Eigenvector centrality defines hierarchy and predicts graduation in therapeutic community units.

INTRODUCTION: Therapeutic communities (TCs) are mutual aid based residential programs for the treatment of substance abuse and criminal behavior. While it is expected that residents will provide feedback to peers, there has been no social network study of the hierarchy through which feedback flows. METHODS: Data for this study was drawn from clinical records of peer corrections exchanged between TC residents in six units kept over periods of less than two to over eight years. Four of the units served men while two served women. Hierarchy position was measured using eigenvector centrality, on the assumption that residents who were more central in the network of corrections were lower in the hierarchy. It was hypothesized that residents would rise in the hierarchy over time. This was tested using Wilcoxon paired samples tests comparing the mean and maximum eigenvector centrality for time in treatment with those in the last month of treatment. It was also hypothesized that residents who rose higher in the hierarchy were more likely to graduate, the outcome of primary interest. Logistic regression was used to test hierarchy position as a predictor of graduation, controlling for age, race, risk of recidivism as measured by the Level of Services Inventory-Revised (LSI-R) and days spent in the program. RESULTS: Residents averaged a statistically significantly lower eigenvector centrality in the last month in all units, indicating a rise in the hierarchy over time. Residents with lower maximum and average eigenvector centrality both over the length of treatment and in the last month of treatment were more likely to graduate in four of the six units, those with lower maximum and average eigenvector centrality in the last month but not over the length of treatment were more likely to graduate in one of the six units, while eigenvector centrality did not predict graduation in one unit. However, this last unit was much smaller than the others, which may have influenced the results. CONCLUSION: These results suggest that TC residents move through a social network hierarchy and that movement through the hierarchy predicts successful graduation.

Trend differences over 20 years between two methadone maintenance clinics, one with and one without cannabis legalization.

BACKGROUND: Although methadone maintenance treatment (MMT) guidelines are well established, patients' characteristics and outcome change over time may be affected by the legality of cannabis. OBJECTIVE: To study trend changes between two clinics over 20 years from Las Vegas (LV) and 27 years from Tel Aviv (TA). METHODS: Patients' characteristics at admission, including drugs in urine at first and 13th month were obtained from their medical charts. Changes by year of admission and cumulative retention were analyzed. RESULTS: The LV MMT clinic (1724 patients) had a lower one-year retention rate compared to the TA MMT clinic (1014 patients) (46.4% vs. 74.4%, respectively, p < 0.0005), and a higher rate of opioid stop after one year (75.9% vs. 68.8%, respectively, p = 0.003). The age at MMT admission and the retention rates decreased in LV and increased in TA. The prevalence of cannabis and benzodiazepine misuse on MMT admission increased in LV with no change recorded in TA. Cocaine on MMT admission decreased in LV and increased in TA, while amphetamine use increased in LV and decreased in TA. Cox models multivariate analyses found cannabis on admission to predict shorter retention in LV (as younger age male and amphetamines), and cannabis after one year in TA (as did cocaine and opiates after one year and BDZ on admission). CONCLUSION: Although cannabis prevalence increased only in LV where it was legalized, it was associated with poor outcomes in both clinics. Younger age, a known poor outcome predictor, may be related to decreased retention in LV.

Stability of Posttreatment Reductions in World Health Organization (WHO) Drinking Risk Levels and Posttreatment Functioning in Older Adults with DSM-5 Alcohol Use Disorder: Secondary Data Analysis of the Elderly Study.

BACKGROUND: Studies have found that reductions in World Health Organization (WHO) drinking risk levels may be a stable outcome of treatment for alcohol use disorder (AUD) and associated with functional improvements. The aim of this study was to investigate whether posttreatment reductions in WHO drinking risk levels are stable over time among older adults and associated with a decrease in consequences of drinking and AUD symptoms and improved quality of life. METHODS: Participants. Individuals 60+ years old, suffering from DSM-5 AUD (n = 693), and seeking outpatient treatment. MEASUREMENTS: WHO drinking risk levels, prior to treatment and at all follow-up points up to 1 year after treatment start, were assessed with Form 90. Outcomes at follow-up included consequences of drinking (Drinker Inventory of Consequences), quality of life (WHOQOL-BREF), and DSM-5 AUD symptoms (Mini International Neuropsychiatric Interview). Logistic regression and linear mixed models were used to examine the probability of maintaining risk-level reductions at follow-up and the association between risk-level reductions and outcomes, respectively. RESULTS: Reductions in risk levels were maintained over time (at least 1 level: OR 5.39, 95% CI 3.43, 8.47; at least 2 levels: OR 9.30, 95% CI 6.14, 14.07). Reductions were associated with reduced consequences of drinking and number of AUD symptoms, and minor, but statistically significant, improvements in quality of life. CONCLUSIONS: Maintaining reductions in WHO risk levels appears achievable for older adults seeking treatment for AUD. The small reduction of AUD symptoms and improvement of quality of life indicates that these reductions may not be adequate as the only treatment goal.

Optimizing Medication Treatment of Opioid Use Disorder During COVID-19 (SARS-CoV-2).

: The COVID-19 health crisis joined, rather than supplanted, the opioid crisis as the most acutely pressing threats to US public health. In the setting of COVID-19, opioid use disorder treatment paradigms are being disrupted, including the fact that methadone clinics are scrambling to give "take-home" doses where they would typically not. The rapid transition away from in-person examination, dosing and group therapy in an era of social isolation calls for adjustments to clinical practice, including emphasizing patient-provider communication, favoring new inductees on buprenorphine and leveraging technology to optimize safety of medication treatment.

The effect of medications for opioid use disorder (MOUD) on residential treatment completion and retention in the US.

BACKGROUND: This study examines whether MOUD increases treatment completion and retention in both short-term (ST) and long-term (LT) residential programs using a national dataset. METHODS: Data were extracted from the 2015-2017 TEDS-D (Treatment Episode Dataset-Discharge) datasets for opioid using adults in ST (n = 87,296) and LT (n = 66,623) residential treatment. Primary outcome variables were treatment completion and retention (ST: length of stay >10 days; LT: >90 days). Logistic regression estimated the effects of MOUD on the probability of treatment completion and retention separately for ST and LT residential treatment, controlling for individual background characteristics. RESULTS: Only 18% of clients in residential treatment programs had MOUD in their treatment plans. For ST residential treatment, MOUD was associated with a 40% increased likelihood of treatment completion (OR = 1.404) and 34% increased retention (OR = 1.337). For LT residential treatment, MOUD was associated with a 26% reduced likelihood of treatment completion (OR = 0.743) and no significant increase in retention. Post hoc analysis suggests insurance coverage may be influencing outcomes. CONCLUSIONS: Despite MOUD being a standard of care for OUD, MOUD is particularly under-utilized in residential treatment. Further research should focus on how best to integrate MOUD within short-term residential treatment and to explore the potential viability of MOUD in long-term residential programs. Given the risk of overdose following residential treatment, for at least short-term residential programs, this setting may be advantageous for integrating psychosocial treatments with early MOUD engagement in a structured therapeutic environment as part of a long-term continuum of care recovery program.

Item Response Theory analyses of DSM-5 substance use disorder criteria in French outpatient addiction clinic participants. How much is craving special?

BACKGROUND: To evaluate the dimensionality and psychometric validity of the 11 DSM-5 criteria for 5 substance use disorders, with a focus on craving, and taking into account age, gender and psychiatric comorbidities in a French sample of subjects seeking addiction treatment. METHODS: This cross-sectional study, included participants with DSM-5 substance use disorders that sought treatment for at least one addiction from outpatient clinics. Diagnostic criteria were evaluated with the Mini international Neuropsychiatric Interview. In Current regular user (2 times per week), factor and 2-parameter IRT analysis was used to investigate the dimensionality and psychometric properties of the 11 DSM-5 SUD criteria. Differential Item and Test functioning (DIF and DTF) analysis were performed across sociodemographic characteristics and psychiatric disorders. RESULTS: 1359 participants (alcohol n = 787, opiates n = 131, cocaine n = 141, tobacco n = 1014, cannabis n = 504), were included (68% male; mean age 38.7). One-factor dimensionality was confirmed, except for tobacco. Craving criterion had the strongest factor loadings, lower difficulty (range, -1.29 to -0.67) and higher discrimination (range, 2.11-3.05), and no DIF compared to other criteria. The tobacco criteria set functioned differently by mood and anxiety disorders. CONCLUSIONS: We confirmed the unidimensionality of the 11 SUD DSM-5 criteria and furthermore that craving was the most selective criterion because of its psychometric properties and no DIF compared to other criteria, regardless of the substance in this adult clinical sample. Unidimensionality of tobacco criteria was not confirmed, suggesting DSM-IV abuse criteria limitations as indicators of the construct.

Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky.

BACKGROUND: Illicit, medically unsupervised use of buprenorphine (i.e., "diverted use") among vulnerable and underserved populations, such as corrections-involved adults, remains underexplored. METHODS: Survey data (2016-2017) collected as part of a clinical assessment of incarcerated adults entering corrections-based substance use treatment in Kentucky were analyzed. For years examined, 12,915 completed the survey. Removing cases for participants who did not reside in Kentucky for >6 months during the one-year pre-incarceration period (n = 908) resulted in a final sample size of 12,007. RESULTS: Over a quarter of the sample reported past-year diverted buprenorphine use prior to incarceration and 21.8 % reported use during the 30-days prior to incarceration, using 6.5 months and 14.3 days on average, respectively. A greater proportion of participants who reported diverted buprenorphine use had previously been engaged with some substance use treatment (77.0 %) and reported greater perceived need for treatment (79.4 %) compared to those who did not report use. Use was more likely among participants who were younger, white, male, and who reported rural or Appalachian residence. Diverted buprenorphine users also evidenced extensive polydrug use and presented with greater substance use disorder severity. Non-medical prescription opioid, heroin, and diverted methadone use were associated with increased odds of diverted buprenorphine use while kratom was not. Diverted methadone use was associated with a 252.9 % increased likelihood of diverted buprenorphine use. CONCLUSIONS: Diverted buprenorphine use among participants in this sample was associated with concerning high-risk behaviors and may indicate barriers to accessing opioid agonist therapies for corrections-involved Kentucky residents, particularly those in rural Appalachia.

Cerebellar Morphometry and Cognition in the Context of Chronic Alcohol Consumption and Cigarette Smoking.

BACKGROUND: Cerebellar atrophy (especially involving the superior-anterior cerebellar vermis) is among the most salient and clinically significant effects of chronic hazardous alcohol consumption on brain structure. Smaller cerebellar volumes are also associated with chronic cigarette smoking. The present study investigated effects of both chronic alcohol consumption and cigarette smoking on cerebellar structure and its relation to performance on select cognitive/behavioral tasks. METHODS: Using T1-weighted Magnetic Resonance Images (MRIs), the Cerebellar Analysis Tool Kit segmented the cerebellum into bilateral hemispheres and 3 vermis parcels from 4 participant groups: smoking (s) and nonsmoking (ns) abstinent alcohol-dependent treatment seekers (ALC) and controls (CON) (i.e., sALC, nsALC, sCON, and nsCON). Cognitive and behavioral data were also obtained. RESULTS: We found detrimental effects of chronic drinking on all cerebellar structural measures in ALC participants, with largest reductions seen in vermis areas. Furthermore, both smoking groups had smaller volumes of cerebellar hemispheres but not vermis areas compared to their nonsmoking counterparts. In exploratory analyses, smaller cerebellar volumes were related to lower measures of intelligence. In sCON, but not sALC, greater smoking severity was related to smaller cerebellar volume and smaller superior-anterior vermis area. In sALC, greater abstinence duration was associated with larger cerebellar and superior-anterior vermis areas, suggesting some recovery with abstinence. CONCLUSIONS: Our results show that both smoking and alcohol status are associated with smaller cerebellar structural measurements, with vermal areas more vulnerable to chronic alcohol consumption and less affected by chronic smoking. These morphometric cerebellar deficits were also associated with lower intelligence and related to duration of abstinence in sALC only.

The evolution of addiction treatment and harm reduction programs in Iran: a chaotic response or a synergistic diversity?

BACKGROUNDS AND AIMS: Iran has 2.1 and 1.8% of its 15-64-year-old population living with illicit substance and opioid use disorders, respectively. To address these problems, Iran has been developing a large and multi-modality addiction treatment system, spanning the time before and after the Islamic Revolution. METHODS: Iran's current drug treatment scene is a combination of services, ranging from medical/harm reduction services to punitive/criminal justice programs. Included in this array of services are drop-in centers providing low-threshold harm reduction services, such as distribution of sterile needles and syringes; opioid maintenance treatment clinics providing methadone, buprenorphine and opium tincture; and abstinence-based residential centers. We will review the evolution of this system in four phases. RESULTS: In 1980, Iran's revolutionary government shut down all voluntary treatment programs and replaced them with residential correctional programs. The first shift in the addiction treatment policies came 15 years later after facing the negative consequences. Addiction is viewed as a disease, and new voluntary treatment centers offering non-agonist medications and psychosocial services were established. With an increased number of people who inject drugs and HIV/AIDS epidemics, in the second shift an extensive move towards harm reduction strategies and opioid-maintenance programs has been implemented to reduce HIV-related high-risk behavior. The emergence of a methamphetamine use crisis creating an increased number of socially marginalized addicted people resulted in public and political demands for stricter policies and ended in the third shift starting in 2010, with extended compulsory court-based residential programs. Currently, there is a new shift towards reducing the severity of criminal penalties for drug use/sales and promoting proposals for opium legalization. CONCLUSION: Iran's evolutionary experience in developing a large addiction treatment program in a complex combination of medical/harm reduction and punitive/criminal justice addiction treatment can be examined in its political, clinical and pragmatic context.

Addiction-Focused Eye Movement Desensitization and Reprocessing Therapy as an Adjunct to Regular Outpatient Treatment for Alcohol Use Disorder: Results From a Randomized Clinical Trial.

BACKGROUND: This study examined the feasibility, safety, and efficacy of addiction-focused eye movement desensitization and reprocessing (AF-EMDR) treatment, as an add-on intervention to treatment as usual (TAU). METHODS: Adult outpatients with alcohol use disorder (AUD) (N = 109) who already received or had just started with TAU (Community Reinforcement Approach) were recruited at 6 outpatient addiction care facilities. They were randomly assigned to either TAU + 7 weekly 90-minute sessions of AF-EMDR (N = 55) or TAU-only (N = 54). Assessments were made at baseline, after AF-EMDR therapy (+ 8 weeks in the TAU-only group), and at 1- and 6-month follow-up. The primary outcomes were changes in drinking behavior as reported by the participant and biomarker indices. RESULTS: Data were analyzed as intent-to-treat with linear mixed models. Additionally, sensitivity analyses were performed. No group or interaction effects were found for any of the outcome variables. Only limited change over time was seen with regard to indices of personal and societal recovery and in some secondary indices of clinical recovery (craving, desire thinking, and rumination). Reliable Change Index calculations showed that more TAU-only participants showed clinical improvement with regard to alcohol consumption while a somewhat higher proportion of participants in the TAU + AF-EMDR group experienced less craving. The acceptability, safety, and feasibility of the treatments received in both groups were comparable. CONCLUSIONS: There was no add-on effect of AF-EMDR on TAU with regard to drinking behavior in outpatients with an AUD. Possible explanations are discussed. Future studies should first establish proof of principle regarding the potential of AF-EMDR therapy to disrupt operant learning and habits relevant in addiction.

Characteristics and current clinical practices of opioid treatment programs in the United States.

BACKGROUND: Given rising rates of opioid use disorder (OUD) and related consequences, opioid treatment programs (OTPs) can play a pivotal role in the U.S. opioid crisis. There is a paucity of recent research to guide how best to leverage OTPs in the opioid response. METHODS: We conducted a national survey of U.S. OTPs using a 46-question electronic survey instrument covering three domains: 1) OTP characteristics; 2) services offered; and 3) current clinical practices. Descriptive statistics and multivariable logistic regression examined variables in these domains. RESULTS: Among responding OTPs, 32.4% reported using all three medications for OUD treatment; 95.8% used methadone, 61.8% used buprenorphine, and 43.9% used naltrexone. The mean (SD) number of patients currently receiving methadone was 383 (20.4), buprenorphine 51 (7.0), extended-release naltrexone 6 (1.0). Viral hepatitis testing was provided by 60.9% of OTPs, 15.3% provided hepatitis B vaccination, 14.9% provided hepatitis A vaccination, and 12.6% provided medication treatment for hepatitis C virus infection. HIV testing was provided by 60.7% of OTPs, 9.5% provided pre-exposure prophylaxis, and 8.4% provided medication treatment for HIV. OTP characteristics associated with using all three forms of medications for OUD included: providing medication for alcohol use disorder (aOR = 5.24, 95% CI:2.99-9.16), providing telemedicine services (aOR = 3.82, 95% CI:2.14-6.84), and directly providing naloxone to patients (aOR = 2.57, 95% CI:1.53-4.29). Multiple barriers to providing buprenorphine and extended-release naltrexone were identified. CONCLUSIONS: Efforts are needed to increase availability of all medications approved to treat OUD in OTPs, integrate infectious disease-related services, and expand the reach of OTPs in the U.S.

Trends in first-time treatment admissions for older adults with alcohol use disorder: Availability of medical and specialty clinical services in hospital, residential, and outpatient facilities.

BACKGROUND: Alcohol use disorder (AUD) is a growing problem among older adults. The aim of this study was to quantify trends in first-time treatment admissions for older adults with AUD in the U.S., and examine the medical and specialty clinical services offered by treatment facility type. METHODS: Patient level data were collected from the Treatment Episode Data Set for Admissions between 2004-2017. Joinpoint regression was used to identify unique trends in first-time treatment admissions for older adults with AUD. Provider level data were collected from the National Survey of Substance Abuse Treatment Services (N-SSATS) for the most recent year, 2017. N-SSATS data were grouped by facility type (inpatient/hospital, residential, and outpatient treatment) to examine differences in medications and clinical services. RESULTS: Among all persons seeking first-time treatment for AUD with alcohol as their primary drug of choice (n = 3,606,948), there was a significant increase in the proportion of older adults seeking treatment from 2004 to 2017 (p-trend<0.001), with an average annual percent change of 6.8% (95% confidence intervals: 6.2%-7.4%). The majority of older adults with AUD sought treatment in outpatient and residential facilities, which compared to hospital-based facilities had lower odds of offering supervised detoxification, acamprosate, naltrexone, psychiatric medications, or mental health services (all p-values<0.001). Fewer than 25% of hospital-based and 20% of residential or outpatient facilities offered specialty services for older adults. CONCLUSIONS: U.S. substance abuse treatment providers are not compensating for the changing nature of admissions by older adults, and are not providing state of the art services for this population.

Drug-related mortality after discharge from treatment: A record-linkage study of substance abuse clients in Texas, 2006-2012.

BACKGROUND: Patients have higher mortality immediately after substance abuse treatment discharge, but there are few data on post-discharge mortality differences across treatment modalities. METHODS: A retrospective cohort study examined individuals discharged from substance abuse treatment during 2006-2012 and probabilistically matched treatment records to death records. Logistic regression examined associations between drug-related death (DRD) and demographics; route, frequency, and classes of drugs abused; and treatment. Primary outcome was DRD during post-discharge days 0-28; secondary outcomes examined DRD during days 29-90 and 91-365. RESULTS: We examined 178,749 patients discharged from 254,814 treatment episodes. There were 97 DRD during days 0-28 (4.1/1000 person-years), 115 DRD during days 29-90 (2.6/1000 person-years; IRR 0.6 [95% CI 0.5-0.8]), and 293 DRD during days 91-365 (1.9/1000 person-years; IRR 0.5 [0.4-0.6]). Higher 28-day DRD was associated with abuse of opioids (aOR 2.5 [1.4-4.4]), depressants (aOR 2.0 [1.2-3.4]), or alcohol (aOR 1.7 [1.1-2.6]); and opioid injection (aOR 2.2 [1.3-3.7]). Lower DRD was associated with treatment completion (aOR 0.6 [0.4-0.9]), female sex (aOR 0.6 [0.4-0.8]), and employment (aOR 0.5 [0.3-0.9]). Among all patients, DRD rates were higher following residential (IRR 2.6, [1.6-4.2]) and detoxification (IRR 2.9, [1.7-4.9]) treatment compared to outpatient. Patients with prior opioid abuse had higher 28-day DRD after outpatient (6.7/1000 person-years; IRR 4.1 [1.8-9.1]), residential (13.6/1000 person-years; IRR 4.2 [2.2-8.2]), and detoxification (8.8/1000 person-years; IRR 3.2 [1.2, 8.5]) compared to those without. CONCLUSIONS: Drug-related mortality is highest during days 0-28 after discharge, especially following residential and detoxification treatment. Opioid abuse is strongly associated with early post-discharge mortality.

Associations between methamphetamine use, psychiatric comorbidities and treatment outcome in two inpatient rehabilitation centers.

The use of methamphetamine is spreading globally and provokes the need for effective treatment options. Previous research showed increased psychiatric comorbidities in methamphetamine users, but its impact on treatment success is still unclear. This study investigates data from two German addiction rehabilitation centers including 108 methamphetamine using individuals. The participants were tested and interviewed at the beginning of the addiction treatment program and at the end of treatment after about six months. In total, 95% of the participants had at least another psychiatric diagnosis. At admission, substance related comorbid diagnoses (meaning abuse or addiction of other substances than methamphetamine) showed a significant effect on treatment dropout. Within the substance related diagnoses, the majority of participants (62%) suffered from cannabinoid dependency. Non-substance related comorbidities and the total number of comorbid diagnoses did not have an impact on treatment outcome. The most frequent non substance specific diagnosis at admission was a depressive disorder (15%). Diagnoses patients had at discharge did not show any effects on the treatment completion. Comparing diagnoses at admission and discharge revealed slight differences, which may rise from a better assessment at discharge due to the fact that clinicians got to know the patients better during the therapeutic process.

The effectiveness of residential treatment services for individuals with substance use disorders: A systematic review.

BACKGROUND: Residential treatment is a standard treatment for individuals with severe and complex substance use problems. However, there is limited evidence on best practice approaches to treatment in these settings. This review provides a comprehensive update on the evidence base for residential treatment, and directions for future research and clinical practice. METHOD: A systematic review of all studies published between January 2013 and December 2018 was conducted. Public health and psychology databases (Medline, CINAHL, PsycARTICLES and PsycINFO) were systematically searched, and forward and backward snowballing were used to identify additional studies. Studies were included if they were quantitative, assessed the effectiveness of residential substance treatment programs for adults, were published in the English language and in peer-reviewed journals. The Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies was used to assess methodological quality. RESULTS: Our search identified 23 studies. Eight were rated as methodologically strong, five as moderate and ten rated as weak. Quality ratings were impacted by attrition at follow-up and research design. Despite limitations, results provide moderate quality evidence for the effectiveness of residential treatment in improving outcomes across a number of substance use and life domains. CONCLUSION: With caution, results suggest that best practice rehabilitation treatment integrates mental health treatment and provides continuity of care post-discharge. Future research and practice should focus on better collection of outcome data and conducting data linkage of key health, welfare and justice agency administrative data to enhance understanding of risk and recovery trajectories.

Prediction of psychiatric comorbidity on premature death in a cohort of patients with substance use disorders: a 42-year follow-up.

BACKGROUND: We need to better understand how the use of different substances and psychiatric comorbidity influence premature death generally and cause-specific death by overdose, intoxication and somatic disorders in people with substance use disorders. METHOD: A cohort of 1405 patients consecutively admitted to a Swedish detoxification unit for substance use disorders in 1970-1995 was followed-up for 42 years. Substances were identified by toxicological analyses. Mortality figures were obtained from a national registry. Causes of death were diagnosed by forensic autopsy in 594 patients deceased by 2012. Predictions were calculated by competing risks analysis. RESULTS: Forty-two per cent of the cohort died during follow-up; more men than women (46.3% vs 30.4%). The standardised mortality ratio (SMR) was calculated as the ratio of observed deaths in males and females in specific age groups in the cohort versus expected deaths in corresponding groups in the general population. SMR was 5.68 for men (CI 95%; 5.04-6.11) and 4.98 (CI 95%; 4.08-5.88) for women. The crude mortality rate (number of deaths divided by number of person observation years) was 2.28% for men and 1.87% for women. Opiates predicted increased risk of premature death while amphetamine and cannabis predicted lower risk. Comorbid psychiatric disorders were identified in 378 cases and personality disorders in 763 cases. Primary psychoses or mood/depression and anxiety disorders predicted a higher risk of premature mortality. Death by overdose was predicted by male gender, younger age at admission to substance treatment, opiate use, and comorbid depression and anxiety syndromes. Cannabis and amphetamine use predicted a lower risk of overdose. Death by intoxication was predicted by male gender, use of sedatives/hypnotics or alcohol/mixed substances, primary psychoses and depression/anxiety syndromes. Premature death by somatic disorder was predicted by male gender and alcohol/mixed abuse. CONCLUSION: Psychiatric comorbid disorders were important risk factors for premature drug-related death. Early identification of these factors may be life-saving in the treatment of patients with substance use disorders.

Outcome in Relation to Drinking Goals in Alcohol-Dependent Individuals: A Follow-up Study 2.5 and 5 Years After Treatment Entry.

AIMS: To evaluate the long-term treatment outcome (up to 5 years) with respect to different drinking goals of patients. METHODS: Alcohol-dependent individuals (n = 349) were recruited from three alcohol treatment units. They were interviewed using the Addiction Severity Index (ASI). They were sub-grouped according to their goal at treatment entry: abstinence, low- risk drinking and no decided goal. RESULTS: Patients with abstinence as a goal at treatment entry reported at 2.5 years follow-up a higher abstinence rate, a more pronounced reduction in alcohol consumption, reduction in total number of DSM-IV criteria, higher frequency of low-risk drinking and fewer diagnoses of alcohol dependence compared to the groups who had low risk drinking as a goal or no decided goal. This improvement remained basically unchanged in all three groups at 5 years follow-up, suggesting long-term stability after the treatment interventions. CONCLUSIONS: The findings suggest that: (1) alcohol-dependent patients who have abstinence as their own drinking goal have a more favorable treatment outcome than those who have low-risk drinking as a goal or no decided goal. (2) Abstinence as a drinking goal should be considered for those who have a longer duration (for example more than 10 years) of their alcohol-related problems. (3) Patients who have no decided goal should be recommended abstinence as a drinking goal.

Why Research Should Pay Attention to Effects of Marketization of Addiction Treatment Systems.

OBJECTIVE: Researchers generally assume that addiction treatment systems can be viewed as entities and planned with the citizens' best interests in mind. We argue that another steering principle, the market logic, has permeated many Western World treatment systems but is neglected in research. We demonstrate how it may affect system-level planning, service provision, and the service users. METHOD: We draw on an ongoing Swedish study, with some Nordic references, using several data sources: (1) public statistics on treatment expenditures and purchases; (2) interviews with service users (n = 36) and their service providers (n = 23) on different market features; (3) an observation of a large public procurement process concluding framework agreements based on competitive tendering; (4) interviews with officials involved with steering of the system and procurement (n = 16); (5) a workshop on procurement in the Nordic countries (n = 11 participants); and (6) 77 interviews with professionals, managers, and elected representatives. RESULTS: We outline seven propositions that call for further research attention: public procurement, as regulated in the European Union, is not suitable for addiction treatment; marketization challenges democracy, equity, needs assessment, and treatment planning; marketization causes new accountability problems and idle monitoring; marketization causes fragmentation and obstructs coordination and continuity of care; marketization causes unification of services and favors big bureaucratically sophisticated providers; treatment professionals' values are downplayed when a mistrust-based market logic replaces a trust- and needs-based logic; and marketization marginalizes treatment professionals and service users by limiting discretion. CONCLUSIONS: Findings point toward the importance of acknowledging and mitigating market principles in treatment systems to safeguard needs assessments and planning that serve the interests of the service users and the public.