Cost-Effectiveness of Publicly Funded Treatment of Opioid Use Disorder in California.

Background: Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Fewer than half of Californians who received treatment in 2014 received opioid agonist treatment (OAT), and regulations for admission to OAT in California are more stringent than federal regulations. Objective: To determine the cost-effectiveness of OAT for all treatment recipients compared with the observed standard of care for patients presenting with opioid use disorder to California's publicly funded treatment facilities. Design: Model-based cost-effectiveness analysis. Data Sources: Linked population-level administrative databases capturing treatment and criminal justice records for California (2006 to 2010); published literature. Target Population: Persons initially presenting for publicly funded treatment of opioid use disorder. Time Horizon: Lifetime. Perspective: Societal. Intervention: Immediate access to OAT with methadone for all treatment recipients compared with the observed standard of care (54.3% initiate opioid use disorder treatment with medically managed withdrawal). Outcome Measures: Discounted quality-adjusted life-years (QALYs) and discounted costs. Results of Base-Case Analysis: Immediate access to OAT for all treatment recipients costs less (by $78 257), with patients accumulating more QALYs (by 0.42) than with the observed standard of care. In a hypothetical scenario where all Californians starting treatment of opioid use disorder in 2014 had immediate access to OAT, total lifetime savings for this cohort could be as high as $3.8 billion. Results of Sensitivity Analysis: 99.6% of the 2000 simulations resulted in lower costs and more QALYs. Limitation: Nonrandomized delivery of OAT or medically managed withdrawal. Conclusion: The value of publicly funded treatment of opioid use disorder in California is maximized when OAT is delivered to all patients presenting for treatment, providing greater health benefits and cost savings than the observed standard of care. Primary Funding Source: National Institute on Drug Abuse.

Comparative Effectiveness of California's Proposition 36 and Drug Court Programs Before and After Propensity Score Matching.

California's voter-initiated Proposition 36 (Prop 36) program is often unfavorably compared to drug courts, but little is empirically known about the comparative effectiveness of the two approaches. Using statewide administrative data, analyses were conducted on all Prop 36 and drug court offenders with official records of arrest and drug treatment. Propensity score matching was used to create equivalent groups, enabling comparisons of success at treatment discharge, recidivism over 12 months post-treatment entry, and magnitude of behavioral changes. Significant behavioral improvements occurred for both Prop 36 and drug court offenders, but while more Prop 36 offenders were successful at discharge, more recidivated over 12 months. Core programmatic differences likely contributed to differences in outcomes. Policy implications are discussed.

Characterizing durations of heroin abstinence in the California Civil Addict Program: results from a 33-year observational cohort study.

In accordance with the chronic disease model of opioid dependence, cessation is often observed as a longitudinal process rather than a discrete endpoint. We aimed to characterize and identify predictors of periods of heroin abstinence in the natural history of recovery from opioid dependence. Data were collected on participants from California who were enrolled in the Civil Addict Program from 1962 onward by use of a natural history interview. Multivariate regression using proportional hazards frailty models was applied to identify independent predictors and correlates of repeated abstinence episode durations. Among 471 heroin-dependent males, 387 (82.2%) reported 932 abstinence episodes, 60.3% of which lasted at least 1 year. Multivariate analysis revealed several important findings. First, demographic factors such as age and ethnicity did not explain variation in durations of abstinence episodes. However, employment and lower drug use severity predicted longer episodes. Second, abstinence durations were longer following sustained treatment versus incarceration. Third, individuals with multiple abstinence episodes remained abstinent for longer durations in successive episodes. Finally, abstinence episodes initiated >10 and ≤20 years after first use lasted longer than others. Public policy facilitating engagement of opioid-dependent individuals in maintenance-oriented drug treatment and employment is recommended to achieve and sustain opioid abstinence.

Offender diversion into substance use disorder treatment: the economic impact of California's proposition 36.

OBJECTIVES: We determined the costs and savings attributable to the California Substance Abuse and Crime Prevention Act (SACPA), which mandated probation or continued parole with substance abuse treatment in lieu of incarceration for adult offenders convicted of nonviolent drug offenses and probation and parole violators. METHODS: We used individually linked, population-level administrative data to define intervention and control cohorts of offenders meeting SACPA eligibility criteria. Using multivariate difference-in-differences analysis, we estimated the effect of SACPA implementation on the total and domain-specific costs to state and county governments, controlling for fixed individual and county characteristics and changes in crime at the county level. RESULTS: The additional costs of treatment were more than offset by savings in other domains, primarily in the costs of incarceration. We estimated the statewide policy effect as an adjusted savings of $2317 (95% confidence interval = $1905, $2730) per offender over a 30-month postconviction period. SACPA implementation resulted in greater incremental cost savings for Blacks and Hispanics, who had markedly higher rates of conviction and incarceration. CONCLUSIONS: The monetary benefits to government exceeded the additional costs of SACPA implementation and provision of treatment.

Developmental trajectories of childhood obesity and risk behaviors in adolescence.

Using group-based trajectory modeling, this study examined 5156 adolescents from the child sample of the 1979 National Longitudinal Survey of Youth to identify developmental trajectories of obesity from ages 6-18 and evaluate associations of such trajectories with risk behaviors and psychosocial health in adolescence. Four distinctive obesity trajectories were identified: "Chronically Obese," "Decreasing," "Increasing," and "Non-obese." Males were overrepresented in the Chronically Obese and Increasing groups; females were overrepresented in the Decreasing group. African-Americans were overrepresented in the Chronically Obese, Increasing, and Decreasing groups; in contrast, Whites were overrepresented in the Non-obese group. Obesity trajectories were not associated with greater trends in alcohol use, marijuana use, or delinquency, but Chronically Obese adolescents showed a greater increase in cigarette smoking over time compared to other trajectories. The Increasing trajectory, representing a transition into obesity status from childhood to adolescence, was associated with poorer psychosocial health compared to other trajectories.

Perceptions about recovery needs and drug-avoidance recovery behaviors among youth in substance abuse treatment.

OBJECTIVE: This study used mixed methods to explore youth attitudes about recovery-related needs and important drug-avoidance behaviors after treatment. METHOD: Focus groups were conducted with 118 substance using youth in treatment (four residential and 10 outpatient settings) throughout Los Angeles County. RESULTS: The average age was 17.4 (SD = 2.9); 78.3% were male, 66.1% Latino; and most were in treatment for primary marijuana (40.9%) or methamphetamine (30.4%) abuse. Quantitatve results from the drug-avoidance activity survey identified the following factors youth rated as important to their recovery after treatment: lifestyle improvement activities (95.7%); changing personal drug behaviors (89.6%); drug environment/culture change activities (82.5%); with the least important being therapeutic activities (78.5%). Qualitative findings from focus groups that asked what youth think are important for recovery programs to address after treatment revealed the following four areas: (1) recovery promotion to developmentally appropriate activities (95%); (2) facilitating the use of coping skills to deal with stress (85%); (3) offering alternative recovery support options (not just abstinence only) (75%); and (4) continuing to provide substance use education (65%). CONCLUSION: Findings highlight essential aspects of recovery in terms of need and drug-avoidance behaviors considered important to youth in treatment. Such information will help to better address clinical and recovery support models aimed at relapse prevention to ensure that the perceived problems of substance-abusing youth are adequately met.

Substance use patterns among high-risk American Indians/Alaska Natives in Los Angeles County.

BACKGROUND: Substance abuse among American Indians/Alaska Natives (AI/ANs) is a significant and long-standing health problem in the U.S. Two-thirds of American AIs/ANs reside in the urban setting. However, studies analyzing substance use characteristics among urban AI/ANs are very limited. METHODS: Substance use patterns among a sample of AI/ANs (n = 77) and other ethnic/racial groups in Los Angeles County at high risk of substance abuse were analyzed utilizing three datasets from programs targeting individuals at high risk for substance abuse and risky sexual behaviors. RESULTS: Compared to all other ethnic/racial groups, AI/ANs demonstrated significantly younger age of onset of alcohol, marijuana, methamphetamine, and "other" drug use, higher correlations of age of first use of amphetamine with a measure of the drug's reinforcement, and higher mean number of illicit drug injections in the 30 days before being interviewed. CONCLUSIONS: Results from this study highlight a critical need for furthering our understanding of substance abuse problems among urban AI/ANs.

The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women.

We examined the effect of women's perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner's risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.

Racial/ethnic differences in breast cancer outcomes among older patients: effects of physician communication and patient empowerment.

OBJECTIVES: To examine racial/ethnic disparities in older women's health-related quality of life (QoL) and type of breast cancer treatment as mediated by physician-level and individual-level variables. METHODS: A cross-sectional survey of a population-based, consecutive sample identified through the Los Angeles Cancer Surveillance Program of Latina (n = 99), African American (n = 66), and White (n = 92) women aged 55 years or older (N = 257) between 3 and 9 months after primary breast cancer diagnosis and at least 1 month posttreatment. An exploratory, empirically developed latent variable model tested the relationships among demographic and physician-related variables, patient attitudes, and health-related outcomes. Health-related outcomes included QoL measures and receipt of breast conserving surgery (BCS). RESULTS: Latinas reported less BCS and poorer QoL compared with Whites. Physician communication that can empower patients, in terms of patient efficacy in patient?physician interactions and breast cancer knowledge, mitigated racial/ethnic disparities in receipt of BCS. Physician emotional support was not related to patient cognitive empowerment and treatment outcomes. Medical mistrust in minority women was related to less self-efficacy and less positive coping, as well as, both directly and indirectly, to reduced QoL. Latinas reported poorer QoL in the tested model. CONCLUSION: Physician communication style, specifically information giving and participatory decision making, may empower older women with breast cancer and help mitigate racial/ethnic disparities in surgical treatment received.

Impact of California's Proposition 36 on the drug treatment system: treatment capacity and displacement.

OBJECTIVES: California's Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. We examined how treatment capacity changed to accommodate Proposition 36 clients and whether displacement of other clients was an unintended consequence. METHODS: Treatment admissions were compared for the year before and 2 years after the law was enacted. Surveys of county administrators and treatment providers were conducted in Kern, Riverside, Sacramento, San Diego, and San Francisco counties. RESULTS: The number of Proposition 36 offenders admitted to treatment continued to increase in the state (approximately 32000 in Year 1 and 48000 in Year 2) and in the 5 counties; total treatment admissions stabilized in Year 2 after increasing in Year 1. Voluntary clients decreased by 8000 each year statewide, but the change varied across counties. One third of treatment providers reported decreased treatment availability for non-Proposition 36 clients in Year 2. CONCLUSION: Despite expanded treatment capacity (mostly in outpatient treatment), indirect evidence suggests that displacement of voluntary clients may have occurred in part because of the demand for treatment by Proposition 36 clients.

Levo-alpha-acetylmethadol (LAAM) versus methadone maintenance: 1-year treatment retention, outcomes and status.

AIMS: To compare levo-alpha-acetylmethadol (LAAM) and methadone maintenance (MM) on treatment retention, drug use during treatment and at follow-up, and abstinence. DESIGN: A two-group experimental design with patients assigned randomly (2:1) to receive fully subsidized LAAM or MM for 52 weeks. SETTING: A community clinic providing maintenance treatment in Los Angeles, California. PARTICIPANTS: A total of 315 treatment-seeking patients willing to be assigned randomly to treatment condition; 289 (91.7%) were interviewed at 52 weeks. INTERVENTION: LAAM or MM, plus ancillary services available to all patients. Medication dose varied according to clinical judgement. MEASUREMENTS: Treatment retention and status at 52-week follow-up, weekly clinical urinalysis, self-reported drug use and research urinalysis on samples collected at follow-up. FINDINGS: LAAM participants were more likely to complete the planned 52 weeks (57.4%) than MM participants (46.2%) and were less likely to be discharged for arrest/incarceration. LAAM produced fewer during treatment clinic opiate-positive samples (M = 48.8) than MM (M = 62.3). Further, 24.4% on LAAM compared to 11.8% on MM were able to sustain at least 12 weeks of abstinence during the last 24 weeks of treatment. Opiate use at follow-up was lowest (50.9%) among LAAM participants in maintenance treatment. No adverse events, cardiological or otherwise, were observed with LAAM administration. CONCLUSIONS: LAAM is an effective medication for the treatment of opiate dependence in community clinics with numerous behavioral and clinical advantages. LAAM is more effective than MM in promoting retention and extended reduction in and abstinence from opiate use while in treatment.

Substance use pathways to methamphetamine use among treated users.

Considerable research has focused on patterns of substance use initiation among adolescents and for users of selected drugs; however, few data are available for methamphetamine (MA) users. This study describes substance initiation patterns for 352 MA users and assesses predictors of age of MA initiation and its sequencing. Subjects were randomly selected from treatment admissions in a large California county and interviewed using an extensive natural history protocol. Average age of MA initiation was 19 years. Nearly all (95%) had used alcohol, marijuana, and tobacco (average initiation age 13); inhalants, hallucinogens, and crack were also commonly used earlier in the drug sequence than MA. Earlier age of MA initiation was related to race/ethnicity (being non-African-American), younger age of first use of any substance, more types of early criminal behavior, and initiating MA use for sensation-seeking reasons. Following initiation of alcohol, marijuana, and/or tobacco, 27% initiated MA before other illicit drugs, 18% initiated another illicit drug before MA, and 56% initiated two or more other illicit drugs before MA. Later MA order in the initiation sequence was related to ethnicity (being African-American) and initiating MA to substitute for another drug. Results may support targeted prevention efforts and development of more effective interventions.

The life course perspective on drug use: a conceptual framework for understanding drug use trajectories.

This article discusses the life course perspective on drug use, including conceptual and analytic issues involved in developing the life course framework to explain how drug use trajectories develop during an individual's lifetime and how this knowledge can guide new research and approaches to management of drug dependence. Central concepts include trajectories marked by transitions and social capital and turning points influencing changes. The life course perspective offers an organizing framework for classifying varying drug use trajectories, identifying critical events and factors contributing to the persistence or change in drug use, analytically ordering events that occur during the life span, and determining contributory relationships.

Trajectories of heroin addiction: growth mixture modeling results based on a 33-year follow-up study.

This study investigates trajectories of heroin use and subsequent consequences in a sample of 471 male heroin addicts who were admitted to the California Civil Addict Program in 1964-1965 and followed over 33 years. Applying a two-part growth mixture modeling strategy to heroin use level during the first 16 years of the addiction careers since first heroin use, the authors identified three groups with distinctive profiles: stably high-level heroin users (n = 278), late decelerated users (n = 149), and early quitters (n = 44). Study findings empirically demonstrate the chronic nature of heroin addiction and subsequent adverse consequences including mortality, mental health, and employment.

Criminal justice itreatment admissions for methamphetamine use in California: a focus on Proposition 36.

Methamphetamine (MA) use is considered as one of the nation's most pressing drug problems. In California, MA use has outstripped all other drugs in epidemiological extent, law enforcement activities, and treatment services demand. An opportunity for further study of MA use and its treatment emerged from a change in offender sentencing options introduced by California's Substance Abuse and Crime Prevention Act of 2000 (SACPA). Results indicate that statewide admissions for MA rose from 8.4% in FY 1992/1993 to 34.6% in FY 2004/2005, a four-fold increase over the 13 years. From the year before SACPA implementation to the year after, the percentage of treatment admissions due to MA use increased from 18.8% to 25.6%, an increase largely due to the fact that SACPA admissions were over 50% MA users. With the exception of alcohol, MA users entering treatment through SACPA had higher completion rates (about one third) from community based treatment than users of other primary drugs. This result held true for demographic and other subgroups of MA users. Multivariate regression results illuminate the relative importance of the variables examined. Implication of the findings for policy, intervention services, and research are discussed.

A 12-year follow-up of a treated cocaine-dependent sample.

The study examined long-term outcomes (mortality, substance use, mental health, employment, criminal involvement) among a cocaine-dependent sample. This 12-year follow-up study, conducted in 2002-2003, updates information obtained at intake and two face-to-face interviews conducted in 1990-1991 and 1991-1992 among 321 male cocaine-dependent veterans admitted to drug treatment in 1988-1989. At the 2002-2003 follow-up, 28 had died and 266 were interviewed. A mixed model examining the longitudinal relationships demonstrated that treatment was associated with lower levels of cocaine use over the 12-year follow-up period after entry into the index treatment and more stable recovery (i.e., continuously abstinent from cocaine for at least 5 years). Few measures at intake predicted stable recovery at follow-up: only being White (vs. being African American) and having greater confidence in ability to avoid cocaine use in high-risk situations. Individuals achieving stable recovery reported less psychiatric symptoms, criminal involvement, and unemployment during the year prior to the interview. Adverse outcomes were apparent for a significant number of cocaine-dependent users who continued to use cocaine for a long period.

Two-year outcomes of treatment for methamphetamine use.

While evaluation research supports the general effectiveness of substance abuse treatment, there is not a comprehensive literature on treatment effectiveness for methamphetamine (MA) use. The authors consider three outcome measures--MA use, criminal activity, and employment--compared across three periods: 24-months pretreatment, during treatment, and 24-months post-treatment. Data are from an intensive natural history interview conducted two to three years after treatment for 349 randomly selected admissions to treatment for MA abuse in a large publicly-funded county treatment system. Through this naturalistic design, data provide a system-wide perspective on effectiveness of treatment as usual. Results showed reduction in MA use and crime during and following treatment and increased employment following treatment over pretreatment levels. Regression analyses showed higher levels of education and more time in treatment related to more positive post-treatment outcomes for all three measures. Lower percentage of post-treatment months with MA use also was related to more pretreatment MA-related problems, lower pretreatment MA use, and residential (compared to outpatient) treatment modality. Lower post-treatment criminal activity was also related to gender (being female), lower pretreatment criminal activity, and residential modality. Higher percentage of post-treatment months with employment also was related to gender (being male), ethnicity (not African-American), and higher pretreatment employment.

Levo-alpha-acetylmethadol (LAAM) versus methadone: treatment retention and opiate use.

AIMS: To compare the effects of levo-alpha-acetylmethadol (LAAM) and methadone maintenance (MM) on treatment retention and abstinence from opiate use. DESIGN: A two-group experimental design with patients randomly assigned (2 : 1 LAAM : MM) to receive LAAM (three doses per week) or methadone (daily dosing). SETTING: A community clinic in Los Angeles, California. PARTICIPANTS: A total of 315 patients seeking LAAM or methadone maintenance. INTERVENTION: LAAM or methadone maintenance, plus ancillary services available to all patients. LAAM and methadone dose levels varied according to clinical judgement. Electrocardiograms were administered to LAAM patients monthly. MEASUREMENTS: Treatment status at 26-week follow-up and number of days retained in treatment, weekly clinical urine tests and 26-week research urine test. FINDINGS: LAAM and methadone patients did not differ on treatment retention. LAAM patients were less likely to test positive for opiate use during treatment (40% versus 60%) and at 26-week follow up (39.8% versus 60.2%). Benefits of LAAM were confined to patients (n = 204) still in treatment at 26 weeks (33% positive in patients receiving LAAM and 61% in patients receiving methadone). No adverse events, cardiological or otherwise, were observed with LAAM administration. CONCLUSIONS: LAAM is an effective medication for the treatment of opiate dependence with clinical advantages due not only to the reduction of opiate use but also to the alternate-day dosing schedule. LAAM may be more effective than methadone in promoting abstinence from opiate use among patients for whom LAAM is an acceptable alternative to methadone.

Methamphetamine treatment: trends and predictors of retention and completion in a large state treatment system (1992-2002).

This report describes trends in treatment admissions for methamphetamine/amphetamine (MA) abuse from 1992 to 2002 in California and assesses predictors of treatment retention and completion. Results show such admissions increasing fivefold and representing a growing proportion of overall treatment admissions. Patients admitted for MA abuse were increasingly diverse in race/ethnicity, older in age, and more frequently under legal supervision status over time. There was a decrease in injection drug use. Several user characteristics played consistent roles as risk factors for noncompletion and shorter treatment retention for both residential and outpatient admissions: having lower than a high school education, being younger at treatment admission, having a disability, having greater severity of MA use, and using injection drugs. Consistently, those with legal supervision status at admission had higher completion rates and longer retention than those reporting no legal status. Overall, findings suggested that clients with greater socioeconomic disadvantage and more severe problems may require greater efforts (e.g., services) to be retained in treatment.

A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence.

AIMS: The Center for Substance Abuse Treatment (CSAT) Methamphetamine Treatment Project (MTP) is the largest randomized clinical trial of treatments for methamphetamine (MA) dependence to date. The objective of the study was to compare the Matrix Model, a manualized treatment method, with treatment-as-usual (TAU) in eight community out-patient settings in the Western United States. DESIGN: Over an 18-month period between 1999 and 2001, 978 treatment-seeking, MA-dependent people were randomly assigned to receive either TAU at each site or a manualized 16-week treatment (Matrix Model). SETTING: The study was conducted as an eight-site out-patient trial, with six sites located in California and one each in Montana and Hawaii. FINDINGS: In the overall sample, and in the majority of sites, those who were assigned to Matrix treatment attended more clinical sessions, stayed in treatment longer, provided more MA-free urine samples during the treatment period and had longer periods of MA abstinence than those assigned to receive TAU. Measures of drug use and functioning collected at treatment discharge and 6 months post-admission indicate significant improvement by participants in all sites and conditions when compared to baseline levels, but the superiority of the Matrix approach did not persist at these two timepoints. CONCLUSIONS: Study results demonstrate a significant initial step in documenting the efficacy of the Matrix approach. Although the superiority of the Matrix approach over TAU was not maintained at the post-treatment timepoints, the in-treatment benefit is an important demonstration of empirical support for this psychosocial treatment approach.