Development and Measurement of the Treatment Perceptions Survey (TPS) for Clients with Substance Use Disorders.

Statistical reliability of the Treatment Perceptions Survey (TPS) questionnaire was examined using data from 19 California counties. The 14-item TPS was designed for clients receiving substance use disorder services at publicly funded community-based programs. The TPS is being used for evaluation of the State's 1115 Medicaid Waiver, external quality review of county-based systems of care, and quality improvement efforts. The survey addresses four domains of access to care, quality of care, care coordination, and general satisfaction that each include multiple items, plus a single item focused on self-reported outcome. Reliability test results of the four domains as composite measures were statistically significant. General satisfaction ratings were the best predictor of self-reported outcome in a path analysis model, followed by ratings of care coordination and quality of care. Separate analyses of TPS data from clients receiving specialty mental health services suggest the questionnaire can also be used reliably in mental health settings.

The Implementation of Integrated Behavioral Health Protocols In Primary Care Settings in Project Care.

PURPOSE: The majority of adults with mental health (MH) and substance use (SU) disorders in the United States do not receive treatment. The Affordable Care Act will create incentives for primary care centers to begin providing behavioral health (MH and SU) services, thus promising to address the MH and SU treatment gaps. This paper examines the implementation of integrated care protocols by three primary care organizations. METHODS: The Behavioral Health Integration in Medical Care (BHIMC) tool was used to evaluate the integrated care capacity of primary care organizations that chose to participate in the Kern County (California) Mental Health Department's Project Care annually for 3years. For a subsample of clinics, change over time was measured. Informed by the Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors, inner and outer contextual factors impacting implementation were identified and analyzed using multiple data sources and qualitative analytic methods. RESULTS: The primary care organizations all offered partially integrated (PI) services throughout the study period. At baseline, organizations offered minimally integrated/partially integrated (MI/PI) services in the Program Milieu, Clinical Process - Treatment, and Staffing domains of the BHIMC, and scores on all domains were at the partially integrated (PI) level or higher in the first and second follow-ups. Integrated care services emphasized the identification and management of MH more than SU in 52.2% of evaluated domains, but did not emphasize SU more than MH in any of them. Many of the gaps between MH and SU emphases were associated with limited capacities related to SU medications. Several outer (socio-political context, funding, leadership) and inner (organizational characteristics, individual adopter characteristics, leadership, innovation-values fit) contextual factors impacted the development of integrated care capacity. CONCLUSIONS: This study of a small sample of primary care organizations showed that it is possible to improve their integrated care capacity as measured by the BHIMC, though it may be difficult or unfeasible for them to provide fully integrated behavioral health services. Integrated services emphasized MH more than SU, and enhancing primary care clinic capacities related to SU medications may help close this gap. Both inner and outer contextual factors may impact integrated service capacity development in primary care clinics. Study findings may be used to inform future research on integrated care and inform the implementation of efforts to enhance integrated care capacity in primary care clinics.

Patient perspectives on buprenorphine/naloxone: a qualitative study of retention during the starting treatment with agonist replacement therapies (START) study.

This study examines the barriers and facilitators of retention among patients receiving buprenorphine/naloxone at eight community-based opioid treatment programs across the United States. Participants (n = 105) were recruited up to three and a half years after having participated in a randomized clinical trial comparing the effect of buprenorphine/naloxone and methadone on liver function. Semi-structured interviews were conducted with 67 patients provided with buprenorphine/naloxone who had terminated early and 38 patients who had completed at least 24 weeks of the trial. Qualitative data were analyzed using the constant comparison method. Barriers to buprenorphine/naloxone retention that emerged included factors associated with: (1) the design of the clinical trial; (2) negative medication or treatment experience; and (3) personal circumstances. The facilitators comprised: (1) positive experience with the medication; (2) personal determination and commitment to complete; and (3) staff encouragement and support. The themes drawn from interviews highlight the importance of considering patients' prior experience with buprenorphine/naloxone and methadone, medication preference, personal circumstances, and motivation to abstain from illicit use or misuse of opioids, as these may influence retention. Ongoing education of patients and staff regarding buprenorphine/naloxone, especially in comparison to methadone, and support from staff and peers are essential.

Integration of substance use disorder services with primary care: health center surveys and qualitative interviews.

BACKGROUND: Each year, nearly 20 million Americans with alcohol or illicit drug dependence do not receive treatment. The Affordable Care Act and parity laws are expected to result in increased access to treatment through integration of substance use disorder (SUD) services with primary care. However, relatively little research exists on the integration of SUD services into primary care settings. Our goal was to assess SUD service integration in California primary care settings and to identify the practice and policy facilitators and barriers encountered by providers who have attempted to integrate these services. METHODS: Primary survey and qualitative interview data were collected from the population of federally qualified health centers (FQHCs) in five California counties known to be engaged in SUD integration efforts was surveyed. From among the organizations that responded to the survey (78% response rate), four were purposively sampled based on their level of integration. Interviews were conducted with management, staff, and patients (n=18) from these organizations to collect further qualitative information on the barriers and facilitators of integration. RESULTS: Compared to mental health services, there was a trend for SUD services to be less integrated with primary care, and SUD services were rated significantly less effective. The perceived difference in effectiveness appeared to be due to provider training. Policy suggestions included expanding the SUD workforce that can bill Medicaid, allowing same-day billing of two services, facilitating easier reimbursement for medications, developing the workforce, and increasing community SUD specialty care capacity. CONCLUSIONS: Efforts to integrate SUD services with primary care face significant barriers, many of which arise at the policy level and are addressable.

Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial.

AIMS: To examine patient and medication characteristics associated with retention and continued illicit opioid use in methadone (MET) versus buprenorphine/naloxone (BUP) treatment for opioid dependence. DESIGN, SETTINGS AND PARTICIPANTS: This secondary analysis included 1267 opioid-dependent individuals participating in nine opioid treatment programs between 2006 and 2009 and randomized to receive open-label BUP or MET for 24 weeks. MEASUREMENTS: The analyses included measures of patient characteristics at baseline (demographics; use of alcohol, cigarettes and illicit drugs; self-rated mental and physical health), medication dose and urine drug screens during treatment, and treatment completion and days in treatment during the 24-week trial. FINDINGS: The treatment completion rate was 74% for MET versus 46% for BUP (P < 0.01); the rate among MET participants increased to 80% when the maximum MET dose reached or exceeded 60 mg/day. With BUP, the completion rate increased linearly with higher doses, reaching 60% with doses of 30-32 mg/day. Of those remaining in treatment, positive opioid urine results were significantly lower [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.52-0.76, P < 0.01] among BUP relative to MET participants during the first 9 weeks of treatment. Higher medication dose was related to lower opiate use, more so among BUP patients. A Cox proportional hazards model revealed factors associated with dropout: (i) BUP [versus MET, hazard ratio (HR) = 1.61, CI = 1.20-2.15], (ii) lower medication dose (<16 mg for BUP, <60 mg for MET; HR = 3.09, CI = 2.19-4.37), (iii) the interaction of dose and treatment condition (those with higher BUP dose were 1.04 times more likely to drop out than those with lower MET dose, and (iv) being younger, Hispanic and using heroin or other substances during treatment. CONCLUSIONS: Provision of methadone appears to be associated with better retention in treatment for opioid dependence than buprenorphine, as does use of provision of higher doses of both medications. Provision of buprenorphine is associated with lower continued use of illicit opioids.

Utilizing drumming for American Indians/Alaska Natives with substance use disorders: a focus group study.

BACKGROUND: Drumming has been utilized among American Indian/Alaska Native (AI/AN) tribes for centuries to promote healing and self-expression. Drum-Assisted Recovery Therapy for Native Americans (DARTNA), currently under development, is a substance abuse treatment utilizing drumming as a core component. OBJECTIVES: Focus groups were conducted to assist in the development of the DARTNA protocol. Feedback obtained from these focus groups will inform a subsequent pretest of DARTNA and an empirical study analyzing its effectiveness. METHODS: Three focus groups were conducted among AIs/ANs with substance use disorders (n = 6), substance abuse treatment providers (n = 8), and a community advisory board (n = 4) to solicit feedback prior to a pretest of the DARTNA protocol. RESULTS: Overall, participants indicated that DARTNA could be beneficial for AIs/ANs with substance use disorders. Four overarching conceptual themes emerged across the focus groups: (1) benefits of drumming, (2) importance of a culture-based focus, (3) addressing gender roles in drumming activities, and (4) providing a foundation of common AI/AN traditions. CONCLUSIONS: The DARTNA protocol is a potentially beneficial and culturally appropriate substance abuse treatment strategy for AIs/ANs. In order to optimize the potential benefits of a substance abuse treatment protocol utilizing drumming for AIs/ANs, adequate attention to tribal diversity and gender roles is needed. SCIENTIFIC SIGNIFICANCE: Due to the shortage of substance abuse treatments utilizing traditional healing activities for AIs/ANs, including drumming, results from this study provide an opportunity to develop an intervention that may meet the unique treatment needs of AIs/ANs.

Health and health care disparities among homeless women.

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.

Turning points in the life course: current findings and future directions in drug use research.

Turning point, a key concept in the developmental life course approach, is currently understudied in the field of substance abuse, but merits further research. A turning point often involves a particular event, experience, or awareness that results in changes in the direction of a pathway or persistent trajectory over the long-term. This article (1) provides an overview of the relevant literature on the concept of turning points from the life course and developmental criminology perspectives, (2) reviews literature on turning points in substance use, (3) discusses methodological considerations, and (4) suggests areas for future research on turning points in drug use. The influence of life course concepts related to drug use trajectories and turning points (including, for example, timing and sequencing of life events, individual characteristics, human agency, and social and historical context) offers a potentially fruitful area of investigation that may increase our understanding of why and how drug users stop and resume using over the long-term. Further research on turning points may be particularly valuable in unpacking the multifaceted and complex underlying mechanisms and factors involved in lasting changes in drug use.

Hospitalizations among homeless women: are there ethnic and drug abuse disparities?

This paper explores associations among the vulnerabilities of being female, being a member of a minority group, and being a drug abuser in homeless women's hospitalizations. It uses a 1997 probability survey of 974 homeless females age 15-44 in Los Angeles. In unadjusted analyses, whites were more likely than other ethnic minority groups to be hospitalized, and drug abusers were more likely to be hospitalized than non-drug abusers. Multiple logistic regression analyses indicated that factors associated with hospitalization differed considerably among the ethnic and drug-abuse subgroups. For example, ethnic disparities in inpatient health care were found for drug-abusing women, but not for those who did not abuse drugs. Pregnancy was the only important determinant of hospitalization in all subgroups (OR, 2.9-17.4). Preventing unintended pregnancy appears to be the most inclusive means of reducing hospitalization and attendant costs among homeless women.

Empirically supported substance abuse treatment approaches: a survey of treatment providers' perspectives and practices.

To better understand the extent that empirically supported and promising substance abuse treatment approaches are implemented in community settings, treatment providers were surveyed regarding their perceptions and use of several psychosocial and pharmacological treatment interventions. Program directors (n=30) and staff members (n=331) from diverse community settings rated the effectiveness and extent of use of various treatment interventions, and provided information on program and workforce characteristics via self-administered questionnaires. On average, program directors and staff rated the psychosocial treatment interventions as effective, with the exception of vouchers/motivational incentives. About half of the treatment providers did not know the effectiveness of certain pharmacological treatments, including buprenorphine and naltrexone. Respondents from the majority of programs (55%-80%) reported using Motivational Enhancement Therapy, Community Reinforcement Approach, and Supportive Expressive Psychotherapy. The extent that programs used several of the treatment interventions was related to organizational training and information resources. The study findings provide important information regarding training and research dissemination efforts.

Predictors of short-term treatment outcomes among California's Proposition 36 participants.

California's voter-initiated Proposition 36 offers non-violent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. This article reports short-term treatment outcomes subsequent to this major shift in drug policy. Data are from 1104 individuals randomly selected from all Proposition 36 participants assessed for treatment in five California counties during 2004. The overall study sample was 30% female, 51% white, 18% Black, 24% Hispanic, and 7% other racial/ethnic groups. The mean+/-SD age was 37+/-10 years. Counties varied considerably in participant characteristics, treatment service intensity, treatment duration, urine testing, and employment and recidivism outcomes, but not in drug use at 3-month follow-up. Controlling for county, logistic regression analysis showed that drug abstinence was predicted by gender (female), employment at baseline (full or part-time), residential (vs. outpatient) stay, low psychiatric severity, frequent urine testing by treatment facility, and more days in treatment. Recidivism was predicted only by shorter treatment duration. Employment predictors included age (younger), gender (male), baseline employment, and lower psychiatric severity. The study findings support drug testing to monitor abstinence and highlight the need to address employment and psychiatric problems among Proposition 36 participants.

Impact of California's Proposition 36 on the drug treatment system: treatment capacity and displacement.

OBJECTIVES: California's Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. We examined how treatment capacity changed to accommodate Proposition 36 clients and whether displacement of other clients was an unintended consequence. METHODS: Treatment admissions were compared for the year before and 2 years after the law was enacted. Surveys of county administrators and treatment providers were conducted in Kern, Riverside, Sacramento, San Diego, and San Francisco counties. RESULTS: The number of Proposition 36 offenders admitted to treatment continued to increase in the state (approximately 32000 in Year 1 and 48000 in Year 2) and in the 5 counties; total treatment admissions stabilized in Year 2 after increasing in Year 1. Voluntary clients decreased by 8000 each year statewide, but the change varied across counties. One third of treatment providers reported decreased treatment availability for non-Proposition 36 clients in Year 2. CONCLUSION: Despite expanded treatment capacity (mostly in outpatient treatment), indirect evidence suggests that displacement of voluntary clients may have occurred in part because of the demand for treatment by Proposition 36 clients.

Implementation of a statewide outcome monitoring system: lessons learned from substance abuse treatment provider staff.

The authors analyze the pilot implementation of a statewide automated outcome monitoring system (OMS) in California, using the perspectives of substance abuse treatment providers responsible for its day-to-day operation. To gain a better understanding of changes experienced by staff and their perceptions of barriers and facilitators of implementation, they conducted 28 focus groups designed to inform midstream adjustments to the system prior to its possible roll-out. Qualitative analysis of the focus group data revealed five important factors influencing implementation: the treatment provider's ethos, the time-consuming nature of the OMS, staff buy-in, resources, and counselor and program discretion. Lessons learned underscored the importance of taking into consideration aspects of organizational change and institutional resources and infrastructure when implementing a major change such as an automated OMS. Findings might be useful to those designing and implementing similar systems or other large organizational change initiatives.

Treatment motivation in drug users: a theory-based analysis.

Motivation for drug use treatment is widely regarded as crucial to a client's engagement in treatment and success in quitting drug use. Motivation is typically measured with items reflecting high treatment readiness (e.g., perceived need for treatment and commitment to participate) and low treatment resistance (e.g., skepticism regarding benefits of treatment). Building upon reactance theory and the psychotherapeutic construct of resistance, we conceptualized these two aspects of treatment motivation - readiness and resistance - as distinct constructs and examined their predictive power in a sample of 1295 drug-using offenders referred to treatment while on probation. The sample was 60.7% African Americans, 33.5% non-Hispanic Whites, and 21.2% women; their ages ranged from 16 to 63 years old. Interviews occurred at treatment entry and 6 months later. Readiness (but not resistance) predicted treatment retention during the 6-month period. Resistance (but not readiness) predicted drug use, especially among offenders for whom the treatment referral was coercive. These findings suggest that readiness and resistance should both be assessed among clients entering treatment, especially when the referral is coercive. Intake and counseling protocols should address readiness and resistance separately.

Gender comparisons of drug abuse treatment outcomes and predictors.

Gender differences in drug treatment outcomes and predictors were examined among a sample of 511 patients recruited from drug treatment programs across Los Angeles County. Face-to-face interviews were conducted at baseline and at 1-year follow-up. Results showed that women and men started their drug use and treatment careers at similar ages, but men reported greater drug use and criminal involvement at baseline. There were no significant differences by gender in drug use and alcohol use at follow-up but men reported more crimes than women. Separate logistic regression analyses showed that for both women and men, longer treatment retention was associated with drug abstinence and crime desistence at follow-up. Additional baseline predictors of abstinence at follow-up included use of multiple drugs and readiness for treatment for women, and spousal drug use for men. For crime desistence, significant predictors include legal involvement and treatment readiness for women, and legal involvement, use of multiple drugs, and living with children for men. For both women and men, participation in 12-step groups and no spousal drug use during follow-up were related to abstinence. There were both similarities and differences in predictors of treatment outcome for women and men.

Treating drug-abusing offenders. Initial findings from a five-county study on the impact of California's Proposition 36 on the treatment system and patient outcomes.

Five counties (Kern, Riverside, Sacramento, San Diego, San Francisco) that demonstrate both variations and similarities in their implementation of Proposition 36 (e.g., treatment approaches, urine testing) and patient mix have been selected to participate in a study assessing how California's Proposition 36 is affecting the drug treatment system and patient outcomes. Except for San Francisco, treatment admissions increased during the first year of Proposition 36 implementation over the prior year (27% in Kern, 21% in Riverside, 17% in Sacramento, and 16% in San Diego), mostly in outpatient drug-free programs. Compared to non-Proposition 36 patients, Proposition 36 patients were more likely to be men, first-time admissions, treated in outpatient drug-free programs, employed full-time, and users of methamphetamine or marijuana. They were less likely to be treated in residential programs or methadone maintenance programs and fewer reported heroin use or injection drug use. Guided by the multilevel open systems framework, the study examines key issues of Proposition 36 that influence treatment systems and outcomes and empirically identifies "best practice" approaches in treating drug-abusing offenders.

Drug-use initiation and conduct disorder among adolescents in drug treatment.

This study investigated effects of drug-use initiation and conduct disorder (CD) among 1031 adolescents who participated in the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) sponsored by the National Institute on Drug Abuse (NIDA). The mean age of first drug use was 12.7 (S.D.=2.2), 57% met DSM-III-R criteria for CD, and earlier initiators were more likely to have CD. About 78% of the adolescents with CD reported that their first CD symptom occurred prior to drug-use initiation. The proportions of adolescents who had prior treatment were similar (about 28%) across all groups, but earlier initiators reported a greater number of treatment episodes and younger ages at their first treatment. Conduct disordered adolescents revealed greater problems prior to DATOS-A treatment, but they appeared to be more motivated and ready for treatment. Although adolescents with CD still showed worse outcomes after treatment, the impact of CD appeared to lessen when pretreatment differences were controlled. To a lesser extent, adolescents who began using drugs at earlier ages had greater alcohol and drug use and other problems at intake, but their treatment outcomes appeared to be similar to later initiators. There were few significant interaction effects of initiation and CD. Findings from this study highlight the importance of better understanding the progression of drug use, treatment utilization, and psychiatric comorbidity among adolescents with substance abuse problems.