Trends in comprehensive service availability in outpatient drug abuse treatment

Workforce Diversity and disparities in wait time and retention among opioid treatment programs

BACKGROUND

Workforce diversity is a key strategy to improve treatment engagement among members of racial and ethnic minority groups. In this study, we seek to determine whether workforce diversity plays a role in reducing racial and ethnic differences in wait time to treatment entry and retention in different types of opioid use disorder treatment programs.

METHODS

We conducted comparative and predictive analysis in a subsample of outpatient opioid treatment programs (OTPs), who completed access and retention survey questions in four waves of the National Drug Abuse Treatment System Survey (162 OTPs in 2000, 173 OTPs in 2005, 282 OTPs in 2014, and 300 OTPs in 2017). We sought to assess the associations between workforce diversity on wait time and retention, accounting for the role of Medicaid expansion and the moderating role of program ownership type (i.e., public, non-profit, for-profit) among OTPs located across the United States.

RESULTS

We found significant differences in wait time to treatment entry and retention in treatment across waves. Average number of waiting days decreased in 2014 and 2017; post Medicaid expansion per the Affordable Care Act, while retention rates varied across years. Key findings show that programs with high diversity, measured by higher percent of African American staff and a higher percent of African American clients, were associated with longer wait times to enter treatment, compared to low diversity programs. Programs with higher percent of Latino staff and a higher percent of Latino clients were associated with lower retention in treatment compared with low diversity programs. However, program ownership type (public, non-profit and for-profit) played a moderating role. Public programs with higher percent of African American staff were associated with lower wait time, while non-profit programs with higher percent of Latino staff were related to higher retention.

CONCLUSIONS

Findings show decreases in wait time over the years with significant variation in retention during the same period. Concordance in high workforce and client diversity was associated with higher wait time and lower retention. But these relations inverted (low wait time and high retention) in public and non-profit programs with high staff diversity. Findings have implications for building resources and service capacity among OTPs that serve a higher proportion of minority clients.

Patient-centered care's relationship with substance use disorder treatment utilization

BACKGROUND

Calls for more patient-centered care are growing in the substance use disorder (SUD) treatment field. However, evidence is sparse regarding whether patient-centered care improves access to, or utilization of, effective treatment services.

METHODS

Using nationally representative survey data from SUD treatment clinics in the United States, we examine the association between patient-centered clinical care and the utilization of six services: methadone, buprenorphine, behavioral treatment, routine medical care, HIV testing, and suicide prevention counseling. We measured clinics' practice of and emphasis on patient-centered care with two variables: (1) whether the clinic regularly invites patients into clinical decision-making processes, and (2) whether supervisors believe in patient-centered healthcare and shared decision-making practices within their clinics.

RESULTS

In 2017, only 23% of SUD treatment clinics regularly invited patients into care decision-making meetings when their cases were discussed. A composite variable captured clinical supervisors' own experience with and expectations for patient-clinician interaction within their clinics (Cronbach's alpha = 0.79). Results from regression models that controlled for several organizational and environmental factors show that patient-centered care was independently associated with greater utilization of four of six evidence-based services.

CONCLUSIONS

A minority of SUD clinics practice patient-centered healthcare in the United States. Given the connection to evidence-based services, increasing participatory mechanisms in SUD treatment service provision can facilitate patients' access to appropriate and evidence-based services.

A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes

Objective: The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders? Methods: We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes. Results: This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care. Conclusions: Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.

Decline In Public Substance Use Disorder Treatment Centers Most Serious In Counties With High Shares Of Black Residents

Previous research has associated declines in health care resources such as hospitals and trauma centers with communities' racial composition. However, little is known about changes in the substance use disorder treatment infrastructure in recent years and the implications for black communities. We used data for the period 2002-10 from the National Survey of Substance Abuse Treatment Services to describe changes in the supply of public and private outpatient facilities for substance use disorder treatment, and to determine whether these trends had implications for the geographical availability of these facilities in counties with high percentages of black residents. During the study period the number of publicly owned facilities declined 17.2 percent, whereas the number of private for-profit facilities grew 19.1 percent. At baseline, counties with very high percentages of black residents (that is, more than one standard deviation above the mean) were more likely than counties with less than the mean percentage of black residents to be served by public facilities and were thus disproportionately affected by the overall decline in public facilities. Future research should examine the effect of expanding eligibility for Medicaid on the supply of substance use disorder treatment facilities across diverse communities.

Do benefits restrictions limit Medicaid acceptance in addiction treatment? Results from a national study

OBJECTIVE

To assess the relationship of restrictions on Medicaid benefits for addiction treatment to Medicaid acceptance among addiction treatment programs.

DATA SOURCES

We collected primary data from the 2013-2014 wave of the National Drug Abuse Treatment System Survey.

STUDY DESIGN

We created two measures of benefits restrictiveness. In the first, we calculated the number of addiction treatment services covered by each state Medicaid program. In the second, we calculated the total number of utilization controls imposed on each service. Using a mixed-effects logistic regression model, we estimated the relationship between state Medicaid benefit restrictiveness for addiction treatment and adjusted odds of Medicaid acceptance among addiction treatment programs.

DATA COLLECTION

Study data come from a nationally-representative sample of 695 addiction treatment programs (85.5% response rate), representatives from Medicaid programs in forty-seven states and the District of Columbia (response rate 92%), and data collected by the American Society for Addiction Medicine.

PRINCIPAL FINDINGS

Addiction treatment programs in states with more restrictive Medicaid benefits for addiction treatment had lower odds of accepting Medicaid enrollees (AOR = 0.65; CI = 0.43, 0.97). The predicted probability of Medicaid acceptance was 35.4% in highly restrictive states, 48.3% in moderately restrictive states, and 61.2% in the least restrictive states.

CONCLUSIONS

Addiction treatment programs are more likely to accept Medicaid in states with less restrictive benefits for addiction treatment. Program ownership and technological infrastructure also play an important role in increasing Medicaid acceptance.

Improving Coordination of Addiction Health Services Organizations with Mental Health and Public Health Services

In this mixed-method study, we examined coordination of mental health and public health services in addiction health services (AHS) in low-income racial and ethnic minority communities in 2011 and 2013. Data from surveys and semistructured interviews were used to evaluate the extent to which environmental and organizational characteristics influenced the likelihood of high coordination with mental health and public health providers among outpatient AHS programs. Coordination was defined and measured as the frequency of interorganizational contact among AHS programs and mental health and public health providers. The analytic sample consisted of 112 programs at time 1 (T1) and 122 programs at time 2 (T2), with 61 programs included in both periods of data collection. Forty-three percent of AHS programs reported high frequency of coordination with mental health providers at T1 compared to 66% at T2. Thirty-one percent of programs reported high frequency of coordination with public health services at T1 compared with 54% at T2. Programs with culturally responsive resources and community linkages were more likely to report high coordination with both services. Qualitative analysis highlighted the role of leadership in leveraging funding and developing creative solutions to deliver coordinated care. Overall, our findings suggest that AHS program funding, leadership, and cultural competence may be important drivers of program capacity to improve coordination with health service providers to serve minorities in an era of health care reform.

Provision of onsite HIV Services in Substance Use Disorder Treatment Programs: A Longitudinal Analysis

The provision of HIV education and testing in substance use disorder (SUD) treatment programs is an important public health strategy for reducing HIV incidence. For many at-risk individuals, SUD treatment represents the primary point of access for testing and receiving HIV-related services. This study uses two waves of nationally representative data of 265 privately-funded SUD treatment programs in the U.S. to examine organizational and patient characteristics associated with offering a dedicated HIV/AIDS treatment track, onsite HIV/AIDS support groups, and onsite HIV testing. Our longitudinal analysis indicated that the majority of treatment programs reported providing education and prevention services, but there was a small, yet significant, decline in the number of programs providing these services. Programs placed more of an emphasis on providing information on the transmission of HIV rather than on acquiring risk-reduction skills. There was a notable and significant increase (from 26.0% to 31.7%) in programs that offered onsite HIV testing, including rapid HIV testing, and an increase in the percentage of patients who received testing in the programs. Larger programs were more likely to offer a dedicated HIV/AIDS treatment track and to offer onsite HIV/AIDS support groups, while accredited programs and programs with a medical infrastructure were more likely to provide HIV testing. The percentage of injection drug users was positively linked to the availability of specialized HIV/AIDS tracks and HIV/AIDS support groups, and the percentage of female clients was associated with the availability of onsite support groups. The odds of offering HIV/AIDS support groups were also greater in programs that had a dedicated LGBT track. The findings suggest that access to hospitals and medical care services is an effective way to facilitate adoption of HIV services and that programs are providing a needed service among a group of patients who have a heightened risk of HIV transmission. Nonetheless, the fact that fewer than one third of programs offered onsite testing, and, of the ones that did, fewer than one third of their patients received testing, raises concern in light of federal guidelines.

Innovation attributes and adoption decisions: perspectives from leaders of a national sample of addiction treatment organizations

Drawing on diffusion theory to further knowledge about evidence-based practices (EBPs) in the treatment of substance use disorders (SUDs), this study describes the perceived importance of innovation attributes in adoption decisions within a national sample of SUD treatment organizations. Face-to-face interviews were conducted with leaders of 307 organizations. A typology differentiated organizations reporting: (1) adoption of a treatment innovation in the past year ("recent adoption"), (2) plans to adopt an innovation in the upcoming year ("planned adoption"), or (3) no actual or planned adoption ("non-adoption"). About 30.7% of organizations reported recent adoption, 20.5% indicated planned adoption, and 48.8% were non-adopters. Leaders of organizations reporting recent adoption (n=93) or planned adoption (n=62) rated the importance of innovation attributes, including relative advantage, compatibility, complexity, and observability, on these adoption decisions using a Likert scale that ranged from 0 to 5. Innovation attributes most strongly endorsed were consistency with the program's treatment philosophy (mean=4.47, SD=1.03), improvement in the program's reputation with referral sources (mean=4.00, SD=1.33), reputational improvement with clients and their families (mean=3.98, SD=1.31), and reductions in treatment dropout (mean=3.75, SD=1.54). Innovation characteristics reflecting organizational growth and implementation costs were less strongly endorsed. Adopters and planners were generally similar in their importance ratings. There were modest differences in importance ratings when pharmacological innovations were compared to psychosocial interventions. These findings are consistent with diffusion theory and suggest that efforts to link EBPs with client satisfaction and potential reputational benefits may enhance the diffusion of EBPs. Attention to these attributes when developing and evaluating SUD treatment interventions may enhance efforts to increase subsequent adoption.

Determinants of the availability of hepatitis C testing services in opioid treatment programs: results from a national study

OBJECTIVES

We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs.

METHODS

We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability.

RESULTS

Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios.

CONCLUSIONS

The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability of HCV testing in opioid treatment programs.

The employment of nurses in publicly funded substance abuse treatment programs

Little is known about the organizational and environmental factors associated with the employment of nurses in substance abuse treatment programs. Using data collected from the administrators of 250 publicly funded substance abuse treatment programs, this study examined the organizational and environmental correlates of nurse employment in these settings. Negative binomial regression models indicated that the number of nurses employed by treatment programs was positively associated with government ownership, location within a healthcare setting, and the availability of detoxification services. Outpatient-only programs employed fewer nurses than programs with inpatient/residential services. Two environmental factors were associated with nurse employment. Programs that more strongly endorsed a scale of financial barriers employed significantly fewer nurses, whereas programs indicating that funding from state contracts could be used to pay for healthcare providers employed significantly more nurses. These findings suggest that organizational decisions about employing nurses may reflect both the characteristics of the program and the funding environment. Future research should continue to examine the employment of nurses in substance abuse treatment settings, particularly given the shifting environment due to the implementation of healthcare reform.

Managing care for patients with substance abuse disorders at community health centers

Coordinating medical and substance use disorder (SUD) services is associated with good health and treatment outcomes but it is not widely practiced. This may be due to a lack of real-world models for coordinating care. This study examined the operational practices associated with a sample of community health centers (CHCs) identified as effectively coordinating SUD services relative to other CHCs. Case studies were used to describe the process of identifying patient need and linking patients with SA treatment services, and to generate propositions about operational approaches for effectively coordinating care. Integrating behavioral health staff within the primary care team was identified as especially critical for facilitating key care transitions. Additional operational approaches that aim to improve care transitions within and across care settings were identified. Future study will be needed to understand the significance of these approaches in terms of health and treatment outcomes. On-going coordination activities among primary care and SUD provided for shared patients remained a challenge for all sites.

Predictors of change in the provision of services within outpatient substance abuse treatment programs

The current study examines patterns and predictors of change over a 2-year period in whether outpatient core and wraparound services are offered on-site or by referral. A sample of 69 outpatient nonmethadone programs from 4 US regions provided organizational information across a 2-year period. Services provided within outpatient substance abuse programs were relatively stable over time, particularly with regard to core therapeutic services. The use of referral networks to provide a broader array of wraparound services increased, with programs adding services that reflect recent national initiatives toward program improvement, namely pharmacotherapy, medical diagnosis and treatment, and psychiatric services. Organizational factors such as parent affiliation, counselor caseload, staff size, budget change, and proportion of dually diagnosed clients were related to change in core and wraparound services. Dynamic organizational factors such as staff size and budgets can serve as barriers to and/or facilitate change in service provision over time and have managerial and policy implications.

Organizational correlates of service availability in outpatient substance abuse treatment programs

In pursuit of quality care for drug abuse treatment programs, researchers continue to monitor program characteristics related to service provision. The current study examines 115 outpatient drug-free programs in four U.S. regions and documents typical methods of offering an array of services and the relationship between program characteristics and services offered onsite and by referral. Core services (e.g., comprehensive assessments) are offered primarily onsite, whereas delivery methods of wraparound services are mixed with transitional services offered generally onsite and medical services traditionally offered offsite. Accredited programs offered more core services onsite, while those providing case management offered more core and wraparound services onsite. Programs with a higher proportion of dually diagnosed clients offered more core services onsite and fewer wraparound services by referral. Programs with a higher concentration of criminal justice-referred clients offered fewer core services onsite. These findings suggest ways of improving access to services.

Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations

OBJECTIVES

Publicly funded addiction treatment organizations have been slow to adopt pharmacotherapies. Few studies have examined the organizational factors associated with adoption of different types of medication in this treatment sector. This study identifies organization-level facilitators and barriers to the use of medications in publicly funded addiction treatment organizations.

METHODS

Face-to-face interviews with a sample of 318 administrators of a representative sample of publicly funded addiction treatment centers in the US.

RESULTS

Only 23.4% of programs reported using any of the five FDA-approved pharmacotherapies for treating addiction. An additional 14.3% of programs only used medications approved for the treatment of psychiatric disorders. Multivariate multinomial logistic regression results revealed that the odds of adoption of addiction pharmacotherapies were significantly greater in government-owned programs and in programs with more medical personnel. Programs that relied more heavily on non-Medicaid public funding tended to be less likely to adopt addiction treatment medications. Greater contact with pharmaceutical representatives was positively associated with medication adoption.

CONCLUSIONS

Current public funding policies and lack of access to medical personnel are barriers to the adoption of medications by publicly funded addiction treatment organizations. Efforts to promote adoption may also benefit from greater detailing activities by pharmaceutical representatives. These findings suggest that the large research investment devoted to developing addiction treatment medications may have limited public health impact due to the characteristics of publicly funded service delivery system as well as the limited attention given to this system by commercial purveyors of medications.

HIV/AIDS services in private substance abuse treatment programs

BACKGROUND

HIV infection among substance abusers is a growing concern in the United States. Little research, however, has examined the provision of HIV/AIDS services in substance abuse treatment programs.

METHODS

This study examines the provision of onsite HIV/AIDS services in a nationally representative sample of 345 privately funded substance abuse treatment programs. Data were collected via face-to-face interviews with administrators and/or clinical directors of treatment programs in 2007-2008.

RESULTS

Results show that larger programs and programs with a higher percentage of both African American and injection drug using (IDU) patients were more likely to offer onsite HIV/AIDS support groups and a dedicated HIV/AIDS treatment track. Multinomial logistic regression reveals that the odds of offering onsite HIV testing services were higher for hospital based programs, programs providing medical services onsite, and programs with higher percentages of African American patients, relative to the odds of offering no HIV testing or referring patients to an external provider for HIV testing services. The odds of providing onsite testing were lower for outpatient-only treatment programs, relative to the odds of offering no HIV testing or referring patients to an external provider for HIV testing services.

CONCLUSIONS

Our findings highlight critical barriers to the adoption of onsite HIV/AIDS services and suggest treatment programs are missing the opportunity to significantly impact HIV-related health outcomes.

Age and HIV sexual risk among women in methadone treatment

This study examines the relationship between age and HIV sexual risk behaviors among a random sample of 372 women in methadone treatment in New York City. Logistic regression results indicate that women of all ages are at risk for HIV through inconsistent condom use. Exposure to intimate partner violence (IPV), alcohol use, and HIV-negative status are associated with inconsistent condom use during vaginal sex. Age (35-44), having a main sexual partner with an HIV risk factor, IPV, and alcohol use are associated with using crack or cocaine during sex. Similarly, age (35-44), having a main sexual partner with an HIV risk factor, IPV, and drug use are associated with consuming four or more drinks prior to sex. The findings highlight the importance of age-appropriate HIV prevention and intervention strategies, as well as the need to address intimate partner violence, mental health, polysubstance use, and relational factors associated with HIV sexual risk behaviors among women in methadone treatment.

Nurse turnover in substance abuse treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network

Voluntary nurse turnover, which is costly and disrupts patient care, has not been studied as an organizational phenomenon within substance abuse treatment organizations. In this exploratory study, we examined the frequency and correlates of nurse turnover within treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network. During face-to-face interviews conducted in 2005-2006, 215 program administrators reported the number of nurses currently employed. Leaders of programs with nursing staff then described the number of nurses who had voluntarily quit in the past year, the degree to which filling vacant nursing positions was difficult, and the average number of days to fill a vacant position. About two thirds of these programs had at least one nurse on staff. In programs with nurses, the average rate of voluntary turnover was 15.0%. Turnover was significantly lower in hospital-based programs and programs offering adolescent treatment but higher in facilities offering residential treatment. Most of the administrators indicated that filling vacant nurse positions was difficult and took more than 2 months to complete. These findings suggest that nurse turnover is a significant issue facing many substance abuse treatment facilities. Efforts to improve retention of the addiction treatment workforce should be expanded to include nursing professionals.

Availability of HIV-related health services in adolescent substance abuse treatment programs

Given that alcohol and drug abuse heightens the risk of adolescents acquiring HIV, substance abuse treatment programs for youths may represent an important site of HIV prevention. In this research, we explored the adoption of three HIV-related health services: risk assessment during intake, HIV prevention programing, and HIV testing. Data were collection through telephone interviews with 149 managers of adolescent-only substance abuse treatment programs in the USA. About half of these programs had adopted HIV risk assessment and HIV prevention. On-site HIV testing was less widely adopted, with only one in four programs offering this service. At the bivariate level, the availability of on-site primary medical care and the availability of an overnight level of care were positively associated with these three types of services. The association for the measure of an overnight level of care was no longer significant once medical services were controlled. However, in a separate analysis, it was found that programs offering an overnight level of care were much more likely to offer on-site medical care than outpatient-only facilities. There was also evidence that publicly funded treatment programs were more likely to offer HIV prevention and on-site HIV testing, after controlling for other organizational characteristics. Much more research about the adoption of HIV-related services in adolescent substance abuse treatment is needed, particularly to offer greater insight into why certain types of organizations are more likely to adopt these health services.

Assessing the Service Linkages of Substance Abuse Agencies with Mental Health and Primary Care Organizations

Fragmentation of substance abuse treatment represents a major barrier to effective treatment for individuals with cooccurring substance abuse and mental and physical health disorders. Linkages of substance abuse treatment organizations with primary care and mental health agencies are widely considered to be a feasible way to integrate services. In this study, we analyzed information collected from a national sample of 62 outpatient substance abuse treatment units (OSATs) to understand the extent of services linkages in these organizations and to identify facilitators and barriers to service linkages. Results showed that OSATs had limited service linkages with primary care and mental health providers. The cited barriers to linkages included clients' financial problems, managed care restrictions, and limited organizational capacity. Onsite service provision was implemented in some OSATs. The pattern of service linkages in OSATs appeared to reflect the health needs of substance abuse clients.

Smoking Cessation Services in Adolescent Substance Abuse Treatment: Opportunities Missed?

The majority of adolescents receiving substance abuse treatment also use tobacco, yet there are few data regarding the adoption of tobacco use assessment and smoking cessation services by adolescent treatment programs. Using data from a national sample of adolescent-only treatment programs (n = 154), this research measures the adoption of aspects of assessment and treatment from the Public Health Service's (2000) guideline, Treating Tobacco Use and Dependence. When adoption of four intake/assessment practices was measured, adoption appeared high, but only 45% of programs had adopted all four practices. About 43% of programs offered some type of smoking cessation services. However, there was no association between adoption of intake procedures and the odds of availability of smoking cessation services, suggesting a lack of connection between the identification of treatment needs and the availability of services. The lack of smoking cessation services may represent a missed opportunity for early intervention with this population.

Top manager effects on buprenorphine adoption in outpatient substance abuse treatment programs

To examine the influence of top managers' characteristics on the adoption of buprenorphine for opioid dependence among U.S. outpatient substance abuse treatment units, this investigation analyzed a cross-sectional national study of 547 such units in the 2004-2005 wave of the Drug Abuse Treatment System Survey. Administrators reported their demographics, training, and treatment orientation, as well as features of the unit and its pattern of use of buprenorphine. Nationally, 15.8% of programs offered any buprenorphine services. Greater adoption of buprenorphine correlated with directors' younger age, longer tenure, male gender, and weaker endorsement of abstinence as the most important treatment goal. Availability of naltrexone and medical services also correlated positively with buprenorphine adoption. The authors conclude that leaders' characteristics are related to the adoption of innovative practices in addiction treatment programs. Future work should examine whether leadership development for community addiction programs might speed up the diffusion of buprenorphine and other innovative, evidence-based practices.

Need-service matching in substance abuse treatment: racial/ethnic differences

This study examines the impact of ancillary health and social services matched to client needs in substance abuse treatment for African Americans, Latinos and Whites. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3142 clients (1812 African Americans, 486 Latinos, 844 Whites) from 59 treatment facilities. Results show that racial/ethnic minorities are underserved compared to Whites in the substance abuse service system. Different racial/ethnic groups come into treatment with distinct needs and receive distinct services. Although groups respond differentially to service types, substance abuse counseling and matching services to needs is an effective strategy both for retaining clients in treatment and for reducing post-treatment substance use for African Americans and Whites. Receipt of access services was related to reduced post-treatment substance use for Latinos. Study findings are relevant to planning special services for African Americans and Latinos.

Organizational- and individual-level correlates of posttreatment substance use: a multilevel analysis

In addressing the need to study the effects of organizational factors on individual-level treatment outcomes, this study used hierarchical models to examine the organizational- and individual-level correlates of posttreatment substance use. Risk for posttreatment use varied significantly across organizations. Factors in the external institutional environment of facilities significantly influenced risk for use: managed care regulation increased the risk, whereas Joint Commission on the Accreditation of Healthcare Organizations accreditation decreased it (p < .01 for both). On the individual level, longer treatment episodes and treatment completion reduced the risk (p < .01 for both) after controlling for client characteristics. The benefits of length of stay in treatment were modified by elements of the external institutional environment and organizational treatment technology. The ameliorative effects of prolonged treatment were reduced by higher levels of managed care regulation, organizational monitoring, caseload size (p < .01 for all), and proportion of degreed staff (p < .05). The results highlight the influence of organizational factors on posttreatment use.

The use of antidepressant medications in substance abuse treatment: the public-private distinction, organizational compatibility, and the environment

Many studies of innovation adoption in health care organizations focus either on organizational characteristics or the institutional environment, but not both. Furthermore, these perspectives are rarely employed simultaneously in both public and private health care organizations. This research considers the public-private distinction, organizational compatibility, and interorganizational referral relationships in the use of selective serotonin reuptake inhibitors (SSRIs) by substance abuse treatment organizations. Using data from nationally representative samples of 363 publicly funded and 403 privately funded substance abuse treatment centers, a four-category typology of public and private organizations initially predicted variation in SSRI use. However some differences were no longer significant once organizational and environmental characteristics were added to the statistical model. These data support hypotheses about the associations between organizational characteristics and SSRI use as well as hypotheses regarding the external environment. Future research should continue to integrate both internal and external factors in theoretical explanations of innovation adoption.

Cigarette smoking cessation services in outpatient substance abuse treatment programs in the United States

OBJECTIVE

The objective of this study was to estimate the prevalence and determinants of cigarette smoking cessation treatment in U.S. outpatient substance abuse treatment (OSAT) units.

METHODS

Program directors and clinical supervisors from a national sample of 550 OSAT units in the United States were surveyed in 2004-2005. Supervisors reported the availability of cigarette smoking assessment, and individual or group counseling and pharmacotherapy for smoking cessation. This analysis examines whether institutional and resource factors influence the delivery of these services.

RESULTS

Of OSAT programs in the United States, 41% offer smoking cessation counseling or pharmacotherapy, 38% offer individual/group counseling, and 17% provide quit-smoking medication. In multivariate models, hospital affiliation, service breadth, the priority given to physical health, the availability of medication to treat addictive problems, assessment of cigarette smoking, and a greater perception of the proportion of patients who smoke were associated with the delivery of smoking cessation services. Program size and medical staffing also influenced the availability of quit-smoking medication.

CONCLUSIONS

Of U.S. OSAT programs, two in five offer behavioral treatment for smoking cessation, but fewer than one in five provide access to pharmacotherapy. Substance abuse treatment programs that are medically oriented, provide more comprehensive services, and recognize the burden of tobacco smoking among their patients are more likely to deliver evidence-based smoking cessation services.

Evidence-based treatment practices for drug-involved adults in the criminal justice system

OBJECTIVE

The aim of this study was to estimate the extent and organizational correlates of evidence-based practices (EBPs) in correctional facilities and community-based substance abuse treatment programs that manage drug-involved adult offenders.

METHODS

Correctional administrators and treatment program directors affiliated with a national sample of 384 criminal justice and community-based programs providing substance abuse treatment to adult offenders in the United States were surveyed in 2004. Correctional administrators reported the availability of up to 13 specified EBPs, and treatment directors up to 15. The sum total of EBPs indicates their extent. Linear models regress the extent of EBPs on variables measuring structure and leadership, culture and climate, administrator attitudes, and network connectedness of the organization.

RESULTS

Most programs offer fewer than 60% of the specified EBPs to drug-involved offenders. In multiple regression models, offender treatment programs that provided more EBPs were community based, accredited, and network connected, with a performance-oriented, nonpunitive culture, more training resources, and leadership with a background in human services, a high regard for the value of substance abuse treatment, and an understanding of EBPs.

CONCLUSIONS

The use of EBPs among facility- and community-based programs that serve drug-involved adult offenders has room for improvement. Initiatives to disseminate EBPs might target these institutional and environmental domains, but further research is needed to determine whether such organization interventions can promote the uptake of EBPs.

Service delivery in substance abuse treatment: reexamining "comprehensive" care

Substance abuse treatment clients present with an array of service needs in various life domains. Ideal models of addiction treatment incorporate provision or linkages to services to meet clients' multiple needs; in turn, these wraparound and supportive services are associated with improvements in client retention and treatment outcomes. Using data from large samples of specialty addiction treatment providers in the public and private sectors, this article examines the extent and organizational correlates of the comprehensiveness of service delivery. Multivariate models indicate that private sector treatment facilities offer more "core" medical and treatment services, whereas public sector programs offer more wraparound and supportive services. However, both sectors fall short of the ideal model of service comprehensiveness in terms of absolute number of services offered. These findings raise concerns regarding the quality and availability of needed services for treatment of addiction.

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE

This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up.

METHODS

Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up.

RESULTS

Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services.

CONCLUSIONS

Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.

The role of organization and management in substance abuse treatment: Review and roadmap

To develop an understanding as to why there exists a seemingly wide gap between research and practice in the field of substance abuse treatment and, more important, to understand how this gap can be closed, researchers have focused their attention on the role of organizational and management factors in the delivery of treatment services. This article's overarching goal is to stimulate research and interventions that focus on these factors so as to improve the standards and outcomes of care in substance abuse treatment. Part 1 introduces the key assumptions and perspectives that guide organization and management research. Part 2 selectively reviews empirical studies that examine relationships between treatment programs' use of research-based treatment practices and organization and management factors. The article concludes with a discussion of the next important steps for research and policy.

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE

This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up.

METHODS

Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up.

RESULTS

Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services.

CONCLUSIONS

Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.

Availability of Services for Women in Outpatient Substance Abuse Treatment: 1995–2000

Women entering substance abuse treatment have more severe substance abuse problems and more medical and psychiatric comorbidities than men. Research shows that specialized women's services are associated with better retention and outcomes but relatively little is known about their availability nationwide. This study examined the adoption and implementation of reproductive and female-sensitive social services in a national sample of outpatient substance abuse treatment (OSAT) organizations in 1995 (N = 617) and 2000 (N = 571) by several organizational factors. Overall, reproductive and social services for women have not been widely adopted, although some services did increase over the study period, particularly social services. There was no evidence of large-scale decreases in service availability over the study period, although child care did decline. Nonprofit and public ownership (relative to for-profit) were associated with greater service provision. Managed care units had greater service adoption compared to nonmanaged care units, and this increased over time. Public units and hospital-affiliated units had greater service implementation than other units. However, OSAT units did not always implement the services they adopted, suggesting access to some services may be restricted.

Does the impact of managed care on substance abuse treatment services vary by provider profit status?

OBJECTIVE

To extend our previous research by determining whether, and how, the impact of managed care (MC) on substance abuse treatment (SAT) services differs by facility ownership.

DATA SOURCES

The 2000 National Survey of Substance Abuse Treatment Services, which is designed to collect data on service offerings and other characteristics of SAT facilities in the U.S. These data are merged with data from the 2002 Area Resource File, a county-specific database containing information on population and MC activity. We use data on 10,513 facilities, virtually a census of all SAT facilities.

STUDY DESIGN

For each facility ownership type (for-profit [FP], not-for-profit [NFP], public), we estimate the impact of MC on the number and types of SAT services offered. We use instrumental variables techniques that account for possible endogeneity between facilities' involvement in MC and service offerings.

PRINCIPAL FINDINGS

We find that the impact of MC on SAT service offerings differs in magnitude and direction by facility ownership. On average, MC causes FPs to offer approximately four additional services, causes publics to offer approximately four fewer services, and has no impact on the number of services offered by NFPs. The differential impact of MC on FPs and publics appears to be concentrated in therapy/counseling, medical testing, and transitional services.

CONCLUSION

Our findings raise policy concerns that MC may reduce the quality of care provided by public SAT facilities by limiting the range of services offered. On the other hand, we find that FP clinics increase their range of services. One explanation is that MC results in standardization of service offerings across facilities of different ownership type. Further research is needed to better understand both the specific mechanisms of MC on SAT and the net impact on society.

Health services for women in outpatient substance abuse treatment

OBJECTIVE

To evaluate how a sample of outpatient substance abuse treatment units respond to organizational and environmental influences by adopting and implementing treatment services for women.

DATA SOURCES

The National Drug Abuse Treatment System Survey from 1995 and 2000, a national survey of outpatient substance abuse treatment units.

STUDY DESIGN

Health services for women are the dependent variables. The predictors include organizational and environmental factors that represent resource dependence and institutional pressures for the treatment unit. Logistic regression and Heckman selection models were used to test hypotheses.

DATA COLLECTION

Program directors and clinical supervisors at each treatment unit were interviewed by telephone in 1995 and 2000.

PRINCIPAL FINDINGS

Units that depended on specific funding for women's programs and that depended on government funds were more likely to adopt, but not necessarily implement, women's services. Methadone units and units that train more staff to work with women were more likely to adopt as well as implement women's services. Private not-for-profit units were more likely to adopt some services, while for-profit units were less so. However, in general, neither for-profit nor not-for-profit units significantly implemented services. There was evidence that the odds of adopting services were greater in 2000 than 1995 for two services, but were otherwise stable.

CONCLUSIONS

There is considerable variation in the adoption and implementation of women's services. In addition, not all adopted services were significantly implemented, which could reflect limited organizational resources and/or conflicting expectations. This also suggests that referral mechanisms to these services, and therefore access, may not be adequate. Government funds and specific funds for women's programs are important resources for the provision of these services. Women's services appear more available in methadone units, suggesting that regulation has been influential and that the recent methadone accreditation system should be evaluated. Staff training may be one strategy to encourage implementation of these services. For the most part, the adoption of services for women did not change between 1995 and 2000.

Treatment services and service delivery models for dually diagnosed clients: variations across mental health and substance abuse providers

This paper reports on a survey of administrators (n = 26) and staff (n = 248) in 10 mental health and 16 substance abuse programs in Los Angeles County providing services to individuals with co-occurring disorders. Although half or more of the administrators and staff reported that their programs had some degree of on-site service integration, there was a lack of agreement within most programs as to the extent of integration. Characteristics of services provided and interactions with other service providers are also examined. Future research is needed regarding the divergent perceptions of administrators and staff and their relationship to treatment outcomes.

Outpatient drug treatment program directors' hepatitis C-related beliefs and their relationship to the provision of HCV services

The hepatitis C virus (HCV) continues to penetrate populations within the United States, especially within the drug-abusing population. Therefore, drug users need access to HCV testing and medical care, and drug treatment programs are well situated to provide these services. Because directors of these programs are gatekeepers who can influence decisions about service provision, their beliefs about the value of providing particular services for drug treatment program patients are of considerable importance. Directors of 121 outpatient drug treatment programs throughout the United States responded to an in-depth telephone survey that included questions on their beliefs about providing HCV services in drug treatment programs. We constructed an eight-item scale to examine these beliefs and investigated the relationship between them and the actual HCV services offered. Overall, directors were moderately supportive of the provision of HCV medical services (on-site or through referral) during drug treatment. Our findings indicate that there is a positive significant relationship between director's beliefs and the provision of HCV antibody testing, follow-up testing, and the provision of HCV medication.

Gender differences in the impact of comprehensive services in substance abuse treatment

This study examines the impact of comprehensive services on treatment outcomes for women and men. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective, cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3,142 clients (1,123 women and 2,019 men) from 59 treatment facilities. The results show that substance abuse treatment benefits both women and men. Further, both women and men benefit from comprehensive services provided as part of substance abuse treatment: specifically, the receipt of educational, housing and income support services is related to reduced post-treatment substance abuse for both women and men. Gender differences are revealed by the fact that, overall, greater proportions of women receive services and, when individual, service, and treatment organizational characteristics are controlled, women show greater reductions in post-treatment substance use. Further, women and men differ in their responsiveness to organizational characteristics: the availability of on-site services and the frequency of counseling significantly predict reduced post-treatment substance use for men but not for women.

A conceptual framework for drug treatment process and outcomes

Evidence from specialized treatment evaluations and large-scale natural studies of treatment effectiveness is organized conceptually into a "treatment model" for summarizing how drug treatment works. Sequential relationships between patient and treatment program attributes, early patient engagement, recovery stages, retention, and favorable outcomes are discussed--along with behavioral, cognitive, and skills training interventions that have been shown to be effective for enhancing specific stages of the patient recovery process. Applications of the treatment model for incorporating science-based innovations into clinical practice for improving early engagement and retention, performance measurements of patient progress, program monitoring and management using aggregated patient records, and organizational functioning and systems change also are addressed.

The effect of matching comprehensive services to patients' needs on drug use improvement in addiction treatment

AIMS

To examine whether need-service matching in addiction treatment leads to improvements in drug use, and whether treatment duration mediates those improvements.

DESIGN, PARTICIPANTS, MEASUREMENTS

This analysis utilizes prospective data from a US cohort of addiction treatment patients who reported service needs beyond core rehabilitative services (n = 3103). 'Drug use improvement' is the difference between the patient's peak drug use frequency (in days per month) in the year before intake and in the year after treatment. Overall and primary use of the major illicit drugs (heroin, powder or crack cocaine and marijuana) are considered separately. 'Need-service match' means that a patient rated a service as important at intake and reported its receipt during treatment. 'Percentage of needs matched' indicates the proportion of five service domains (medical, mental health, family, vocational and housing) so matched.

FINDINGS

In mixed regression models controlling for multiple factors, a greater percentage of needs matched tended to improve primary (beta = 0.028, P = 0.09) and overall (beta = 0.049, P = 0.05) drug use in the follow-up year. Exclusion of treatment duration as a covariate doubled the magnitude of these coefficients. The benefits of matching were concentrated among the half of patients reporting needs in four to five rather than one to three domains, and were strongest among patients in long-term residential facilities. Addressing vocational and housing needs exerted the greatest effects.

CONCLUSIONS

Matching comprehensive services to needs is a useful addiction treatment practice, especially for high-need patients. Treatment duration might partially mediate its effect.

To what extent are key services offered in treatment programs for special populations?

Many substance abuse treatment (SAT) facilities offer programs designed specifically for special populations such as women, adolescents, gays/lesbians and others. Previous research shows that there are specific services that are integral to the successful treatment of these populations (e.g., family therapy for adolescents, childcare and transportation assistance for women, and HIV testing and counseling for gays/lesbians). This study examines whether facilities that self-report having programs for special populations actually offer the recommended services. The data come from the 2000 National Survey of Substance Abuse Treatment Services, which contains information on service offerings, special programs and other characteristics for all SAT facilities in the USA. The results indicate that facilities with special programs are more likely to offer the recommended key services. However, often less than half of these facilities provide the key services. There are consistent differences by ownership status, with for-profit facilities less likely to offer many of the key services.

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

Designated case managers as facilitators of medical and psychosocial service delivery in addiction treatment programs

This study examines whether having designated case management staff facilitates delivery of comprehensive medical and psychosocial services in substance abuse treatment programs. A multilevel, prospective cohort study of 2829 clients admitted to selected substance abuse treatment programs was used to study clients from long-term residential, outpatient, and methadone treatment modalities. Program directors reported whether the program had staff designated as case managers. After treatment discharge, clients reported their receipt of 9 supplemental services during the treatment episode. In multivariate models controlling for multiple program-level and client-level factors, program-level availability of designated case managers increased client-level receipt of only 2 of 9 services, and exerted no effect on service comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs.