What Happens After Treatment? Long-Term Effects of Continued Substance Use, Psychiatric Problems and Help-Seeking on Social Status of Alcohol-Dependent Individuals.

PURPOSE: We examined whether alcohol-dependent individuals with sustained substance use or psychiatric problems after completing treatment were more likely to experience low social status and whether continued help-seeking would improve outcomes. SHORT SUMMARY: Ongoing alcohol, drug and psychiatric problems after completing treatment were associated with increased odds of low social status (unemployment, unstable housing and/or living in high-poverty neighborhood) over 7 years. The impact of drug problems declined over time, and there were small, delayed benefits of AA attendance on social status. METHOD: Alcohol-dependent individuals sampled from public and private treatment programs (N = 491; 62% male) in Northern California were interviewed at treatment entry and 1, 3, 5 and 7 years later. Random effects models tested relationships between problem severity (alcohol, drug and psychiatric problems) and help-seeking (attending specialty alcohol/drug treatment and Alcoholics Anonymous, AA) with low social status (unemployment, unstable housing and/or living in a high-poverty neighborhood) over time. RESULTS: The proportion of participants experiencing none of the indicators of low social status increased between baseline and the 1-year follow-up and remained stable thereafter. Higher alcohol problem scores and having any drug and/or psychiatric problems in the years after treatment were associated with increased odds of low social status over time. An interaction of drug problems with time indicated the impact of drug problems on social status declined over the 7-year period. Both treatment-seeking and AA attendance were associated with increased odds of low social status, although lagged models suggested there were small, delayed benefits of AA attendance on improved social status over time. CONCLUSION: Specialty addiction treatment alone was not sufficient to have positive long-term impacts on social status and social integration of most alcohol-dependent people.

Costs of day hospital and community residential chemical dependency treatment.

BACKGROUND: Patient placement criteria developed by the American Society of Addiction Medicine (ASAM) have identified a need for low-intensity residential treatment as an alternative to day hospital for patients with higher levels of severity. A recent clinical trial found similar outcomes at social model residential treatment and clinically-oriented day hospital programs, but did not report on costs. AIMS: This paper addresses whether the similar outcomes in the recent trial were delivered with comparable costs, overall and within gender and ethnicity stratum. METHOD: This paper reports on clients not at environmental risk who participated in a randomized trial conducted in three metropolitan areas served by a large pre-paid health plan. Cost data were collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP). Costs per episode were calculated by multiplying DATCAP-derived program-specific costs by each client's length of stay. Differences in length of stay, and in per-episode costs, were compared between residential and day hospital subjects. RESULTS: Lengths of stay at residential treatment were significantly longer than at day hospital, in the sample overall and in disaggregated analyses. This difference was especially marked among non-Whites. The average cost per week was USD 575 per week at day hospital, versus USD 370 per week at the residential programs. However, because of the longer stays in residential, per-episode costs were significantly higher in the sample overall and among non-Whites (and marginally higher for men). DISCUSSION: These cost results must be considered in light of the null findings comparing outcomes between subjects randomized to residential versus day hospital programs. The longer stays in the sample overall and for non-White clients at residential programs came at higher costs but did not lead to better rates of abstinence. The short stays in day hospital among non-Whites call into question the attractiveness of day hospital for minority clients. CONCLUSION: Outcomes and costs at residential versus day hospital programs were similar for women and for Whites. For non-Whites, and marginally for men, a preference for residential care would appear to come at a higher cost. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Lengths of stay in residential treatment were significantly longer than in day hospital, but costs per week were lower. Women and Whites appear to be equally well-served in residential and day hospital programs, with no significant cost differential. Provision of residential treatment for non-Whites may be more costly than day hospital, because their residential stays are likely to be 3 times longer than they would be if treated in day hospital. For men, residential care will be marginally more costly. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Residential treatment appears to represent a cost-effective alternative to day hospital for female and White clients with severe alcohol and drug problems who are not at environmental risk. IMPLICATIONS FOR FURTHER RESEARCH: The much shorter stays in day hospital than at residential among non-Whites highlight the need for research to better understand how to best meet the needs and preferences of non-White clients when considering both costs and outcomes.

Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients.

Male and female managed care clients randomized to day hospital (n=154) or community residential treatment (n=139) were compared on substance use outcomes at 6 and 12 months. To address possible bias in naturalistic studies, outcomes were also examined for clients who self-selected day hospital (n=321) and for clients excluded from randomization and directed to residential treatment because of high environmental risk (n=82). American Society of Addiction Medicine criteria defined study and randomization eligibility. More than 50% of followed clients reported past-30-day abstinence at follow-ups (unadjusted rates, not significant between groups). Despite differing baseline severities, randomized, self-selecting, and directed clients displayed similar abstinence outcomes in multivariate longitudinal models. Index treatment days and 12-step attendance were associated with abstinence (p<.001). Other prognostic effects (including gender and ethnicity) were not significant predictors of differences in outcomes for clients in the treatment modalities. Although 12-step attendance continued to be important for the full 12 months, treatment beyond the index stay was not, suggesting an advantage for engaging clients in treatment initially and promoting 12-step attendance for at least a year.

Understanding results from randomized trials: use of program- and client-level data to study medical and nonmedical treatment programs.

OBJECTIVE: To address unanticipated results from randomized trials, researchers often focus on client-level data about services received during treatment. Program-level observations can also be helpful, especially in understanding treatment delivered in groups. Using both approaches, this article strives to better understand inconsistent results from a trial comparing medical and nonmedical group-format day treatment. METHOD: Dependent treatment seekers were randomized to a hospital-based medical day-treatment program or to one of two community-based nonmedical day treatment programs. Services received during treatment were captured from clients using the Treatment Services Review (N = 230 subjects; 78 women), and group sessions were observed to measure therapeutic style using an Event Form (N = 48 observations). RESULTS: The trial had found better medical outcomes at the hospital than at either nonmedical program, but most other tests had demonstrated similar outcomes at day hospital and one of the nonmedical sites and worse outcomes (psychiatric, family/social and employment) at the other nonmedical study site. Our analysis of services reported by study participants found a pattern of fewer substance misuse-oriented groups and less serious discussions about medical, psychiatric and family/social problems at the same nonmedical site that had worse outcomes. The way that services were delivered at that site further helped to explain the poorer outcomes there: Groups tended to be more didactic, classroom-like and less discussion-oriented. CONCLUSIONS: Although services received are helpful in explaining treatment outcome, treatment observation adds explanatory value. Without increasing the cost of service provision, programs that rely heavily on didactic approaches might improve their outcomes simply by encouraging more interactive discussions that engage the clients.

Women's programs versus mixed-gender day treatment: results from a randomized study.

AIMS: To compare outcomes and costs of out-patient women's treatment to mixed-gender programs. DESIGN: Randomized clinical trial. SETTING: Northern California (USA). INTERVENTION: Day treatment: one community-based women's program, two mixed-gender community-based programs and one mixed-gender hospital-based program. PARTICIPANTS: Substance-dependent women recruited from the community (n = 122). MEASUREMENTS: Women were interviewed at baseline, at the end of treatment (94% response rate) and at 6 and 12 months post-treatment (100% response rates). Measures included alcohol and drug use, and psychiatric and social problems. Program costs were estimated using the Drug Abuse Treatment Cost Analysis Program. FINDINGS: No significant differences between the women's program and any of the mixed-gender programs were found for psychiatric problem severity, problems with family and friends or rates of drug use at any of the follow-up points. Rates of alcohol abstinence and total abstinence were similar between the women's program and both of the mixed-gender community programs, but were higher at the mixed-gender hospital program. Only one of these results was replicated in the multivariate analysis, with the odds of total abstinence significantly lower for those randomized to the women's program than the mixed-gender hospital program. However, the average cost of a treatment episode was significantly higher at the hospital program than at the women's program (1212 US dollars versus 543 US dollars). CONCLUSIONS: These findings suggest that female substance abusers may be treated as effectively in mixed-gender programs as in women's programs.

Outcomes and costs of day hospital treatment and nonmedical day treatment for chemical dependency.

OBJECTIVE: The purpose of this study was to estimate the outcomes and costs of day hospital and nonmedical community-based day treatment for chemical dependency. METHOD: A community sample of 271 adults (179 men) dependent on alcohol and/or drugs was recruited and randomized to either a hospital-based (medical) day treatment program or to a community-based (nonmedical) day treatment program. The day hospital (DH) program lasted for 3 weeks. One community-based program (CP2) lasted for 4 weeks, and the other (CP1) lasted for 6 weeks but with shorter treatment days and more criminal justice clients. Because of our concerns regarding treatment fidelity, we replaced CP1 with CP2 as the randomization site for the nonmedical, community-based arm of the trial halfway through the study. RESULTS: Abstinence rates were similar between DH and CP2 subjects, with 53% and 60% of each group, respectively, reporting no drinking for the 30 days preceding both follow-up interviews. DH subjects were less likely than those in either of the nonmedical programs to report medical problems at both follow-ups. Average episode costs per client were significantly (p < .01) lower at CP1 (dollars 526) than at DH (dollars 1,274) or CP2 (dollars 1,163). A pattern of weaker effects was observed at the less costly problematic community program (CP1), including less abstinence than was reported at CP2 (only 40% of CP1 subjects were alcohol free at both follow-ups) and worse psychiatric, family/friend and employment outcomes than were reported at DH or CP2. CONCLUSIONS: Our results not only demonstrate the clinical diversity that exists between nonmedical, community-based day treatment programs but also show that nonmedical programs can compete with DH treatment in cost as well as in most outcomes.

Self-help organizations for alcohol and drug problems: toward evidence-based practice and policy.

This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to client's needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse.