Treatment for drug abuse. Follow-up outcomes and length of time spent.

A sample of 1,496 persons admitted to 26 community treatment agencies participating in the Drug Abuse Reporting Program (DARP) during 1972 and 1973 were located and interviewed in 1978 and 1979. Favorableness of one-year posttreatment outcomes with respect to illicit drug use, criminality, and employment and other productive activities was found to increase linearly with the length of time patients stayed in methadone maintenance, a therapeutic community, or outpatient drug-free treatment. In addition, follow-up outcome for persons who spent less than three months in treatment was least favorable, and was not significantly different from that of persons in outpatient detoxification programs or who were admitted but not treated (intake-only). Persons who completed treatment generally stayed in treatment longer, as expected; they also had a more favorable outcome after DARP treatment than did others.

Drug abuse treatment readmissions and outcomes. Three-year follow-up of DARP patients.

Temporal patterns of drug abuse treatment reentry and other outcome measures were examined over a three-year period based on a national follow-up sample of persons admitted to treatment in the Drug Abuse Reporting Program (DARP) during 1969 to 1972. Follow-up treatment modes included methadone maintenance, residence in a therapeutic community, outpatient drug-free treatment, outpatient detoxification treatment, and a comparison group whose members completed intake only and did not return for treatment in the DARP. Treatment readmission patterns were examined in relation to outcome measures for illicit drug use, alcohol use, employment, and criminality over time. The findings showed there were reliable associations between readmission patterns and posttreatment outcomes, which suggested there were beneficial effects of drug abuse treatment.

Follow-up evaluation of treatment of drug abuse during 1969 to 1972.

A sample of 3,131 persons from approximately 25,000 admitted to drug abuse treatment programs in the Drug Abuse Reporting Program during 1969-1972 were followed up in 1975-1976. Treatment groups included methadone hydrochloride maintenance, therapeutic community, outpatient drug free, outpatient detoxification, and a comparison group that completed intake but did not enter treatment. Outcome criterion measures (drug use, employment, criminality, and treatment readmissions) based on the first year after treatment were more favorable in the methadone maintenance, therapeutic community, and outpatient drug-free groups than in the outpatient detoxification and intake-only groups. Evaluation of differential outcomes and their relationships with pretreatment and during-treatment measures within each group indicated that pretreatment criminal history, during-treatment performance, and length of time in treatment were significantly related to posttreatment outcomes.

Six-year follow-up of opioid addicts after admission to treatment.

Long-term behavioral outcome status of 990 daily opioid users, recorded in follow-up interviews about six years after admission to community-based treatment programs, was classified in terms of longitudinal patterns of opioid use. Sixty-one percent of these individuals had achieved abstinence from opioid drugs for a year or longer immediately before the follow-up interview. Compared with those who continued heavy opioid drug use, and with others who had problems with nonopioid drugs or alcohol over time, persons who achieved abstinence also had significantly better long-term outcomes on criminality, use of nonopioid drugs and alcohol, and productive activities. Except for criminal history, outcome status was generally unrelated to client demographic and background predictors, but behavioral improvements over time were strongly associated with participation in drug abuse treatment.

A national evaluation of treatment outcomes for cocaine dependence.

BACKGROUND: This national study focused on posttreatment outcomes of community treatments of cocaine dependence. Relapse to weekly (or more frequent) cocaine use in the first year after discharge from 3 major treatment modalities was examined in relation to patient problem severity at admission to the treatment program and length of stay. METHODS: We studied 1605 cocaine-dependent patients from 11 cities located throughout the United States using a naturalistic, nonexperimental evaluation design. They were sequentially admitted from November 1991 to December 1993 to 55 community-based treatment programs in the national Drug Abuse Treatment Outcome Studies. Included were 542 patients admitted to 19 long-term residential programs, 458 patients admitted to 24 outpatient drug-free programs, and 605 patients admitted to 12 short-term inpatient programs. RESULTS: Of 1605 patients, 377 (23.5%) reported weekly cocaine use in the year following treatment (dropping from 73.1% in the year before admission). An additional 18.0% had returned to another drug treatment program. Higher severity of patient problems at program intake and shorter stays in treatment (<90 days) were related to higher cocaine relapse rates. CONCLUSIONS: Patients with the most severe problems were more likely to enter long-term residential programs, and better outcomes were reported by those treated 90 days or longer. Dimensions of psychosocial problem severity and length of stay are, therefore, important considerations in the treatment of cocaine dependence. Cocaine relapse rates for patients with few problems at program intake were most favorable across all treatment conditions, but better outcomes for patients with medium- to high-level problems were dependent on longer treatment stays.

The relation of time spent in drug abuse treatment to posttreatment outcome.

The author examined follow-up outcomes in the first year after treatment in relation to time spent in treatment in the Drug Abuse Reporting Program. Follow-up interviews were completed with more than 3,000 people admitted to drug abuse treatment during 1969--1972, including clients treated with methadone maintenance, therapeutic communities, outpatient drug-free programs, and outpatient detoxification, as well as a group who completed intake procedures but did not return for treatment. Longer time in treatment was related to better posttreatment outcome, but clients who spent less than 3 months in treatment were not significantly different from the detoxification-only group or the intake-only group.

Diagnostic value of brush cytology in the diagnosis of duodenal, biliary, and ampullary neoplasms.

Endoscopy is a valuable tool in the diagnosis and management of duodenal lesions and biliary strictures. We assessed the value of cytology in the evaluation of these lesions and analyzed the causes of discrepancy among clinical, histologic, and cytologic parameters. The study included 118 patients with duodenal ulcers, ampullary neoplasms, or biliary strictures who were examined between 1975 and 1995; 120 cytologic examinations were performed. The specimens included brushings of the duodenum (DB, n = 50), ampulla (AB, n = 32), and biliary ducts (BB, n = 38). Endoscopic biopsies performed concurrently included the duodenum (n = 37), the ampulla (n = 22), and the biliary ducts (n = 23). Comparison of cytologic and histologic results showed the following sensitivity and specificity: DB, 40% and 97%, respectively; AB, 100% each; BB, 75% and 93%, respectively. The DB, AB, and BB revealed malignant neoplasms in 2 of 5, 7 of 7, and 6 of 8 cases, respectively. Twenty-three duodenal neoplasms were diagnosed by either modality and included 11 adenocarcinomas, 9 villous tumors, 2 metastatic renal cell carcinomas, and 1 large cell non-Hodgkin's lymphoma. Endoscopic brush cytology is an effective means of diagnosing ampullary neoplasms, and it complements tissue biopsy in cases of bile duct stricture. Location, predominance of tumor-induced stroma, an extramucosal growth pattern, sampling error, and interpretative experience influence the diagnostic evaluation. Cytologic diagnosis of an adenoma does not exclude an underlying malignant neoplasm in ampullary tumors. In some instances, it may be difficult to distinguish between villous tumors with severe dysplasia and adenocarcinomas by cytology alone.

Prison-based substance abuse treatment, residential aftercare and recidivism.

AIMS: This study examined the impact of residential aftercare on recidivism following prison-based treatment for drug-involved offenders. DESIGN: A matched group quasi-experimental design. Survival regression analyses were used to predict time until rearrest. A logistic regression model was constructed for predicting aftercare completion. SETTING: A 9-month in-prison therapeutic community (ITC) and several community-based transitional therapeutic communities (TTCs). PARTICIPANTS: Data were collected from 396 male inmates (293 treated, 103 untreated). MEASUREMENTS: Background information (gender, ethnicity, age, education level, criminal history and risk for recidivism) was abstracted from the state criminal justice databases and a structured interview led by clinical staff. During treatment process measures were based on inmate self-ratings of their counselors, program and peers. A post-treatment interview conducted by field research staff assessed satisfaction with transitional aftercare. Post-release recidivism was based on state-maintained computerized criminal history records. FINDINGS: ITC treatment, especially when followed by residential aftercare, was effective for reducing post-release recidivism rates. Lower satisfaction with transitional aftercare treatment was associated with not completing the residential phase of community-based aftercare. CONCLUSIONS: Corrections-based treatment policy should emphasize a continuum of care model (from institution to community) with high quality programs and services.

Effects of readiness for drug abuse treatment on client retention and assessment of process.

AIMS: This study examined client motivation as a predictor of retention and therapeutic engagement across the major types of treatment settings represented in the third national drug abuse treatment outcome study (DATOS) conducted in the United States. DESIGN: Sequential admissions during 1991-93 to 37 programs provided representative samples of community-based treatment populations. Based on this naturalistic non-experimental evaluation design, hierarchical linear model (HLM) analysis for nested data was used to control for systematic variations in retention rates and client attributes among programs within modalities. SETTING: The data were collected from long-term residential (LTR), outpatient methadone (OMT) and outpatient drug-free (ODF) programs located in 11 large cities. PARTICIPANTS: A total of 2265 clients in 18 LTR, 981 clients in 13 OMT and 1791 clients in 16 ODF programs were studied. MEASUREMENTS: Pre-treatment variables included problem recognition and treatment readiness (two stages of motivation), socio-demographic indicators, drug use history and dependence, criminality, co-morbid psychiatric diagnosis and previous treatment. Retention and engagement (based on ratings of client and counselor relationships) served as outcome criteria. FINDINGS: Pre-treatment motivation was related to retention in all three modalities, and the treatment readiness scale was the strongest predictor in LTR and OMT. Higher treatment readiness also was significantly related to early therapeutic engagement in each modality. CONCLUSIONS: Indicators of intrinsic motivation--especially readiness for treatment--were not only significant predictors of engagement and retention, but were more important than socio-demographic, drug use and other background variables. Improved assessments and planning of interventions that focus on stages of readiness for change and recovery should help improve treatment systems.

HIV risks, gender, and cocaine use among opiate users.

HIV risks involving injection and sex behaviors were analyzed in relation to cocaine use and gender among 487 opiate-dependent clients in methadone treatment. Those who also used cocaine were at greater risk than non-cocaine users on HIV risky injection variables. Females were at more risk than males on the HIV risky sex behaviors involving unprotected sex in exchange for money or drugs and with injection users. There were interactions between cocaine use and gender, however, in relation to frequency of injecting with dirty works and sharing dirty works with strangers, as well as having unprotected sex for money or drugs, with injection users, and while intoxicated. HIV risks increased as a direct function of cocaine usage level among males, but not among females; instead, low-to-intermediate levels of cocaine use by females was associated with high-risk behaviors. Implications for HIV risk reduction interventions in drug treatment programs are discussed.

Drug abuse treatment retention and process effects on follow-up outcomes.

After finding that retention in methadone treatment for a year or longer was a highly significant predictor of patient outcomes following discharge, measures of pretreatment motivation and early therapeutic engagement were examined as predictors of program retention. Personal interviews were conducted with a sample of 435 patients 12 months after discharge from three methadone treatment programs. Logistic regression results showed several patient attributes--i.e. over 35, lower injection frequency before admission, and higher motivation for treatment--were each associated with twofold increases in the likelihood of having favorable follow-up outcomes on illicit drug use, alcohol use, and criminal involvement. Patients staying in treatment a year or longer, however, were nearly five times more likely to have better outcomes. Further analyses established that length of treatment stay was predicted by higher patient motivation at intake and early program involvement. The findings suggest that more comprehensive models of patient attributes, therapeutic process, and environmental influences are needed, and that treatment enhancement efforts should focus on such during-treatment measures as interim criteria for improving posttreatment outcomes.

Retention and patient engagement models for different treatment modalities in DATOS.

A model to explain treatment retention in terms of process components--therapeutic involvement and session attributes for the 1st month--and patient background factors were tested in long-term residential (LTR), outpatient drug free (ODF), and outpatient methadone (OMT) treatments. The data was collected in the national Drug Abuse Treatment Outcome Studies (DATOS), and included 1362 patients in LTR, 866 in ODF, and 981 in OMT programs. Structural equation models showed there were positive reciprocal effects between therapeutic involvement and session attributes in all three modalities, and these variables had direct positive effects on treatment retention. Motivation at intake was a strong determinant of therapeutic involvement. Other patient background factors were significantly related to retention, including pretreatment depression, alcohol dependence, legal pressure, and frequency of cocaine use.

Patient and program attributes related to treatment process indicators in DATOS.

Patient ratings of their personal confidence in treatment and commitment to recovery were examined in a national sample of long-term residential, outpatient drug-free, and outpatient methadone programs. It was found that patients expressing greater confidence and commitment after 3 months of treatment generally began with higher motivation at intake, had formed better rapport with counselors, and attended counseling sessions more frequently. In addition, overall levels of patient involvement (as indicated by confidence and commitment) varied across programs; those programs with higher average involvement by patients used more social and public health services, maintained more consistent attendance at counseling sessions, and served patients who collectively had more similar kinds of needs. Thus, patient and program attributes both play a role in determining therapeutic engagement of persons who enter drug treatment.

Gender, cocaine and during-treatment HIV risk reduction among injection opioid users in methadone maintenance.

HIV risk behavior was examined in relation to gender and cocaine use among a sample of 327 daily opioid users in methadone maintenance treatment. Women and cocaine users tended to be at higher risk than men and non-users prior to treatment entry. Significant reductions in both injection and sex-related risks occurred from intake to months 3 and 6 of treatment; HIV risks were also reduced among the subsample of clients who continued to inject drugs during treatment. The rate of HIV risk reduction was similar for both cocaine and non-cocaine users, but women had lower rates of risk reduction than men in terms of injecting with used equipment and number of sex partners. Measures of risk behavior at month 6 of treatment showed that women used 'dirty works' more often than men, and cocaine users injected more frequently and had more sex partners than non-cocaine users. Study outcomes highlight the need for specialized interventions targeting women and cocaine-using opioid addicts.

Contingency management in outpatient methadone treatment: a meta-analysis.

A meta-analysis was conducted on contingency management interventions in outpatient methadone treatment settings. The outcome measure of interest was drug use during treatment, as detected through urinalysis. The results confirm that contingency management is effective in reducing supplemental drug use for these patients. The analysis of behavioral interventions yielded an overall effect size (r) of 0.25 based on 30 studies. Significant moderators of outcomes included type of reinforcement provided, time to reinforcement delivery, the drug targeted for behavioral change, number of urine specimens collected per week, and type of subject assignment. These factors represent important considerations for reducing drug use during treatment.

Maintenance of HIV risk reduction among injection opioid users: a 12 month posttreatment follow-up.

Study objectives were to examine HIV risk behaviors 12 months following methadone maintenance (MM) treatment termination, and to assess the effects of treatment tenure, cocaine use, and gender on posttreatment HIV risk. Injection and sex risk behaviors were measured at treatment entry and 12 months after leaving treatment among 435 injection opioid users. Multi-way contingency tables for treatment tenure and HIV risk at treatment intake and at 12 month follow-up were analyzed using the GSK weighted least-squares estimation procedure. The effects of treatment tenure, gender, and cocaine use on risk behavior at follow-up, while controlling for intake risk and background variables were tested using a series of multiple logistic regression analyses. Results showed that injection and sex risk behaviors were significantly lower at 12 month follow-up than at treatment entry. Additionally, increased tenure was related to risk reductions, while cocaine use was related to increased risk-taking. Gender was generally unrelated to risk changes. These findings support broader use of MM in helping reduce HIV risks among injection drug users and highlight the need to explore ways to encourage treatment compliance in order to reduce risky practices.

Psychiatric comorbidity measures as predictors of retention in drug abuse treatment programs.

OBJECTIVE: To examine lifetime and current psychiatric comorbidity measures as predictors of drug abuse treatment retention, and to test the generalizability of results across treatment agencies in diverse settings and with varying practices. DATA SOURCES/STUDY SETTING: The national Drug Abuse Treatment Outcome Studies (DATOS), a longitudinal study of clients from 96 treatment agencies in 11 U.S. cities. STUDY DESIGN: The design is naturalistic and uses longitudinal analysis of treatment retention in long-term residential, outpatient drug-free, and outpatient methadone treatment modalities; client background (including psychiatric comorbidity) and program service provision are predictors. Clinical thresholds for adequate treatment retention were 90 days for long-term residential and outpatient drug-free, and 360 days for outpatient methadone. Psychiatric indicators included lifetime DSM-III-R diagnoses of depression/anxiety and antisocial personality, and dimensional measures of current symptoms for depression and hostility. DATA COLLECTION/EXTRACTION METHODS: Data include structured interviews with clients, a survey of treatment program administrators, and program discharge records. PRINCIPAL FINDINGS: Dimensional measures of current psychiatric symptoms emerged as better predictors than lifetime DSM-III-R diagnoses. In addition, the predictive association of hostility with retention varied significantly across treatment agencies, both in the long-term residential and outpatient drug-free modalities. Other notable findings were that on-site mental health services in long-term residential programs were associated with better retention for clients with symptoms of hostility. CONCLUSIONS: Assessment issues and stability of results across programs are important considerations for treatment research and practice.

Psychosocial correlates of AIDS-risk drug use and sexual behaviors.

Theoretical and empirical research suggests psychosocial functioning is important in drug abuse intervention strategies, especially those focusing on efforts to change AIDS risk behaviors. Self-esteem, depression, anxiety, proneness to risk taking, decision-making confidence, self-assessment of drug use problems, and desire for help with drug problems, along with personal background and health history indicators, were assessed for 194 injection drug users in an AIDS prevention outreach program in New Orleans. Composite index scores for needle risk behaviors were associated with low self-esteem and low decision-making confidence as well as with higher scores on depression, anxiety, drug use problems, and desire for help. However, these psychosocial measures were not significantly related to the composite index for sex risks. Health history measures, represented by previous exposures to hepatitis and sexually transmitted diseases, were significantly related to both needle and sex risk indices. Implications for AIDS intervention efforts are discussed.

HIV risk reduction in outpatient drug abuse treatment: individual and geographic differences.

In the national Drug Abuse Treatment Outcome Studies (DATOS), many clients in outpatient methadone treatment (OMT) and outpatient drug-free (ODF) modalities were admitted with multiple sex and needle-risk behaviors, but they reduced these risks significantly during treatment. Using hierarchical linear model regression analysis, we examined client and treatment program characteristics as predictors of initial risk levels and of reductions over time. Clients who used cocaine frequently before treatment or had antisocial personality disorder entered treatment with elevated risks. In both modalities, cocaine users reduced risky behaviors significantly, but antisocial clients did so only in OMT. Treatment programs located in cities with higher prevalence rates of HIV/AIDS admitted clients with lower baseline levels of risk behavior than found in other cities. OMT programs in lower prevalence cities achieved higher rates of risk reduction than programs in higher prevalence cities. Reduction of sex and needle risks in both the OMT and ODF modalities indicates the importance of outpatient drug abuse treatment to national HIV prevention policy.

Assessment of an AIDS intervention program during drug abuse treatment.

Since 1985, many drug abuse treatment centers and health care providers have implemented special education programs for individuals who inject drugs. They focus primarily on increasing awareness of the threat of the human immunodeficiency virus (HIV) being spread through drug injection equipment and by sexual activities. As part of the Drug Abuse Treatment for AIDS-Risk Reduction (DATAR) project, the AIDS/HIV Risk Reduction Module was designed to meet these special intervention needs. This study examined program impact on 110 methadone treatment clients. Results indicated that for those in treatment less than 4 months, the AIDS intervention program enhanced specialized knowledge about AIDS, aided in the reduction of AIDS-risky behaviors, and enhanced attitudes toward achieving and maintaining abstinence from drug use. Thus, AIDS education and intervention programs appear to be effective and should be emphasized in the early phase of drug abuse treatment.