Opioid agonist therapy during residential treatment of opioid use disorder: Cohort study on access and outcomes.

OBJECTIVE: To determine access to opioid agonist therapy (OAT) for those entering residential treatment for opioid use disorder; to report on treatment outcomes for those taking OAT and those not taking OAT; and to determine the association between OAT use and residential treatment completion. DESIGN: Retrospective cohort study. SETTING: Ontario. PARTICIPANTS: Patients with opioid use disorder admitted to publicly funded residential treatment programs in the province of Ontario between January 1, 2013, and December 31, 2016. MAIN OUTCOME MEASURES: Access to OAT during residential treatment using descriptive statistics. Treatment outcomes (ie, completed the program, voluntarily left early, involuntary discharged, and other) for the entire cohort and for the OAT and non-OAT groups using descriptive statistics. Association between OAT use at admission and treatment completion (a binary outcome) using bivariate and multivariate models. RESULTS: Among an identified cohort of 1910 patients with opioid use disorder, 52.8% entered programs that permitted access to OAT. Overall, 56.8% of patients completed treatment, 23.3% voluntarily left early (eg, were no-shows, dropped out), 17.0% were involuntarily discharged, and 2.9% were discharged early for other reasons. Those taking OAT were as likely to complete treatment as those not taking OAT (53.9% vs 57.5%, respectively; adjusted odds ratio of 1.07, 95% CI 0.77 to 1.38). CONCLUSION: This study demonstrates 2 large gaps in care for patients with opioid use disorder. First, these patients have poor access to OAT-the first-line treatment of opioid use disorder-while in publicly funded residential treatment programs; and second, many are involuntarily discharged from treatment. Additionally, this study indicates that patients taking OAT have similar likelihood of completing residential treatment as those not taking OAT do. Limitations of this study are that it is based on observational data for patients who self-selected before admission to use OAT or not, and it is likely not all confounders were accounted for.

Factors Associated with Long-Stays in an Italian Psychiatric Intensive Treatment Facility: 1-Year Retrospective Observational Analysis.

Psychiatric Intensive Treatment Facilities (PITF) are health inpatient settings for patients affected by sub-acute psychiatric disorders with impaired personal and social functioning. The aim of this study is to analyse the demographic and clinical variables related to long-stays in an Italian PITF in order to highlight the risk factors for stay lengthening. We retrospectively collected the selected variables from all patients and their stays in a PITF from 1 to 11-2016 to 31-10-2017. We divided the stays according to the median of duration, ≤29 and > 29 days, to compare selected variables in the two groups of stay length. Patients hospitalized for >29 days more frequently presented "Self-neglect", nursing diagnosis NANDA-I, and needed economic social service support. Multiple linear regression revealed that the presence of some variables as "many medical consultations", "economic social service support", "clinical interviews extended to institutional figures" were statistically significantly associated with an increased stay duration, suggesting that both clinical severity and difficult economic conditions were associated with the lengthening of stay. The knowledge of these factors can contribute to improve psychiatric treatments, reducing potential risk conditions for patient institutional dependence.

Barriers to Accessing Detox Facilities, Substance Use Treatment, and Residential Services among Women Impacted by Commercial Sexual Exploitation and Trafficking.

More than 50% of women entering substance use treatment in the United States reported having traded sex for money or drugs. Women's participation in addiction treatment and related services is essential to their recovery and increased safety, stabilization, and quality of life. This article's aim is to explore the barriers related to accessing detox facilities and essential services including substance use treatment and residential services for women impacted by commercial sexual exploitation (CSE). Data are drawn from a larger, community-based, grounded theory study. In-depth interview data were collected from 30 adult women who traded sex as adults (through maximum variation and snowball sampling), as well as 20 service providers who come into contact with adult women who trade sex (through nominations and purposive sampling). Finding suggest that women often encountered sobriety requirements, which created barriers to accessing addiction treatment or residential services. Some organizations' policies required evicting women if they were caught using, which created additional challenges for women who relapsed. Women wanted to avoid becoming "dopesick" on the streets or at home, which partially contributed to them needing to maintain their addiction. Consequently, some returned to sex trading, thus increasing their risk of trafficking. Some women engaged in creative strategies, such as claiming they were suicidal, in order to access the detox facilities in hospitals. Some women indicated they were only able to detox when they were forced to do so in jail or prison, often without medical assistance. Implications to improve health care delivery for this population are discussed.

Placement and Delinquency Outcomes Among System-Involved Youth Referred to Multisystemic Therapy: A Propensity Score Matching Analysis.

Multisystemic therapy (MST) was developed to help youth with serious social, emotional, and behavioral problems. Research on the efficacy and effectiveness of MST has shown positive outcomes in different domains of development and functioning among various populations of youth. Nonetheless, even with a large body of literature investigating the treatment effects of MST, few studies have focused on the effectiveness of MST through large-scale dissemination efforts. Utilizing a large sample of youth involved in a statewide dissemination of MST (n = 740; 43% females; 14% Black; 29% Hispanic; 49% White; Mage = 14.9 years), propensity score matching was employed to account for baseline differences between the treatment (n = 577) and comparison (n = 163) groups. Treatment effects were examined based on three outcomes: out-of-home placement, adjudication, and placement in a juvenile training school over a 6-year period. Significant group differences remained after adjusting for baseline differences, with youth who received MST experiencing better outcomes in offending rates than youth who did not have an opportunity to complete MST due to non-clinical or administrative reasons. Survival analyses revealed rates of all three outcomes were approximately 40% lower among the treatment group. Overall, this study adds to the body of literature supporting the long-term effectiveness of MST in reducing offending among high-risk youth. The findings underscore the potential benefits of taking evidence-based programs such as MST to scale to improve the well-being and functioning of high-risk youth. However, strategies to effectively deliver the program in mental health service settings, and to address the specific needs of high-risk youth are necessary.

Inpatient hospitalization for substance use disorders one year after residential rehabilitation: predictors among US veterans.

BACKGROUND: The Veterans Health Administration (VHA) is among the principal providers of the full range of substance use disorders (SUD) treatment in the US. Relatively little, however, is known about patient outcomes after residential rehabilitation. OBJECTIVE: To identify predictors of SUD inpatient hospitalization (primarily medically managed detoxification) in the year after SUD residential rehabilitation among US veterans. METHODS: Medical records of 64 veterans admitted to one of two residential rehabilitation programs in the Northeast during the first quarter of FY 2012 were abstracted. Data included demographic, clinical, and treatment (inpatient and outpatient) information for the year before and after residential rehabilitation. Annual rates of treatment utilization were compared. RESULTS: The veterans (mean age, 48.2 years) used substances for a mean of 27.6 years. Alcohol was the primary drug of choice (69%). More than half had SUD inpatient hospitalizations in the year before (79%) and after (53%) residential rehabilitation; SUD inpatient admission occurred an average of 64 days after discharge. According to the multivariate Cox regression model, the estimated risk of SUD inpatient hospitalization increased by 25% for each past year SUD inpatient hospitalization, decreased by 74% if there was no opiate use disorder diagnosis, and decreased by 2% for each day increase in residential rehabilitation length of stay when extent of service connected disability, marital status, and days since last SUD inpatient admission are taken into account. CONCLUSIONS: Risk factors for SUD inpatient hospitalization after residential rehabilitation have been identified and, if confirmed, may represent opportunities for targeted program change.

Does the Hospital Predict Readmission? A Multi-level Survival Analysis Approach.

Time to psychiatric rehospitalization was predicted for a sample of 1473 Medicaid-insured youth in Illinois in 2005 and 2006. A multi-level model statistical strategy was employed to account for the fact that youth days to rehospitalization were nested within hospital and to test the hypothesis that hospitals would vary significantly in return rates, controlling for individual-level (e.g., symptom, demographic) variables. Hospitals did not vary significantly in days to rehospitalization. At the individual-level, level of externalizing behavior and residential treatment placement predicted a faster return to the hospital. These results support the perspective that hospital outcomes are best operationalized using variables tied more directly to the inpatient episode (e.g., LOS, reductions in acuity).

Self- and proxy reports of quality of life among adolescents living in residential youth care compared to adolescents in the general population and mental health services.

BACKGROUND: Child welfare services are aimed at providing care and protection, fostering well-being and prosocial behaviour. Thus, Quality of Life (QoL) should be an important outcome measure in Residential Youth Care (RYC) institutions. However, the dearth of research in this area gives rise to serious concern. The present study is the first large scale, nationwide study assessing QoL among adolescents living in RYC. To provide a reference frame, adolescent self- and primary contact proxy reports were compared to the general population and to adolescent outpatients in Child and Adolescent Mental Health Service (CAMHS). Also, we investigated the association between self-report of QoL in adolescents living in RYC and proxy reports of their primary contacts at the institution. METHODS: All residents between the ages of 12-23 years living in RYC in Norway were the inclusion criteria. Eighty-six RYC institutions (with 601 eligible youths) were included, 201 youths/ parents did not give their consent. Finally, 400 youths aged 12-20 years participated, yielding a response rate of 67%. As a reference frame for comparison, a general population (N = 1444) and an outpatient sample of adolescents in CAMHS (N = 68) were available. We used the Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). General Linear Model analyses (ANCOVA) were conducted with five KINDL life domains as dependent variables and group as independent variable. RESULTS: Self- and proxy reports of QoL in adolescents living in RYC revealed a significantly (p < 0.001) poorer QoL compared to the general population on the life domains Physical- and Emotional well-being, Self-esteem, and relationship with Friends. Adolescents evaluated their physical well-being as worse compared to adolescents in CAHMS. Self- and proxy reports in RYC differed significantly on two of five life domains, but correlated low to moderate with each other. CONCLUSIONS: The results in this study raise major concerns about the poor QoL of the adolescents living in RYC, thereby challenging the child welfare system and decision makers to take action to improve the QoL of this group. The use of QoL as outcome measures is highly recommended.

Differences between older and younger adults in residential treatment for co-occurring disorders.

OBJECTIVE: The purpose of this study was to examine differences between older and younger adults who received integrated treatment for co-occurring substance use and mental disorders, including differences on demographic and baseline characteristics (e.g., substance use, readiness for change, mental health symptoms, and severity of problems associated with substance use), as well as predictors of retention in treatment. METHODS: This study included 1400 adults who received integrated substance abuse and mental health treatment services at one of two private residential facilities offering residential and outpatient services. Initial analyses consisted of basic descriptive and bivariate analyses to examine differences between older (≥ 50 years old) and younger (< 50 years old) adults on baseline variables. Next, three ordinary least squares regression models were employed to examine the influence of baseline characteristics on length of stay. RESULTS: Three main findings emerged. First, older adults differed from younger adults on pre-treatment characteristics. Older adults used more alcohol and experienced greater problem severity in the medical and alcohol domains, while younger adults used more illicit drugs (e.g., heroin, marijuana, and cocaine) and experienced problems in the drug, legal, and family/social domains. Second, while readiness to change did not differ between groups at baseline, older adults remained enrolled in treatment for a shorter period of time (nearly four days on average) than younger adults. Third, the pattern of variables that influenced length of stay in treatment for older adults differed from that of younger adults. Treatment retention for older adults was most influenced by internal factors, like psychological symptoms and problems, while younger adults seemed influenced primarily by external factors, like drug use, employment difficulties, and readiness for change. CONCLUSIONS: The results of this study add to the limited knowledge base regarding older adults receiving integrated treatment for co-occurring substance use and mental health disorders by documenting that age-based differences exist in general and in the factors that are associated with the length of stay in residential treatment.

Community-based relapse prevention for opiate dependents: a randomized community controlled trial.

Relapse prevention (RP) programs mainly focus on patients and their families; however a patient's community can also play a significant role in RP. A randomized-controlled-trial was conducted among opiate-dependents discharging from residential abstinence-based treatment programs to assess the effect of a community-based relapse prevention program (CBRP) on the RP. Seventy-one participants were consented and randomized into CBPR (n = 35) or treatment-as-usual arms. Developing and implementing CBRP, social-workers and peer-group counselors facilitated and advocated thirty-six RP projects across 7 communities during a three-month follow-up period. Negative-drug-tests, 45 and 90 days after discharge from residential programs were considered as the main outcome. Abstinence rates were significantly greater for patients who received CBRP in comparison to the subjects in the treatment-as-usual arm at 45 days (27 and 20, P < 0.004) and 90 days (27 and 21, P < 0.007) after discharge. CBRP was an effective method for RP among opiate-dependents after being discharged from the residential programs.

Who seeks residential treatment? A report of patient characteristics, pathology, and functioning in females at a residential treatment facility.

There has been a growth in the availability and use of residential treatment for eating disorders. Yet there is a paucity of information on the individuals who seek this treatment. This study provides data on 259 consecutive patients (116 adults and 143 adolescents) entering residential treatment for their eating disorders. Upon admission all patients provided individual characteristics data and the following measures: the Eating Disorder Inventory-3 (EDI-3), the Beck Depression Inventory-II, the Beck Anxiety Inventory, the Eating Disorder Quality of Life (EDQOL), and the SF-36 Health Survey-Version 2. Findings are presented by diagnosis (anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified) and age (adult and adolescent). Results show that 61% of adolescents and 80% of adults were above the clinical cutoff for depression, and 59% of adolescents and 78% of adults were above the clinical cutoff for anxiety. Scores on the EDI-3 are presented by subscale and diagnosis. Very low quality of life is reported for both adults and adolescents on the EDQOL. For both adolescents and adults the SF-36 showed average population scores for the physical scale but very low mental scores. Implications for these findings and future directions for this work are discussed.

Disclosure of sexual abuse among youth in residential treatment care: a multiple informant comparison.

This exploratory study describes the child sexual abuse experiences of 53 youth (ages 14-17) in child protective services residential treatment care using three informants: youth (via the Childhood Trauma Questionnaire), residential treatment workers (via the Child Welfare Trauma Referral Tool), and the child protective services record. Child sexual abuse was self-reported by 38% of youth, with reporting by females almost four times higher. Child sexual abuse co-occurred with physical abuse, emotional abuse, and neglect in 75% of cases. Agreement between youth and residential treatment worker reports was high, while agreement between youth reports and their child protective services record was low. The study suggests systematic child sexual abuse screening among residential treatment care youth through self-reports and residential treatment worker reports. Case studies are provided, and implications for practice, policy, and future research are discussed.

[Alcohol-addiction inpatient: characteristics of patients and rehabilitation program]. / La residenzialità alcologica ospedaliera: caratteristiche dei pazienti e dei percorsi terapeutici/riabilitativi.

AIM: The treatment of alcohol addiction in Italy has had a progressive evolution of therapeutic structures for in-and outpatients. During the last 20 years there had been a crescent presence of short residential treatment facilities (1-6 months) characterized by a high level of medical and psychotherapeutic intervention. About two years ago 12 of them jointed together in an association called CORRAL (COordinamento of Residenzialità Riabilitive Alcologiche). The aim of this study was to describe the socio-demographic medical and other characteristics of the patients coming for this type of treatment and to describe the characteristics of the residential treatment itself including referring and aftercare. METHODS: Two thousand sixty-one hospitalized patients of the 12 rehabilitative alcohol units were examined by using a questionnaire and collecting various sociodemographic variables and clinical diagnosis of the patients. Even it was asked who had referred the patients, the characteristics of the residential treatment and of the planned aftercare. RESULTS: The present residential facilities are mainly distributed in the North of Italy. The typical patient is male, with a high school instruction and with a comorbidity regarding psychiatric and liver disorders. The majority of the patients were referred by the public ambulatory services for addictions (SerT/SerD). The characteristics of the residential treatment were medical, pharmacological and psychotherapeutic interventions with a high intensity and the presence of a general-purpose staff. CONCLUSIONS: This study outlined a model of residential rehabilitation of alcohol disorders characterized by short duration and a complex, intense therapeutic intervention mainly addressed to patients with a severe clinical condition and a low level of social problems. Further research should be useful to understand better which sort of patient characteristics obtain a better clinical result and for that even economically a major effectiveness from this type of residential treatment.

Residential family treatment for parents with substance use disorders who are involved with child welfare: two perspectives on program design, collaboration, and sustainability.

This article discusses the service design, implementation, and evaluation findings of two residential family treatment programs: Wayside House (MN) and OnTrack (OR). Both programs specialize in family-centered services for adults with substance use disorders (SUD) who are involved with child welfare. Information on program design, services offered, and key collaborations are detailed. Implications for program sustainability are provided.

Compensation and treatment: disability benefits and outcomes of U.S. veterans receiving residential PTSD treatment.

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma-related symptoms in addition to providing service-connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.

Differential service utilization associated with trauma-informed integrated treatment for women with co-occurring disorders.

Women with co-occurring mental health and substance use disorders and trauma histories vary greatly in symptom severity and use of support services. This study estimated differential effects of an integrated treatment intervention (IT) across sub-groups of women in this population on services utilization outcomes. Data from a national study were used to cluster participants by symptoms and service utilization, and then estimate the effect of IT versus usual care on 12-month service utilization for each sub-group. The intervention effect varied significantly across groups, in particular indicating relative increases in residential treatment utilization associated with IT among women with predominating trauma and substance abuse symptoms. Understanding how IT influences service utilization for different groups of women in this population with complex needs is an important step toward achieving an optimal balance between need for treatment and service utilization, which can ultimately improve outcomes and conserve resources.

Juvenile offender recidivism: an examination of risk factors.

One hundred and seventy three male juvenile offenders were followed two years postrelease from a residential treatment facility to assess recidivism and factors related to recidivism. The overall recidivism rate was 23.9%. Logistic regression with stepwise and backward variable selection methods was used to examine the relationship between recidivism and nine specific variables: offense type, age at initial involvement in juvenile justice, child welfare system involvement, termination of parental rights, parental criminal history, family support, program completion status, length of treatment stay, and discharge placement. Offender type was the only factor found to have a significant impact on recidivism with general and substance-involved offenders more likely to recidivate than sex offenders. Implications for future research are discussed.

Chronic medical conditions among jail detainees in residential psychiatric treatment: a latent class analysis.

Studies of incarcerates with serious mental illnesses have found elevated rates of chronic medical conditions such as asthma and diabetes, and of infectious diseases such as tuberculosis compared with general population rates. This study explored the pattern of chronic medical conditions in a sample of adult detainees in psychiatric treatment in a large urban jail to develop a clinical profile encompassing the full range of medical conditions. A total of 431 male and female detainees were sampled with certainty from admissions to a residential psychiatric treatment program (overall recruitment rate = 67%). Interviews used the World Mental Health version of the Composite International Diagnostic Interview to assess psychiatric and substance use disorders per DSM-IV criteria and chronic medical conditions. Latent class analysis was conducted using 17 medical conditions as class indicators, yielding a 3-class model composed of: a latent class with a high to intermediate probability of multiple medical conditions (HMC; 12.5% of the sample); an intermediate class with a lower probability of having a smaller number of medical conditions (MMC; 43.2%); and a class with a low probability of any medical condition (44.3%). Those in the HMC class were more likely to report respiratory problems, severe headaches, musculoskeletal pain, hypertension, and arthritis, have greater functional impairment, and have a higher number of co-occurring psychiatric disorders. Being older (50+ years) and female were associated with higher odds of being in the HMC or MMC classes. The policy implications for providing medical care to incarcerates with complex mixtures of medical conditions and psychiatric disorders are considered.

Utilization of residential alcoholism treatment in bipolar disorder.

Despite the high prevalence rate of comorbid alcohol dependence and bipolar disorder, little is known about how many bipolar patients are actively engaged in addiction treatment or the alcohol consumption characteristics of this group. This retrospective study reviewed the medical records from patients with alcohol dependence admitted to residential treatment at our institution (n = 588). The analyses focused on alcoholism severity measures and discharge clinical diagnoses. Patients with alcoholism + bipolar disorder compromised only 5% of the total study group. The number of drinking years was lower for patients with alcoholism + bipolar disorder (23.1 ± 17.7) than for those with alcoholism + depression (26.8 ± 13.9) or alcoholism alone (28.1 ± 13.2). A trend of higher mean lifetime maximum daily drinks was observed for patients with alcoholism + bipolar disorder; this was because of the significantly higher maximum drinks for women with bipolar disorder (21.0 ± 11.5) than for women in other diagnostic groups. Despite high rates of comorbidity in community-based studies, this retrospective study suggests that patients with bipolar disorder are not highly represented in residential alcoholism addiction treatment. Future studies are encouraged to better understand utilization rates of addiction treatment among patients with bipolar disorder and to identify clinical correlates that predispose bipolar women to high-dose drinking.

Trazodone and alcohol relapse: a retrospective study following residential treatment.

Trazodone is one of the most commonly prescribed hypnotic medications in patients with sleep disturbances in alcohol recovery. A recent study concluded that treating insomnia with trazodone in patients with alcohol dependence might impede improvements in alcohol consumption and lead to increased drinking when trazodone is stopped. We set out to investigate the relationship between trazodone use during alcoholism treatment and relapse rates in patients who were discharged from a residential alcohol treatment program. We retrospectively reviewed records of patients with a diagnosis of alcohol dependence in a residential addiction treatment center from 2005 to 2008 and analyzed the association of trazodone use at discharge and alcohol relapse at 6 months. We also assessed the association between trazodone use and relapse at 6 months adjusting for sex, drug dependence, nonsubstance use Axis I psychiatric diagnoses, patient self-report of difficulties with sleep, and anti-dipsotropic medication use at discharge and evaluated pair-wise interactions of trazodone use with the adjustment variables. Of 283 patients eligible for inclusion, 85 (30%) were taking trazodone at discharge. Older age, self-reported sleep problems, and having a nonsubstance use Axis I psychiatric diagnosis were associated with trazodone use. After discharge, 170 (60%) subjects responded to follow-up efforts. Neither intent to treat nor responder only analysis revealed any association between trazodone use and relapse. Our retrospective study of a complex patient population discharged from a residential treatment setting did not find an association between trazodone use at discharge and relapse rates at 6 months.