevel models tested whether groups differed on substance use outcomes and treatment utilization during the year following the index treatment episode Results Despite a more severe clinical profile at baseline among OD, all groups experienced similar during-treatment increases on therapeutic targets (e.g., abstinence self-efficacy), while OD showed a greater decline in psychiatric symptoms. During follow-up relative to OM, both NO and OD had significantly greater Percent Days Abstinent, and significantly less cannabis use. OD attended significantly more outpatient treatment sessions than OM or NO; 29% of OD was completely abstinent at 12-month follow-up Conclusions Findings here suggest residential treatment may be helpful for emerging adults with opioid dependence. This benefit may be less prominent, though, among non-dependent opioid misusers. Randomized trials are needed to compare more directly the relative benefits of outpatient agonist-based treatment to abstinence-based, residential care in this vulnerable age-group, and to examine the feasibility of an integrated model.
Article
Compared to other life stages, young adulthood (ages 18–24) is characterized by qualitative differences including the highest rates of co-occurring substance use and psychiatric disorders (COD). Little is known, however, regarding young adults’ response to SUD treatment, especially those with COD. Greater knowledge in this area could inform and enhance the effectiveness and efficiency of SUD care for this patient population. The current study investigated differences between 141 COD and 159 SUD-only young adults attending psychiatrically integrated residential SUD treatment on intake characteristics, during-treatment changes on clinical targets (e.g., coping skills; abstinence self-efficacy), and outcomes during the year post-discharge. Contrary to expectations, despite more severe clinical profiles at intake, COD patients showed similar during-treatment improvements on clinical target variables, and comparable abstinence rates and psychiatric symptoms during the year post-treatment. Clinicians referring young adults with COD to specialized care may wish to consider residential SUD treatment programs that integrate evidence-based psychiatric services.
Article
Although the Addiction Severity Index (ASI) is one of the most frequently used measures in alcohol and other drug research, it has rarely been used to assess clinical and reliable change. This study assessed clients' clinical and reliable change at The Salvation Army residential substance abuse treatment centers in Australia. A total of 296 clients completed ASI interviews on admission to treatment and 3 months after discharge from treatment. Clients demonstrated significant improvement on all seven ASI composites. The range of reliable change for each ASI composite varied from 30% to 70%. More than two-thirds of clients experienced clinically significant improvement for alcohol and drug problems. Psychiatric distress was clinically reduced in 44% of clients. This research indicates that residential substance abuse treatment can make important differences in client's lives at a clinical and functional level. However, the research highlights the challenge of effectively targeting psychiatric comorbidity within alcohol and other drug abuse populations.
Article
The Institute of Medicine and Project MATCH have promoted the concept that various treatment programs are equally effective. Yet little attention has been paid to common treatment models in current use. This paper compares three dominant models evident in public and private substance abuse treatment today: the Minnesota Model, the California Social Model Programs, and the addiction Therapeutic Community. We explore their common roots in Alcoholics Anonymous (AA), and how each approach selectively borrowed particular AA principles (e.g., abstinence as the goal, reliance on the experiential knowledge of recovery, etc.) while rejecting others (i.e., Therapeutic Communities adapted some of AA's 12 steps, but without spirituality as an ingredient). We then examine the dominant forces that were exerted on these emerging treatment approaches, including the development of the treatment industry (with alcoholics and drug addicts initially treated separately, but later merged), the professionalization of counselor roles (with Social Model Programs most vulnerable), and managed care to achieve cost containment. The current status of each model is presented which indicates that the differences among them had significantly narrowed by the year 2000. Homogeneity among models raises the issue of when a treatment center can legitimately identify itself as using a specific model: How can a policy maker, funder, or researcher be assured that a treatment center operates with its advertised model? Finally, we discuss the common therapeutic ingredient that remains: the peer-group process.
Article
This study is a report of a systematic review to assess current evidence for the efficacy of psychosocial interventions for reducing substance use, as well as improving mental state and encouraging treatment retention, among people with dual diagnosis. Substance misuse by people with a severe mental illness is common and of concern because of its many adverse consequences and lack of evidence for effective psychosocial interventions. Several electronic databases were searched to identify studies published between January 1990 and February 2008. Additional searches were conducted by means of reference lists and contact with authors. Results from studies using meta-analysis, randomized and non-randomized trials assessing any psychosocial intervention for people with a severe mental illness and substance misuse were included. Fifty-four studies were included: one systematic review with meta-analysis, 30 randomized controlled trials and 23 non-experimental studies. Although some inconsistencies were apparent, results showed that motivational interviewing had the most quality evidence for reducing substance use over the short term and, when combined with cognitive behavioural therapy, improvements in mental state were also apparent. Cognitive behavioural therapy alone showed little consistent support. Support was found for long-term integrated residential programmes; however, the evidence is of lesser quality. Contingency management shows promise, but there were few studies assessing this intervention. These results indicate the importance of motivational interviewing in psychiatric settings for the reduction of substance use, at least in the short term. Further quality research should target particular diagnoses and substance use, as some interventions may work better for some subgroups.
Article
Substance use disorder is the most common and clinically significant co-morbidity among clients with severe mental illnesses, associated with poor treatment response, homelessness and other adverse outcomes. Residential programs for clients with dual disorders integrate mental health treatment, substance abuse interventions, housing and other supports. Ten controlled studies suggest that greater levels of integration of substance abuse and mental health services are more effective than less integration. Because the research is limited by methodological problems, further research is needed to establish the effectiveness of residential programs, to characterize important program elements, to establish methods to improve engagement into and retention in residential programs and to clarify which clients benefit from this type of service.
Article
This report reviews studies of psychosocial interventions for people with co-occurring substance use disorder and severe mental illness. We identified 45 controlled studies (22 experimental and 23 quasi-experimental) of psychosocial dual diagnosis interventions through several search strategies. Three types of interventions (group counseling, contingency management, and residential dual diagnosis treatment) show consistent positive effects on substance use disorder, whereas other interventions have significant impacts on other areas of adjustment (e.g., case management enhances community tenure and legal interventions increase treatment participation). Current studies are limited by heterogeneity of interventions, participants, methods, outcomes, and measures. Treatment of co-occurring severe mental illness and substance use disorder now has a large but heterogeneous evidence base that nevertheless supports several types of interventions. Future research will need to address methodological standardization, longitudinal perspectives, interventions for subgroups and stages, sequenced interventions, and the changing realities of treatment systems.
clinical and reliable change in an Australian residential substance use program using the addiction severity index
  • F P Deane
  • P J Kelly
  • T P Crowe
  • J C Coulson
  • G C B Lyons
  • D A Carmo
  • S M M Palma
  • A Ribeiro
  • A P Trevizol
  • E Brietzke
  • R R Abdalla
  • A L S Alonso
  • C J Da Silva
  • Q Cordeiro
  • R Laranjeira
  • M Ribeiro
Deane, F.P., Kelly, P.J., Crowe, T.P., Coulson, J.C., Lyons, G.C.B., 2013. clinical and reliable change in an Australian residential substance use program using the addiction severity index. J. Addict. Dis. 32, 194-205. https://doi.org/10.1080/10550887. 2013.795470. do Carmo, D.A., Palma, S.M.M., Ribeiro, A., Trevizol, A.P., Brietzke, E., Abdalla, R.R., Alonso, A.L.S., da Silva, C.J., Cordeiro, Q., Laranjeira, R., Ribeiro, M., 2018. Preliminary results from Brazil's first recovery housing program. Trends Psychiatry Psychother. 40, 285-291. https://doi.org/10.1590/2237-6089-2017-0084.
Global Burden of Disease
Institute for Health Metrics and Evaluation, 2016. Global Burden of Disease 2015 Results Tool. Available from:Last accessed: 1 August 2018. http://ghdx.healthdata.org/gbdresults-tool.
  • D De Andrade
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