An instrument for treatment progress and matching: the recovery attitude and treatment evaluator (RAATE)

Examining differential effects of psychosocial treatments for cocaine dependence: an application of latent trajectory analyses

BACKGROUND

The NIDA Collaborative Cocaine Treatment Study yielded different efficacies for different psychosocial treatments for cocaine dependence. However, substantial heterogeneity of patient outcomes was evident. Longitudinal data analysis techniques can be helpful in examining differential effects of psychosocial interventions on specific subpopulations of patients.

METHODS

Overall drug and cocaine use of 346 patients diagnosed with DSM-IV cocaine dependence and treated with one of four psychosocial interventions were assessed monthly during 6-month treatment. Growth mixture models were used to identify patient subgroups based on typical patterns of change in substance use during treatment and to evaluate differential treatment effects within these subgroups.

RESULTS

Three patient subgroups following different change patterns in cocaine and overall drug use were identified irrespective of the treatment type: (a) those with moderate baseline severity of drug use and very rapid reduction of drug use during treatment, (b) those with moderate baseline severity of drug use and moderate reduction of drug use during treatment, and (c) those with severe levels of baseline drug use with moderate reduction of drug use during treatment. Patient baseline characteristics enabled discrimination between these subgroups. Individual drug counseling was most efficacious among those patients with moderate baseline severity and moderate treatment response. There were no differential treatment effects in the two other patient subgroups.

CONCLUSIONS

The population of treatment-seeking cocaine dependent individuals is heterogeneous. Research on patient subgroups with different change patterns revealed its potential to enable classifications of patients that indicate which treatment is most effective for which type of patient.

Success of Referral for Alcohol Dependent Patients from a General Hospital

To assess the effectiveness of a multidisciplinary evaluation and referral process in a prospective cohort of general hospital patients with alcohol dependence. Alcohol-dependent patients were identified in the wards of the general hospital and its primary care center. They were evaluated and then referred to treatment by a multidisciplinary team; those patients who accepted to participate in this cohort study were consecutively included and followed for 6 months. Not included patients were lost for follow-up, whereas all included patients were assessed at time of inclusion, 2 and 6 months later by a research psychologist in order to collect standardized baseline patients' characteristics, process salient features and patients outcomes (defined as treatment adherence and abstinence). Multidisciplinary evaluation and therapeutic referral was feasible and effective, with a success rate of 43%for treatment adherence and 28%for abstinence at 6 months. Among patients' characteristics, predictors of success were an age over 45, not living alone, being employed and being motivated to treatment (RAATE-A score < 18), whereas successful process characteristics included detoxification of the patient at time of referral and a full multidisciplinary referral meeting. This multidisciplinary model of evaluation and referral of alcohol dependent patients of a general hospital had a satisfactory level of effectiveness. Predictors of success and failure allow to identify subsets of patients for whom new strategies of motivation and treatment referral should be designed.

Reliability of Multidimensional Substance Abuse Treatment Matching

For meaningful adoption, the Patient Placement Criteria (PPC) of the American Society of Addiction Medicine (ASAM) will need adequate interrater reliability. In a decision analysis of the original PPC, we reduced potential sources of unreliability, mapped question items from clinical research instruments to each decision point, and programmed the item map as a computerized structured interview. Then, target videotapes from eight substance dependent adults who had been distributed by the algorithm into three levels of care (LOC) were independently scored by four raters who were blind as to ASAM LOC. The intraclass correlation coefficient for ASAM LOC assignment was .77. For all but two subscales of component instruments, values were above .70 and significant, indicating high interrater reliability. With these methods, excellent reliability is possible for complex decision trees, making it possible to improve the validity of the ASAM Criteria and similar complex hierarchical clinical protocols.

On beyond urine: clinically useful assessment instruments in the treatment of drug dependence

Although there are a wealth of clinically useful, brief, and low-cost assessment instruments available for use with drug-dependent populations, relatively few are broadly used in clinical practice. With an emphasis on: (1). the multidimensional nature of drug users' problems; and (2). assessments that can be integrated into empirically validated treatments, clinically useful assessments in four general categories (evaluation and diagnosis of drug dependence, identifying concurrent disorders and problems, treatment planning, and evaluation of treatment outcome) are briefly summarized. Progress in the field of drug abuse treatment has been significantly hampered by the failure to adopt, across research and clinical settings, a common set of assessments.

Ultrarapid opioid detoxification: effects on cardiopulmonary physiology, stress hormones and clinical outcomes

This study explored the acute and long-term consequences of ultrarapid opioid detoxification (URD) in individuals with opioid dependence. In an open case series, seven patients underwent URD and subsequent treatment with daily naltrexone. Structured interviews, integrated rehabilitation and hair sampling were employed in the 12-week course of longitudinal follow-up. Cardiac and pulmonary physiology did not change significantly during the anesthesia phase of URD, but plasma ACTH and cortisol levels increased 15- and 13-fold, respectively. Marked withdrawal and tachypnea in all patients and respiratory distress in one patient occurred during the acute post-anesthesia phase. Withdrawal scores were significantly elevated for 3 weeks compared with baseline in the face of minimal self-reported craving for opioids. Anxiety, depression and vegetative symptoms improved gradually. Four patients remained abstinent of opioid use, two reported a brief period of opioid intake and one relapsed into daily opioid consumption. Given its effect on breathing and stress hormones, this procedure should be conducted by experienced anesthesiologists. The fact that URD and subsequent naltrexone treatment appears to cause a dissociation effect in the usual relationship between withdrawal and craving has implications for behavioral pharmacology. Further research is needed on the efficacy, safety, mechanisms and neurobiological sequelae of the procedure.

A review of factors affecting treatment outcomes: Expected Treatment Outcome Scale

The Expected Treatment Outcome Scales was developed to gather information on clients who abuse drugs or alcohol, to assess their severity of illness, and to evaluate the effectiveness of drug treatment in nonrandomized clinical studies. The scale is based upon a multiattribute value model reflecting the opinions of an expert panel. The experts identified 25 variables, or predictors of relapse, from which 48 questions were constructed. Answers to the questions are individually scored. These scores are summed to produce an overall Expected Treatment Outcome score. This paper focuses on the development and preliminary validation of the Expected Treatment Outcome Scale. Results of our analysis show a correlation of .89 between the experts' average ratings of hypothetical clients and scores based on our scale. This finding suggests that the Expected Treatment Outcome Scale has face validity and accurately simulates the experts' judgments regarding treatment outcome. Further research is necessary to assess the reliability as well as the concurrent and predictive validity of our instrument.

Attitude toward recovery and completion of a substance abuse treatment program

This study tested the ability of the Recovery Attitude and Treatment Evaluator (RAATE; Mee-Lee, Hoffmann, & Smith, 1992) to predict attrition from treatment for pregnant and postpartum substance abusing women. During the first month of treatment, the RAATE was completed by both the clinician and the patient. Three types of discharge status were considered: completion of the treatment program, dropping out of the program, and being administratively discharged. No group differences were found concerning the clinician version of the RAATE. Initial analyses of the patient version revealed that subjects who completed the program had lower ratings of resistance to treatment and continuing care compared to those who dropped out; further analysis suggested that those who completed less than 1 month of treatment exhibited the highest resistance. These results suggest the RAATE is a potentially effective tool for predicting early attrition from substance abuse treatment in this population.

The development and reliability of the Recovery Attitude and Treatment Evaluator-Questionnaire I (RAATE-QI)

A reliability study was performed on a new 94-item true-false report instrument called the Recovery Attitude And Treatment Evaluator-Questionnaire I (RAATE-QI). The RAATE-QI consists of five dimensions which assess a patient's status in five clinically relevant areas for making admission assessment, treatment placement/matching and planning decisions, and discharge/follow-up outcome assessments. The five dimensions measure: resistance to treatment (treatment motivation and denial), resistance to continuing care (long-term denial), biomedical acuity, psychiatric/psychological acuity, and social/family environmental support status. Data on 143 inpatients who completed the RAATE-QI from a public sector chemical dependency/dual diagnosis treatment unit demonstrated test-retest reliabilities in the range from .73 to .87, and internal consistency reliabilities in the range from .63 to .78 across the five dimensions. These preliminary data suggest that the RAATE-QI may be a clinically reliable assessment/placement tool.

Organizational change required for paradigmatic shift in addiction treatment

The requirement for major organizational change to accomplish a paradigmatic shift for a staff at a residential addiction treatment center in Central Texas necessitates a number of strategies. The paradigmatic shift involves moving a staff accustomed to conceptualizing addiction treatment as a fixed-length program with similar components for all and levels of care as discrete programs to the concept of treatment as a flexible process that involves fluid movement of a patient through an individualized set of program components and multiple levels of care within one treatment episode. Conceptualization of the programmatic changes, necessary language changes, and the use of new criteria for patient placement and flexible movement between levels of care results not only in improved patient care, but also in improved staff morale if handled with cognizance for the principles of organizational change and adult education.

The development and reliability of the RAATE-CE

The Recovery Attitude And Treatment Evaluator-Clinical Evaluation (RAATE-CE) utilizes a brief, structured clinical interview that assesses five key dimensions that produce a clinically relevant and useful severity profile of the patient for making placement, continued stay, discharge, and treatment-planning decisions. The RAATE-CE also measures treatment progress. These five dimensions are: (A) degree of resistance to treatment (including denial of addiction problems); (B) degree of resistance to continuing care (including self-help groups); (C) acuity of biomedical problems; (D) acuity of psychiatric-psychological problems; and (E) the degree to which the psychosocial environment is supportive or detrimental to recovery. Data on 139 publicly funded, high-severity subjects suggest that the RAATE-CE demonstrates an interrater reliability across the five dimensions between .59 and .77, and an internal consistency reliability range between .65 and .87.