Recommendations for improving drug treatment

Trends in comprehensive service availability in outpatient drug abuse treatment

Comprehensive medical and psychosocial services are essential to quality addiction treatment, but their availability declined in the 1980s. To determine whether this downward trend in the availability of comprehensive services continued in the 1990s, we analyzed data from a national panel study of outpatient substance abuse treatment units in 1990, 1995, and 2000. Response rates were greater than 85%. Regarding the availability of comprehensive services, including physical examinations, routine medical care, mental health services, financial counseling and employment counseling, administrators reported whether any substance abuse treatment client received the service in the past year. With the exception of physical examinations, whose reported availability increased from 1990 to 1995, and financial counseling, whose reported availability decreased during the same time, the reported availability of comprehensive services changed little during the 1990s. These findings highlight the continuing need to monitor access to comprehensive services and other quality markers in addiction treatment over time.

Linkage to medical services in the Drug Abuse Treatment Outcome Study

BACKGROUND

An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population.

OBJECTIVES

The goal of this study was to examine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs.

RESEARCH DESIGN

This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview.

MEASURES

Program directors' surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment.

RESULTS

Exclusive on-site delivery increased medical utilization during the first month of drug abuse treatment (beta estimate, 0.22; standard error [SE], 0.06; P <0.001). Transportation services also increased 1-month medical utilization (beta estimate, 0.13; SE, 0.03; P <0.001).

CONCLUSIONS

Exclusive on-site delivery of medical services increased drug abuse treatment patients' utilization of medical services in the first month of treatment. Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment.

Treatment readiness training and probationers' evaluation of substance abuse treatment in a criminal justice setting

Clients who are legally coerced into substance abuse treatment often have low intrinsic motivation to participate, are less ready for treatment, and are consequently more problematic to treat and less satisfied with their treatment than are voluntary clients. A set of readiness training activities, designed to promote early involvement in treatment, was implemented in a 4-month residential criminal justice program. Five hundred probationers were randomly assigned to receive either the readiness training we developed or the approach typically used at the facility. Based on their response to an intake interview, probationers were categorized as having low, medium, or high readiness for treatment. Probationers in the readiness training group rated their counselors, groups, and community meetings higher than did probationers in the standard group. In addition, probationers in the readiness training group rated themselves as "working the program" to a greater extent than did probationers in the standard group. Probationers with higher initial levels of readiness for treatment rated their counselors, sessions, and security staff higher than did probationers with lower levels. The results suggest that the readiness training activities may help probationers become more involved in treatment and that this may lead to greater satisfaction with counselors and sessions.

Predicting retention in a residential drug treatment alternative to prison program

One hundred and fifty felony drug offenders diverted from prison to community-based, residential drug treatment alternative to prison program completed a comprehensive interview as part of a longitudinal study. Treatment completion predictors were sought examining intake data (demographics, family, social, employment, medical, psychological, criminal, sexual behavior, drug use and treatment histories). Logistic regression results found completers had more social conformity and close friends, and less need for employment counseling, felony drug convictions, drug dealing income, and unprotected sex than dropouts. Completers were also less likely to encounter recent problems with significant other, have a psychiatric history, experience gunshot or stabbing, and commenced heroin use at older ages than dropouts. However, completers reported higher alcohol use than counterparts. Further analyses explored subcategory models: "life choice" (substance use, criminal and sexual behavior), static (background and dispositional), and dynamic situational influences (employment, psychological state, recent and past encounters). Treatment implications considering findings are discussed.

Positive effects on life skills motivation and self-efficacy: node-link maps in a modified therapeutic community

In recent years, one response to drug abuse problems has been to provide treatment in prison and probation settings. Results are promising, although the need for improving mandated treatment has been expressed. The Cognitive Enhancements for Treatment of Probationers (CETOP) project is investigating cognitive enhancements in a modified therapeutic community (TC) setting. One enhancement is node-link mapping, a visual graphing strategy. Map "nodes" contain ideas, actions, and feelings; these are connected by links that illustrate meaningful relationships. Current findings indicate increases in group participation, ratings of session depth, and positive ratings of coresidents, counselors, and security staff. The present study extends this research by comparing mapping-enhanced counseling to standard counseling on self-efficacy and motivation for basic psychosocial skills (e.g., emotional control). Probationers (n = 381) in a 16-week residential program were assigned randomly to conditions in 12 TCs (n = 30-35). Motivation and self-efficacy were assessed by two self-report questionnaires, one midway and one at the end of treatment. A five-factor solution was produced from each questionnaire. With community as the unit of analysis, means of enhanced counseling were higher in all cases. Wilcoxen tests indicated four significant differences at midterm for mapping on motivation and self-efficacy of communication and emotional control (p < .05). At the end of treatment, mapping was higher for motivation of cognition and emotional control and self-efficacy was higher for communication. Discussing Bandura's model, these findings provide evidence that maps may enhance psychosocial skills, which have been associated with maintaining recovery.

Developing a rural therapy with big city approaches

Both rural communities and urban communities experience problems associated with drug use and drug dependence. However, existing treatment interventions are not tailored for rural settings. This article describes a project which will modify an existing social skills behavioral therapy for rural populations, refine the therapy, develop a manual, train and supervise therapists, and pilot test the structured behavioral outpatient rural therapy to treat rural drug users and drug dependents as Stage I Research for NIDA's Behavioral Therapies Development Program.

Mapping Techniques to Improve Substance Abuse Treatment in Criminal Justice Settings

Node-link mapping, a graphic representation tool, was used to improve mandated substance-abuse treatment in a 4-month residential criminal justice program. Three hundred eighty probationers (residents) were randomly assigned to either mapping-enhanced or standard counseling. Compared to those in standard counseling, residents receiving mapping gave more favorable evaluations to their group meetings, counselors, co-residents, and security staff. They also rated themselves higher on treatment effort and self-efficacy measures than did their counterparts. These findings suggest that mapping-enhanced counseling fosters more effective communication during meetings, promotes stronger therapeutic alliances, and thus enhances the perceptions of the effectiveness of the program and of the people associated with it.