Rethinking patient placement: the human service matrix model for matching services to needs

Effects of perceived cocaine availability on subjective and objective responses to the drug

RATIONALE

Several lines of evidence suggest that cocaine expectancy and craving are two related phenomena. The present study assessed this potential link by contrasting reactions to varying degrees of the drug's perceived availability.

METHOD

Non-treatment seeking individuals with cocaine dependence were administered an intravenous bolus of cocaine (0.2 mg/kg) under 100% ('unblinded'; N = 33) and 33% ('blinded'; N = 12) probability conditions for the delivery of drug. Subjective ratings of craving, high, rush and low along with heart rate and blood pressure measurements were collected at baseline and every minute for 20 minutes following the infusions.

RESULTS

Compared to the 'blinded' subjects, their 'unblinded' counterparts had similar craving scores on a multidimensional assessment several hours before the infusion, but reported higher craving levels on a more proximal evaluation, immediately prior to the receipt of cocaine. Furthermore, the 'unblinded' subjects displayed a more rapid onset of high and rush cocaine responses along with significantly higher cocaine-induced heart rate elevations.

CONCLUSION

These results support the hypothesis that cocaine expectancy modulates subjective and objective responses to the drug. Provided the important public health policy implications of heavy cocaine use, health policy makers and clinicians alike may favor cocaine craving assessments performed in the settings with access to the drug rather than in more neutral environments as a more meaningful marker of disease staging and assignment to the proper level of care.

Analysis model for planning chemical dependence treatment systems

Statewide needs assessments commonly generate a single estimate of the number of persons needing chemical dependence treatment. The present analysis utilizes help-seeking behavior models and patient placement concepts to break a single statewide need estimate into operational units of services and costs that can be used for planning and resource allocation. The analyses are presented as allocation models for placements, service populations, service capacities, and costs. The guide was tested using state data for a target year and the results were compared to actual treatment admissions, which revealed a lack of convergence. Only 9% of persons were estimated to need intensive residential treatment whereas actual admissions to intensive residential treatment accounted for 29% of all admissions. The disparities may be accounted for by sampling bias of the needs estimate and by the likelihood that persons with more severe problems may be overrepresented when only a small proportion of treatment need is being met. These findings suggest that if resources become available to narrow the treatment gap, a larger proportion of outpatient services and less intensive services may be appropriate for the expanded clientele.

The relationship between problem severity and ancillary treatment services: is substance abuse treatment responsive to client need?

This study examined whether a greater self-reported problem severity at intake is associated with a greater likelihood of receiving related ancillary treatment services. The sample of 3,625 adult substance abuse treatment completers represents 162 outpatient and 41 short-term inpatient/residential programs located throughout Minnesota. Problem severity and receipt of ancillary services were assessed in medical, psychological, family/social, employment, financial, and legal domains. Across treatment setting and client gender, individuals with higher problem severity were significantly more likely to receive related ancillary services in the areas of medical services, psychotropic medication, family/relationship counseling, financial services, and legal services. For other services, the positive association between problem severity and receipt of related ancillary services held for some but not all groups defined by treatment setting or gender. Despite consistent relationships between service need and receipt, large gaps remain with respect to programs' responsiveness to client needs.

Patient placement criteria and their relation to access to appropriate level of care and engagement in alcoholism treatment

Patient placement criteria (PPC) facilitate treatment matching through detailed, standardized assessment of patients' needs. This process affords the alcoholism treatment field an opportunity to address issues that influence access to appropriate level of care by highlighting these issues during the assessment. The American Society of Addiction Medicine Patient Placement Criteria can integrate assessment of social and environmental, institutional and patient issues that affect access to appropriate care and treatment engagement. They can ultimately improve access through an iterative approach: developing a broad consensus on guidelines based on research evidence and expert clinical opinion, making criteria clear and easy to use both for assessment and for teaching purposes, addressing the needs of special populations, and testing and improving the validity of decision rules to achieve optimal access and treatment engagement. Early evidence suggests that PPC are promising but there is much about them that remains to be tested and improved.