A critical component of the continuum of care for substance use disorders: recovery homes in Philadelphia.

For many struggling with addiction, the ability to achieve stable recovery is often jeopardized by untenable housing or unsupportive living environments. Despite promising research on recovery residences, there are still significant gaps in the research on them. Using data collected from a stratified random sample of recovery homes in Philadelphia (N = 25), this study describes the organizational, operational, and programmatic characteristics of these homes and explores potential differences in these characteristics by funding source and gender of residents served. Although not licensed treatment providers, the majority of these homes operated in a recovery-oriented manner and offered a range of different services to their residents-all for a reasonable monthly fee (M = $340.40, SE = 18.60). Few differences emerged between homes that received funding from the Philadelphia Office of Addiction Services and those that did not or between those that served males as opposed to females. More research is needed to address resident outcomes and how Philadelphia recovery homes may compare with recovery residences in other parts of the country.

Assessing Adolescent Substance Abuse Programs with Updated Quality Indicators: The Development of a Consumer Guide for Adolescent Treatment.

When adolescent substance abuse requires treatment, few parents know which treatment features are important and which treatment programs are effective. There are few resources to help them select appropriate care. We describe early work on an evaluation method and comparative treatment guide for parents based upon the premise that the quality of a program and its potential effectiveness is a function of the number and frequency of evidence-based treatment practices (EBPs) delivered. Thus, we describe the development of and measurement approach for a set of EBPs toward the goal of developing a Consumer Guide to Adolescent Substance Abuse Treatment.

National Trends in Adolescent Substance Use Disorders and Treatment Availability: 2003-2010.

This study examines trends in adolescent substance use disorders (SUDs) and treatment utilization in the US using data from the National Household Survey on Drug Use and Health (NSDUH) and data from the National Survey of Substance Abuse Treatment Services (N-SSATS). Results indicate an overall decrease in the percent of adolescents meeting past year criteria for an alcohol or illicit drug disorder between 2003 and 2010, but the percent of adolescents meeting criteria who had not received any treatment in the past year was substantial and has remained stable since 2003. In 2010, less than 30% of facilities participating in the N-SSATS survey indicated that they offered special programming for adolescents, reflecting an overall decrease since 2003.

Compliance with buprenorphine medication-assisted treatment and relapse to opioid use.

Opioid dependence (OD), often characterized as a chronic relapsing disorder, affects millions of people worldwide. The purpose of this study was to examine the effect of compliance with buprenorphine on reducing relapse among a sample of patients in treatment for OD. Patients new to buprenorphine (N = 703) completed the Addiction Severity Index (ASI) at baseline, and at 1, 2, and 3 months postbaseline. The ASI is a semistructured interview designed to measure problem severity in seven functional areas known to be affected by alcohol and drug dependence. Compliance was defined as taking buprenorphine medication on at least 22 of the past 28 days (80%), while relapse classification was based on resumed use of opioids during the follow-up period (months 2 and 3). Relapse was regressed onto demographic indicators, baseline ASI composite scores, and compliance with buprenorphine. Noncompliant patients were over 10 times more likely to relapse than those who were compliant (exp ß= 10.55; p < .001). Neither demographics nor baseline ASI composite scores were predictive of relapse (p's > .05). Compliance with medication-assisted treatment supports abstinence, essential for patient recovery. Understanding the factors that drive treatment compliance and noncompliance may assist providers in supporting patient compliance and recovery.

Relationship of Mental Health and Illness in Substance Abuse Patients.

This study examined the latent structure of a number of measures of mental health (MH) and mental illness (MI) in substance use disorder outpatients to determine whether they represent two independent dimensions, as Keyes (2005) found in a community sample. Seven aspects of MI assessed were assessed - optimism, personal meaning, spirituality/religiosity, social support, positive mood, hope, and vitality. MI was assessed with two measures of negative psychological moods/states, a measure of antisociality, and the Addiction Severity Index's recent psychiatric and family-social problem scores. Correlational and exploratory factor analyses revealed that MH and MI appear to reflect two independent, but correlated, constructs. However, optimism and social support had relatively high loadings on both factors. Antisociality and the family-social problem score failed to load significantly on the MI factor. Confirmatory factor analysis supported the existence of two obliquely related, negatively correlated dimensions. Study findings, although generally supporting the independence of MH and MI, suggest that the specific answers to this question may be influenced by the constructs and assessments used to measure them.

Treatment history: relationship to treatment outcomes.

It is important to understand whether the number of prior treatment episodes relate to treatment completion, discharge status, and 6-month outcomes. The data set contains information on 2,429 clients in treatment. A modified Addiction Severity Index was administered at the time of admission and at 6-months postdischarge. Additionally, length of stay and discharge status data were obtained. ANOVAs, MANOVAs, and chi(2) tests were used. Clients with the most prior treatment episodes had greater baseline substance use and psychosocial severity, and were more likely to be treated in residential settings. Nonetheless, treatment acceptance was greatest for these clients. Clients with no prior treatment reported the least acceptance. Treatment completion rates did not vary as a function of treatment experience. Clients achieved positive changes in multiple life domains regardless of treatment history. Nevertheless, at admission, discharge and follow-up, clients with >or= 2 treatments generally had greater problems than clients with fewer treatments.

Initial reliability and validity studies of the revised Treatment Services Review (TSR-6).

OBJECTIVE: Report the results of initial reliability and validity analyses for a revised Treatment Services Review (TSR-6) instrument which measures a broader range of services than the original TSR. METHOD: First, the number of services for a 28-day period was compared for three versions of the instrument varying in their reporting timeframes. Accordingly, four successive 7-day TSR-6s, two 14-day TSR-6s, or one 28-day TSR-6 were administered to more than 300 clients (30% women) in substance abuse treatment (SAT). Second, short-term (2-5 days) test-retest reliabilities were compared for an initial 7-, 14-, or 28-day version of the TSR-6. Third, test-retest reliabilities were compared when an initial in-person (IP) administration was followed by either IP or telephone (TEL) TSR-6 administration. Finally, preliminary discriminative validity analyses were conducted. RESULTS: Few differences in the quantity of services reported for a 4-week period were found with versions of the TSR-6 that used different timeframes. Also, comparisons of test-retest reliabilities for the different version of the TSR-6 revealed few differences. Test-retest reliabilities were generally comparable for the IP-TEL and IP-IP conditions. Finally, analyses demonstrated preliminary discriminative validity for the instrument when services for three distinctive forms of treatment: intensive outpatient, methadone and residential were compared. CONCLUSIONS: The findings of this study support the reliability and validity of the TSR-6 and suggest that a version with a 28-day reporting period can provide information comparable to that obtained with versions using shorter reporting periods.

Extending residential care through telephone counseling: initial results from the Betty Ford Center Focused Continuing Care protocol.

There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the "real world". This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described.

Initial evidence for the reliability and validity of a "Lite" version of the Addiction Severity Index.

PURPOSE: To evaluate the psychometric properties of a shortened version of the baseline ASI-5, the ASI-L-VA. METHOD: Two samples were recruited from intensive outpatient treatment and a methadone maintenance clinic. For Sample A (n=145), two versions of the Addiction Severity Index (i.e., ASI-5 and ASI-L-VA) were administered several days apart in counterbalanced order by different interviewers. Sample B (n=50) was similarly administered the standard ASI-5 twice. RESULTS: For Sample A, the internal consistency (coefficient alphas) of 11 of 19 summary scores derived from the ASI-5 were good, 4 fair, and 4 unacceptable. The results for the ASI-L-VA summary scores indicated that eight were good, six fair, and five unacceptable. The correlations between ASI problem areas were generally low for both versions (supporting the independence of the ASI areas), and none of the t-tests comparing corresponding correlations between the ASI-5 and ASI-L-VA approached statistical significance. The Sample A intraclass correlation coefficient (ICC) results evaluating agreement of the summary scores derived from the ASI-5 at one timepoint and those derived from ASI-L-VA at another point (i.e., concurrent validity) revealed at least fair agreement in all but one instance. Additionally, a comparison of the ICC results for Samples A and B (i.e., ASI-L-VA/ASI-5 versus ASI-5/ASI-5, respectively) revealed that in 13 of 26 cases the ICCs were at the same level of agreement. When level of agreement was discordant, in nine cases the ICCs comparing the ASI-5 and ASI-L-VA exhibited greater agreement and in four cases the ICCs comparing two ASI-5 administrations exhibited greater agreement. CONCLUSIONS: The ASI-L-VA, a reduced item set from the ASI-5, yielded similar information on problem severity as the standard ASI-5.

Addiction Severity Index Recent and Lifetime summary indexes based on nonparametric item response theory methods.

Baseline Addiction Severity Index (5th ed.; ASI-5) data of 2,142 substance abuse patients were analyzed with two nonparametric item response theory (NIRT) methods: Mokken scaling and conditional covariance techniques. Nine reliable and dimensionally homogeneous Recent Problem indexes emerged in the ASI-5's seven areas, including two each in the Employment/Support and Family/Social Relationships areas. Lifetime Problem indexes were derived for five of the areas--Medical, Drug, Alcohol, Legal, and Psychiatric--but not for the Employment/Support and Family/Social Relationships areas. Correlational analyses conducted on a subsample of 586 patients revealed the indexes for the seven areas to be largely independent. At least moderate correlations were obtained between the Recent and Lifetime indexes within each area where both existed. Concurrent validity analyses conducted on this same subsample found meaningful relationships, except for the Employment/Support area. NIRT-based methods were able to add to findings produced previously by classical psychometric methods and appear to offer promise for the psychometric analysis of complex, mixed-format instruments such as the ASI-5.

Predicting DSM-IV dependence diagnoses from Addiction Severity Index composite scores.

This study, using data from the Drug Evaluation Network System and a study conducted through the Center for Studies on Addiction of the University of Pennsylvania/Philadelphia Veterans Administration Medical Center, sought to determine the potential of the Addiction Severity Index (ASI) to serve as a screening instrument for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) substance dependence. A significant positive correlation was found between ASI composite scores (CSs) and DSM-IV diagnoses of dependence in both the alcohol (r > .7) and drug (r > .5) domains (p < .01). Receiver operating characteristic analyses were run to predict DSM-IV alcohol and drug dependence diagnoses from the respective ASI CSs. Results showed good to strong prediction; ASI CSs identified dependent clients with approximately 85% sensitivity and 80% specificity. We recommend strategies for using ASI CSs as a diagnostic screening instrument in both research and treatment delivery environments.

Reconsidering the evaluation of addiction treatment: from retrospective follow-up to concurrent recovery monitoring.

Historically, addiction treatments have been delivered and evaluated under an acute-care format. Fixed amounts or durations of treatment have been provided and their effects evaluated 6-12 months after completion of care. The explicit expectation of treatment has been enduring reductions in substance use, improved personal health and social function, generally referred to as 'recovery'. In contrast, treatments for chronic illnesses such as diabetes, hypertension and asthma have been provided for indeterminate periods and their effects evaluated during the course of those treatments. Here the expectations are for most of the same results, but only during the course of continuing care and monitoring. The many similarities between addiction and mainstream chronic illnesses stand in contrast to the differences in the ways addiction is conceptualized, treated and evaluated. This paper builds upon established methods of during-treatment evaluation developed for the treatment of other chronic illnesses and suggests a parallel evaluation system for out-patient, continuing-care forms of addiction treatment. The suggested system retains traditional patient-level, behavioral outcome measures of recovery, but suggests that these outcomes should be collected and reported immediately and regularly by clinicians at the beginning of addiction treatment sessions, as a way of evaluating recovery progress and making decisions about continuing care. We refer to this paradigm as 'concurrent recovery monitoring' and discuss its potential for producing more timely, efficient, clinically relevant and accountable evaluations.

Treatment outcomes: first time versus treatment-experienced clients.

A sample of treatment seeking clients was assessed at intake and 6, 12, 24 and 30 months later. Treatment-naive and treatment-experienced clients were compared in terms of baseline characteristics, 6-month outcomes, and predictors of these outcomes. Long-term outcomes of clients achieving an initially successful outcome were compared for the two groups. Results revealed significant short-term improvement for both groups, although treatment-experienced clients reported more serious drug use. The most consistent significant predictors of substance use outcomes were baseline severity of substance use and self-help participation. Outcome predictors unique to each group were also identified. Long-term outcomes for clients with an initial successful outcome tended to be better for treatment-experienced than treatment-naive clients. Both groups tended to have poorer outcomes as the follow-up duration increased. The results suggest that common and unique predictors of outcomes be considered in treating these two groups of clients. Additionally, treatment-naive clients may be at increased risk for poor outcomes even when initial success is achieved.

Using Web searches to track interest in synthetic cannabinoids (a/k/a 'herbal incense').

INTRODUCTION AND AIMS: This article reports a content analysis of Internet websites related to an emerging designer drug, synthetic cannabinoids. The number of synthetic cannabinoids searchers in the USA has steadily increased from November 2008 to November 2011. DESIGN AND METHODS: To determine the information available on the Internet in relation to synthetic cannabinoids, sites were identified using the Google search engine and the search term 'herbal incense'. The first 100 consecutive sites were visited and classified by two coders. The websites were evaluated for type of content (retail, information, news, other). US unique monthly visitor data were examined for the top 10 retail sites, and these sites were coded for the quality of information available regarding the legality of synthetic cannabinoids sale and use. RESULTS: The Google search yielded 2,730,000 sites for 'herbal incense' (for comparison of search terms: 'synthetic marijuana', 1,170,000; 'K2 Spice', 247,000; and 'synthetic weed', 122,000). Moreover, in the Google search, 87% of the sites were retail sites, 5% news, 4% informational and 4% non-synthetic cannabinoid sites. DISCUSSION AND CONCLUSIONS: Many tools found within Google free services hold promise in providing a technique to identify emerging drug markets. We recommend continued surveillance of the Internet using the online tools presented in this brief report by both drug researchers and policy-makers to identify the emerging trends in synthetic drugs' availability and interest.

Effect of patient choice in an adaptive sequential randomization trial of treatment for alcohol and cocaine dependence.

OBJECTIVE: To evaluate the effect of providing choice of treatment alternatives to patients who fail to engage in or drop out of intensive outpatient programs (IOPs) for substance dependence. METHOD: Alcohol- and/or cocaine-dependent patients (N = 500) participated in a sequential, multiple-assignment, randomized trial (SMART). Those who failed to engage in an IOP at Week 2 (N = 189) or who dropped out after engagement (N = 84) were randomized for motivational-interviewing (MI) telephone calls that focused on engagement in an IOP (MI-IOP) or provided a choice of IOP type or 3 treatment options (MI-PC, or patient choice). Those not engaged at both 2 and 8 weeks (N = 102) were re-randomized either to MI-PC or no further outreach. Outcomes were treatment attendance and measures of alcohol and cocaine use obtained at 1, 2, 3, and 6 months. RESULTS: MI-PC produced better attendance than comparison conditions in patients who dropped out after initial engagement and in those re-randomized at 8 weeks. However, contrary to study hypotheses, MI-IOP produced significantly better alcohol-use outcomes than MI-PC in alcohol-dependent patients not engaged at Week 2. There were no other significant differences between treatment conditions on other main-effect analyses with alcohol- or cocaine-outcome measures. CONCLUSION: Providing treatment options via telephone calls to patients who failed to engage in IOP did not produce better substance-use outcomes than outreach calls focused on engagement in IOP. Future researchers should investigate the potential benefits of choice at other points in treatment (e.g., at intake) as well as choice of other combinations of treatments.

Alcohol dependence and abuse in three groups at varying familial alcoholism risk.

Three groups of young men varying in familial alcoholism risk were compared for lifetime and current Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnoses. A withdrawal gate diagnostic model (WGM) requiring withdrawal for a dependence diagnosis was also evaluated. Extremely high lifetime DSM-IV diagnostic rates were found for all groups (> or = 78%), with the highest rate in the highest risk group. Similar group differences obtained for individual criteria or symptoms. Although lifetime diagnostic rates were similar for the WGM and DSM-IV, virtually all cases of dependence were preceded by abuse for the WGM, unlike DSM-IV. The findings underline the importance of distinguishing degrees of familial alcoholism risk. The WGM model temporal onset findings versus DSM-IV and the high lifetime diagnostic rates obtained suggest some limitations of the DSM-IV diagnoses.

The prediction of violent and nonviolent criminal behavior in a methadone maintenance population.

The utility of traits associated with Antisocial Personality Disorder in making risk assessments of violent and nonviolent crimes was examined in 254 subjects sampled from a methadone maintenance population. A factor analysis of a number of baseline measures resulted in five factors measuring hostility, insecure attachment, impaired reality testing, antisocial personality, and empathy. These factors were used in logistic regression analysis to predict charges for violent and nonviolent crimes over a 2-year period. Individuals with high scores on the antisocial personality factor had an increased risk of both violent and nonviolent criminal charges. Individuals with low scores on the empathy factor were at high risk for violent crimes. In an analysis using the factor components rather than the factors, the measures of perspective-taking and a socialization were associated with violent criminal charges, and the measure of psychopathy, but not antisocial behavior, was associated with nonviolent criminal charges. The results support the use of measures of personality traits in addition to measures of a history of antisocial behavior in making violence risk assessments in substance-dependent patients. The DSM construct and diagnosis of Antisocial Personality Disorder may be enhanced by greater emphasis on personality traits associated with antisocial behavior.

The role of family history in addiction severity and treatment response.

This study examined the relationship between familial history of substance use and addiction severity and treatment outcomes of opiate-dependent patients. The sample was comprised of 281 methadone maintenance patients at a VA or community-based clinic. Using the family history section of the Renard Diagnostic Interview, three familial risk groups were identified based on patients' self-report of their relatives' substance use. The three groups considered both the number and type (e.g., first vs. second degree) of biological relatives with a substance use problem. These three risk groups included: (1) high risk (HR, n = 111), (2) medium risk (MR, n = 80), and (3) low risk (LR, n = 90). HR patients reported a history of more severe asocial behavior at baseline and they reported more medical problems and a greater degree of concurrent alcohol use both prior to and after 6 months of treatment compared to LR patients. In addition, the HR group reported more family/social problems at baseline compared to the MR and LR group and both HR and MR patients reported more psychological problems than LR patients after 6 months of treatment. However, when accounting for baseline differences, the regression analyses demonstrated that familial risk was not predictive of drug treatment outcomes after 6 months of methadone maintenance treatment.

Comparison of embedded and isolated administrations of the California Psychological Inventory's Socialization subscale.

Alternate administration methods were tested for the Socialization (So) subscale of the California Psychological Inventory (CPI; H. G. Gough, 1994; H. G. Gough & P. Bradley, 1996) in 437 young adult men. One method administered the 46 CPI-So items in isolation from the CPI, whereas the 2nd method administered the 46 items embedded in the CPI. External validity measures of antisociality were also administered over the 2 sessions. Isolated administration produced somewhat higher internal consistency and significantly better concurrent validity and demonstrated construct validity as a measure of antisociality. Additional factor analytic studies of the CPI-So and CPI revealed that the 2 CPI-So versions had different factorial structures and that the embedded CPI-So subscale did not retain factorial integrity or an appreciable amount of reliable and uniquely interpretable variance.

The long-term outcomes of drug use by methadone maintenance patients.

The aim of the study is to predict long-term outcomes of methadone maintenance (MM), other than continued heroin use, on the basis of drug use occurring early in MM treatment. In previous research, the weak association of initial drug use during MM with measures of rehabilitation status may be due to the use of measures that do not differentiate trends in different types of drug use. In the present study, 222 patients who completed 6 months of MM were assessed at program intake, evaluated for opiates and cocaine in the first 6 months of treatment, and given a follow-up assessment 2 years after treatment entry. The intake status of the patients was assessed using the Addiction Severity Index. Opiate and cocaine use during the first 6 months of MM was assessed by urine toxicology. Outcomes were assessed using a structured interview and official criminal records at follow-up. Cluster analysis of urine toxicologies during treatment identified 3 trajectory classes of MM patients: (A) variably high levels of opiate use, but consistently low cocaine use; (B) low and diminishing opiate and cocaine use; and (C) consistently high cocaine use, with diminishing opiate use. In an 18-month period, after these trends were observed, Cluster C had significantly more criminal charges than Cluster B had (3 times as many), but not significantly more than those of Cluster A. Clusters A and B did not differ significantly in criminal charges. Regardless of cluster membership, subjects with increasing levels of cocaine use in the first 6 months of MM had more hospitalizations for drug and alcohol problems during the follow-up period than subjects without increasing levels of cocaine use had. The results provide evidence of negative sequelae of cocaine use during MM that underscore the importance of clinical efforts to reduce levels of cocaine and other nonopiate drug use by MM patients.