Indigenous Ecohumanist Architecture for Health in Canada's Far North.

BACKGROUND: Circumpolar nations are experiencing unprecedented environmental and public health policy challenges due to global climate change, exploitation of nonrenewable natural resources, the endangerment of myriad wildlife species, and growing sovereignty disputes. In a call to action, the Arctic states' health ministers recently signed a declaration identifying shared priorities for mutual international cooperation. Among agreed-upon collaborations, an enhancement of intercultural understanding and promotion of culturally appropriate healthcare delivery systems is to be of high priority going forward. PURPOSE AND AIM: In far north Canada, health policies perpetuated for generations upon indigenous communities have, traditionally, often had adverse consequences for the medically underserved inhabitants of these communities. This discussion addresses the cultural disconnect between the colonial era and current indigenous, decolonialist health and healing design strategies. METHOD AND RESULT: In response, two architectural design case studies are presented that synthesize ecological site planning precepts with salutogenic architectural design attributes-a behavioral health and substance abuse residential treatment center and three elderhousing prototypes for construction in Canada's Northwest Territories. CONCLUSION: This conceptual synthesis is practicable, transferable, and adaptable to varied, extreme climatic conditions, as reflective of best practices in the delivery of healthcare facilities that express a synthesis of ecohumanist and salutogenic values and methodologies. The discussion concludes with a call for empathic, evidence-based collaboration and research that further examines the blending together of prefabricated off-site construction with on-site construction approaches.

Application of a RE-AIM Evaluation Framework to Test Integration of a Mindfulness Based Parenting Intervention into a Drug Treatment Program.

Background The RE-AIM framework was applied to the Mindfulness Based Parenting (MBP) intervention to evaluate the feasibility and effectiveness of this innovative trauma informed model in a drug treatment program. The MBP intervention is aimed at mitigating the stress experienced by women in treatment for substance use disorders, and thereby improving parenting and dyadic attachment between mother and child. Methods This was a single arm pre-test post-test design using repeated measure data collected between 2013 and 2016. The design also includes comprehensive process and impact evaluation data. Participants were 120 parenting women enrolled in an opioid treatment program between 2013 and 2016 in Philadelphia, PA. The MBP intervention included weekly 2-h MBP group sessions over 12 weeks, including three dyadic sessions with their child. The main outcomes of this study include the five facets of RE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Results The MBP intervention was associated with improvements in parenting across participants. Data showed implementation and sustainability are contingent upon a strong multidisciplinary team and clinical staff support and "buy-in". Iterative adaptations of interventions used in the general population may be necessary when working with a traumatized population burdened by low literacy levels, trauma history and co-occurring disorders. Conclusions MBP is a feasible and effective intervention for improving parenting and dyadic attachment between women with opioid use disorder and their children, and may be useful for other programs that serve parenting women with substance use disorders.

Process Evaluation of a Community Outpatient Program Treating Substance Use Disorders.

Addiction treatment can improve its impact by providing evidence-based care for the variety of problems that accompany substance use disorders. We conducted a retrospective evaluation of a new treatment program in California that aimed at providing multifaceted services through affiliated licensed and certified outpatient providers. The process evaluation used a logic model, focusing on program inputs, activities, and outputs, to understand the services received by the initial 18 clients who entered treatment. Outcomes for these patients were not assessed. Results indicated that clients received a variety of services: On average clients contracted for 118 treatment sessions and received 143 sessions. Among the many types of services provided, the most frequently received were integrative healthcare (averaging 42 sessions), group therapy (32 sessions), and individual therapy (32 sessions). This logic-model process evaluation indicated that a range of services were provided. The comprehensive approach may have promise for extending addiction treatment beyond its usual boundaries.

A system-level study of initiation, engagement, and equity in outpatient substance use treatment.

Understanding the nature of variations in the quality of substance use treatment is critical to ensuring equity in service delivery and maximizing treatment effectiveness. We used adapted versions of the US Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement measures to assess care quality in specialized outpatient services for substance use in Ontario, Canada. Using administrative data, we calculated rates of outpatient treatment initiation and engagement (N = 120,394 episodes) and investigated variation by client characteristics and treatment mandates. About half of clients who entered outpatient treatment met the criteria for initiation (i.e., had a second visit within 14 days) and 30% met the criteria for engagement (i.e., had another two visits within 30 days of initiation). The likelihood of treatment initiation and engagement was greater among older people, those with more education, those who were not mandated to enter treatment, and those with greater substance use at admission. People who entered treatment for cannabis were less likely to engage. Engagement was less likely among men than women, but gender differences were slight overall. This study demonstrates the feasibility of using adapted versions of two common measures to characterise care quality in substance use treatment services in the Canadian context. Overall, the magnitude of associations with client characteristics were quite small, suggesting that initiation and engagement were not overly localized to specific client subgroups. Findings suggest that the Ontario system has difficulty retaining clients who enter treatment and that most outpatient treatment involves care episodes of limited duration.

Patterns of co-occurring addictions, posttraumatic stress disorder, and major depressive disorder in detoxification treatment seekers: Implications for improving detoxification treatment outcomes.

BACKGROUND AND OBJECTIVES: Poly-substance use and psychiatric comorbidity are common among individuals receiving substance detoxification services. Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are the most common co-occurring psychiatric disorders with substance use disorder (SUD). Current treatment favors a one-size-fits-all approach to treating addiction focusing on one substance or one comorbidity. Research examining patterns of substance use and comorbidities can inform efforts to effectively identify and differentially treat individuals with co-occurring conditions. METHODS: Using latent class analysis, the current study identified four patterns of PTSD, MDD, and substance use among 375 addiction treatment seekers receiving medically supervised detoxification. RESULTS: The four identified classes were: 1) a PTSD-MDD-Poly SUD class characterized by PTSD and MDD occurring in the context of opioid, cannabis, and tobacco use disorders; 2) an MDD-Poly SUD class characterized by MDD and alcohol, opioid, tobacco, and cannabis use disorders; 3) an alcohol-tobacco class characterized by alcohol and tobacco use disorders; and 4) an opioid-tobacco use disorder class characterized by opioid and tobacco use disorders. The observed classes differed on gender and clinical characteristics including addiction severity, trauma history, and PTSD/MDD symptom severity. DISCUSSION AND CONCLUSIONS: The observed classes likely require differing treatment approaches. For example, people in the PTSD-MDD-Poly SUD class would likely benefit from treatment approaches targeting anxiety sensitivity and distress tolerance, while the opioid-tobacco class would benefit from treatments that incorporate motivational interviewing. Appropriate matching of treatment to class could optimize treatment outcomes for polysubstance and comorbid psychiatric treatment seekers. These findings also underscore the importance of well-developed referral networks to optimize outpatient psychotherapy for detoxification treatment-seekers to enhance long-term recovery, particularly those that include transdiagnostic treatment components.

What Influences Participation in QI? A Randomized Trial of Addiction Treatment Organizations.

Healthcare providers have increased the use of quality improvement (QI) techniques, but organizational variables that affect QI uptake and implementation warrant further exploration. This study investigates organizational characteristics associated with clinics that enroll and participate over time in QI. The Network for the Improvement of Addiction Treatment (NIATx) conducted a large cluster-randomized trial of outpatient addiction treatment clinics, called NIATx 200, which randomized clinics to one of four QI implementation strategies: (1) interest circle calls, (2) coaching, (3) learning sessions, and (4) the combination of all three components. Data on organizational culture and structure were collected before, after randomization, and during the 18-month intervention. Using univariate descriptive analyses and regression techniques, the study identified two significant differences between clinics that enrolled in the QI study (n = 201) versus those that did not (n = 447). Larger programs were more likely to enroll and clinics serving more African Americans were less likely to enroll. Once enrolled, higher rates of QI participation were associated with clinics' not having a hospital affiliation, being privately owned, and having staff who perceived management support for QI. The study discusses lessons for the field and future research needs.

[Requirements of a regional medical service for drug addicted patients]. / Anforderungen an ein regionalisiertes medizinisches Versorgungssystem für Drogenabhängige.

Modern services for persons with disorders resulting from psychoactive drug abuse must conform to the complexity of their needs. Low threshold access, standards for the prescription of opiates, out-patient, in-patient and day-hospital detoxification, rehabilitation and abstinence oriented strategies are fundamental prerequisites. The quality of services for drug dependent patients is defined by the percentage finding access to the service, the percentage of those continuing in the service, the easy and rapid transition between the different elements of the service, the degree of abstinence, decriminalization, physical comorbidity and mortality. Finally the cost of treated and untreated drug dependence should be considered.

Comparison of movement-to-music, rhythm activities, and competitive games on depression, stress, anxiety, and anger of females in substance abuse rehabilitation.

Over the past several decades the number of females using addictive substances has continuously increased. Females have different reasons for initiating substance abuse and specific treatment needs that differ from males. Researchers suggested gender specific drug rehabilitation treatment, in which female clients developed or improved functional behaviors. The purpose of this study was to investigate the effects of 3 different types of music therapy interventions on levels of depression, stress, anxiety, and anger of female clients in substance abuse rehabilitation. Ten females in an outpatient substance abuse rehabilitation program participated twice a week for 6 weeks in a music therapy program, participating in movement-to-music activities, rhythm activities, and competitive games for 2 weeks, 4 sessions each. After each intervention state-trait anxiety and levels of anger were measured. A repeated-measures ANOVA indicated no significant differences for the three types of music therapy interventions; however, data collected on daily scores, immediately before and after each session, indicated that individuals reported a decrease in depression, stress, anxiety, and anger immediately following the music therapy sessions.

Contrasting the views of substance misuse and mental health treatment providers on treating the dually diagnosed.

Service delivery to dually diagnosed individuals is often impeded by the divergent treatment approaches used by mental health and substance misuse treatment providers. This paper describes findings from a survey of mental health and substance misuse treatment program administrators and staff in Los Angeles County (n = 275) on their views about treating the dually diagnosed. All groups agreed about the challenges of treating dually diagnosed patients; however, there were differences both between and within providers in the two treatment systems on other aspects of treatment. The findings are discussed within the context of clinical and programmatic efforts to improve service delivery to the dually diagnosed.

Are the treatment goals of culturally competent outpatient substance abuse treatment units congruent with their client profile?

This study examines whether organizational treatment goals varied among outpatient substance abuse treatment (OSAT) units identified as providing a level of culturally competent care for African Americans. Cross-sectional data from the 1995 National Drug Abuse Treatment System Survey (NDATSS) was used. Of the nationally representative, stratified sample of 699 units, 618 (88%) participated. Spearman correlation, analysis of variance, Behrens-Fisher t-tests, chi-square, and multivariate logistic regression were used. Culturally competent units, even after controlling for organizational and client characteristics, were more apt than non-culturally competent units to indicate that achieving steady employment, spiritual strength, and physical health were important treatment goals. A congruency exists among culturally competent OSAT units between the client profile, which is more distressful than that for non-culturally competent units, and the orientation of treatment goals, which are more holistic; that is, treating the total individual, rather than the addiction only.

Outcomes of inpatients treated on a VA psychiatric unit and a substance abuse treatment unit.

OBJECTIVE: The utility of the Treatment Outcome Profile (TOP) for measuring the effectiveness of acute inpatient psychiatric and substance abuse treatment was tested, including its internal reliability, validity, and sensitivity to treatment gains. The relationship between patients' satisfaction with services and treatment gains in quality of life, symptoms, and level of functioning was explored. METHODS: A pre-post research design was used with consecutive admissions to an inpatient psychiatric unit (N = 66) and a substance abuse treatment unit (N = 88) at a VA medical center. At admission and at discharge, the TOP, a self-report instrument assessing quality of life, symptoms, level of functioning, and patient satisfaction with services (at discharge only) was completed. Multivariate analysis of variance and univariate analysis of variance were used to test differences in scores between admission and discharge. RESULTS: Patients demonstrated significant treatment gains. Overall, compared with patients on the substance abuse unit, those receiving psychiatric treatment were more impaired at admission and had lower levels of self-reported therapeutic gain at discharge. Improvement for both groups occurred in quality of life, symptoms, and level of functioning. Both groups reported high levels of patient satisfaction, comparable with levels in other service industries. A high positive correlation (alpha = .61) was found between patient satisfaction and overall self-reported treatment gain. CONCLUSIONS: The results indicate that it is important to compare treatment effectiveness as well as costs when seeking less costly alternatives to inpatient care. The TOP is a valid and sensitive outcome measurement tool. Patient satisfaction is an important outcome variable and positively related to treatment gains in quality of life, symptoms, and level of functioning.

Improving access, efficacy, and cost effectiveness of alcohol rehabilitation for poor patients.

Numerous alcoholics and alcohol abusers unknown to other agencies enter hospitals for treatment of alcohol-related illnesses. Two well-constructed studies focusing on poor clients enrolled in alcohol rehabilitation programs do not duplicate the long-term medical cost savings typical for higher income populations. Study limitations are indicated. Alcohol rehabilitation might avert or reduce potentially even higher long-term costs for poor clients as well as a host of social costs. It is important to demonstrate and improve the accessibility, efficacy, and cost effectiveness of alcohol treatment programs for the poor, especially since the viability and stability of public programs may be threatened due to competition with private facilities for insured and self-pay clients to subsidize the costs of treating the poor. Theoretical and practice issues and advances are discussed.

Methadone maintenance and drug-related crime.

Using data from an evaluation of methadone maintenance treatment, this study investigated factors associated with continued involvement in crime during treatment, and in particular whether there appeared to be differences in effectiveness of treatment between different methadone clinics. The methodology was an observational study, in which 304 patients attending three low-intervention, private methadone clinics in Sydney were interviewed on three occasions over a twelve month period. Outcome measures were self-reported criminal activity and police department records of convictions. By self-report, crime dropped promptly and substantially on entry to treatment, to a level of acquisitive crime about one-eighth that reported during the last addiction period. Analysis of official records indicated that rates of acquisitive convictions were significantly lower in the in-treatment period compared to prior to entry to treatment, corroborating the changes suggested by self-report. Persisting involvement in crime in treatment was predicted by two factors: the cost of persisting use of illicit drugs, particularly cannabis, and ASPD symptom count. Treatment factors also were independently predictive of continued involvement in crime. By both self-report and official records, and adjusting for subject factors, treatment at one clinic was associated with greater involvement in crime. This clinic operated in a chaotic and poorly organized way. It is concluded that crime during methadone treatment is substantially lower than during street addiction, although the extent of reduction depends on the quality of treatment being delivered.