Classifying substance use disorder treatment facilities with co-located mental health services: A latent class analysis approach.

BACKGROUND: The Affordable Care Act calls for increased integration and coordination of behavioral health services, as people with co-occurring disorders (CODs), meeting criteria for both substance use and psychiatric disorders, are overrepresented in treatment samples. Nationwide estimates of mental health (MH) service co-location in substance use disorder (SUD) treatment facilities are needed. We empirically derived a multiple-indicator categorization of services for CODs in SUD treatment facilities. METHODS: We used latent class analysis to categorize 14,037 SUD treatment facilities in the United States and territories included in the 2012 National Survey of Substance Abuse Treatment Services. Latent class indicators included MH screening and diagnosis, MH support services, psychiatric medications, groups for CODs, and psychosocial approaches. Multinomial logistic regression compared facility-identified primary focus (i.e., SUD, MH, mix of SUD-MH, and general/other) and other facility characteristics across classes. RESULTS: A four-class solution was chosen with the following classes: Comprehensive MH/COD Services (25%), MH without COD Services (25%), MH Screening Services (21%), and Limited MH Services (29%). The former two classes with co-located MH services were less likely to report a SUD-primary focus than the latter classes reporting only MH screening or Limited MH Services. Only the Comprehensive MH/COD Services class also had a high probability of providing special groups for CODs. CONCLUSIONS: Approximately half of SUD treatment facilities were in classes with co-located mental health services, but only a quarter provided comprehensive COD services. Future studies should assess differences in patient experiences and treatment outcomes across facilities with and without COD services.

Organizational capacity to address co-occurring substance use and psychiatric disorders: assessing variation by level of care.

OBJECTIVES: There is widespread recognition that services to persons with co-occurring substance use and psychiatric disorders should be accessible, yet most persons with these disorders do not receive care for both problems. Estimates of available services vary widely and have not examined potential variation by level of care. METHODS: The present study samples 180 community addiction treatment programs and utilizes a standardized observational assessment of these programs using the dual diagnosis capability of addiction treatment (DDCAT) index. By level of care, the sample consisted of 53 outpatient programs, 50 intensive outpatient programs, and 77 residential programs. RESULTS: Overall, approximately 81.1% of programs across levels of care offered addiction-only services, 18.3% dual diagnosis capable services, and less than 1% dual diagnosis enhanced services. Relative to residential and intensive outpatient programs, outpatient programs were more likely to have greater dual diagnosis capability (dual diagnosis capable services). Outpatient programs scored significantly higher on the DDCAT dimensions associated with program policies and continuity of care. Specific DDCAT benchmark items revealing detailed differences were found in these dimensions and specific assessment and treatment practices. Access to physician-prescriber or to psychotropic medications did not differ by level of care. CONCLUSIONS: The findings suggest that across levels of care, addiction-treatment systems and programs must continue to improve capacity for patients with co-occurring disorders. The application of a standardized, objective, and observational instrument may be useful to guide and measure the effectiveness of these efforts.

Racial/ethnic differences in access to substance abuse treatment.

A secondary dataset, Collaborative Psychiatric Epidemiology Surveys (CPES), 2001-2003, was employed to examine racial/ethnic differences in access to specialty and non-specialty substance abuse treatment (compared with no access to treatment). The study found that non-Hispanic White Americans were (1) likelier than members of all racial/ethnic minority groups (other than Hispanics) to address substance abuse by accessing care through specialty addiction-treatment facilities, and were (2) also less likely to access substance abuse care through non-specialty facilities. Because non-specialty facilities may have staffs whose professional training does not target treating chronic, bio-psycho-social illness such as substance abuse, our results imply that treatment facilities deemed non-specialty may need to enhance staff training, in order to ensure individuals are properly screened for substance use conditions and are referred for or provided with effective counseling and medications as appropriate.

Controlled-release oxycodone admissions in public and private substance abuse treatment: associations with organizational characteristics.

Although non-medical use of controlled-release (CR) oxycodone is increasing, little is known about the substance abuse treatment facilities serving individuals dependent on this medication. This study examines the associations between the characteristics of treatment organizations and two dependent variables: any CR-oxycodone admissions and the number of CR-oxycodone admissions in the past six months. Face-to-face interviews were conducted with administrators of 363 publicly funded and 401 privately funded treatment centers in the US. Publicly funded non-profit organizations were less likely to have treated this population than government- owned, privately funded non-profit, and for-profit treatment centers. Some evidence indicated the availability of pharmacotherapies and detoxification services were associated with the dependent variables. Twelve-step programs were more likely to have treated oxycodone-dependent clients. Rural facilities treated significantly more clients than those in metropolitan areas. The high prevalence of CR-oxycodone admissions suggests the need for widespread training of treatment providers regarding treatment for CR-oxycodone dependence.

Propuesta de inclusión curricular de la unidad temática: "Menejo de adolescentes con dependencia de sustancias psicoactivas en la residencia medica de pediatria, HMI, gestión 2001-2004 / Proposal of curriculum inclusion of the thematic unit: \"Management of adolecentes with dependency of psychoactive substances in the medical pediatric residence, HMI, management 2001-1004

El presente trabajo se realizo por la motivación surgida, al observar el tratamiento que realizan actualmente los Médicos Residentes de Pediatria en el Hospital Materno Infantil de la Caja Nacional de Salud, a pacientes hospitalizados en edad adolecente con dependencia de sustancias psicoactivas y por el incremento de hospitalizaciones en los últimos años de este grupo de pacientes. Actualmente, el tratamiento de éstos pacientes ha adquirido un sin fin de consideraciones, entre ellas es saber reconocer que es de orden integral, o sea, que intervienen además del Médico Pediatria, un equipo formado por Trabajadora Social, Psicólogo, Psiquiatra y una enfermera que trabajan simultáneamente para lograr éxito en el manejo; otras consideraciones a tener en cuenta es que los profesionales jóvenes son los que tienen más posiblidades se acercarse al paciente y logar que ellos acepten su recuperación y, una vez egresados Pediatras, los Residentes en su práctica cotidiana deberán de desenvolverse con la mayor sabiduraia rescatando los conocimientos que recibieron durante su formación...

Documenting changes in the delivery of substance abuse services: the Status of the "100 best treatment centers for alcoholism and drug abuse" of 1988.

This study explores the impact of managed care on the substance abuse service system by reviewing the current status of the programs that were among the elite service providers in 1988. A survey was conducted assessing the status of the one hundred centers touted as the 100 best treatment centers for alcoholism and drug abuse (Sunshine& Wright, 1988). Findings include the following: Almost a third of these centers (31%) are no longer providing services, the majority of the programs who reported data continue to provide services primarily at a residential level of care (92%); however occupancy rates have dropped, the number of annual inpatient admissions have risen, and the length of treatment episodes has significantly decreased. In 1988, almost all (97.5%) facilities adhered to the 28-day treatment regiment, as evidenced by average treatment episodes of 26 days or longer. However, in 2001, the majority of programs (57.5%) reported treatment episodes of 25 days or less. While these facilities represent a fraction of the number of facilities that provide substance abuse services, they do exemplify elite programs that should be insulated from economic troubles, and help to document the changes that have occurred in the delivery system. Awareness of these changes is important for every social worker that advocates for substance abuse services.

Factors associated with interorganizational relationships among outpatient drug treatment organizations 1990-2000.

OBJECTIVE: To identify the factors associated with drug abuse treatment center participation in interorganizational relationships (IORs). DATA SOURCES: Three nationally representative samples of outpatient drug abuse treatment units surveyed in 1990, 1995, and 1999/2000 as part of the National Drug Abuse Treatment System Survey (NDATSS), stratified by public/private status, treatment modality (methadone or nonmethadone), and organizational affiliation. STUDY DESIGN: Probit analyses on 647 lagged treatment center-year observations from the years 1990 to 1995 with outcomes in 1995 and 2000, respectively. Standard errors were adjusted for clustering of center-year observations within centers. PRINCIPAL FINDINGS: Centers with greater motivation to form IORs (e.g., as a result of client diversity or government revenue) were more likely to do so, as were centers with greater opportunities to form IORs (e.g., centers whose directors participated in policy making). CONCLUSIONS: Both motivating and enabling factors promoted the formation of IORs by drug abuse treatment centers. Managed care also played a distinct role, in this case appearing to undermine interorganizational cooperation. Because IORs can improve access to care and quality, policy makers should consider using both incentives and support such as management training to promote IOR formation.

Opinión de los usuarios sobre la atención prestada en un centro ambulatorio de atención a drogodependientes / User perception of services received at an outpatient drug addiction treatment centre

Fundamento: El propósito de este estudio es conocer qué piensan los usuarios del Centro de Drogodependencias de Mérida, sobre la atención que se les está prestando Métodos: Estudio descriptivo. Período del estudio: septiembre, octubre y primera quincena de noviembre de 2001. La opinión sobre la satisfacción de los usuarios se realizó mediante cuestionario elaborado ad hoc que contemplaba 6 dimensiones: accesibilidad, información sobre proceso terapéutico, intervención, horarios de atención y tiempos de espera, instalaciones y servicios, y valoración global. El cuestionario fue entregado a todos los pacientes del Centro que cumplían los criterios de inclusión.Resultados: La puntuación media de la dimensión valoración global obtuvo un 4,88 (ñ 1,13) en una escala de 1 a 6. La proporción de usuarios satisfechos, estableciendo el punto de corte para la dimensión Valoración Global en 4, fue del 86,5 por ciento. La puntuación más baja la recibió la dimensión Instalaciones y Servicios, siendo su ítem peor valorado las Instalaciones. La dimensión mejor valorada fue la Accesibilidad. Conclusiones: La opinión de los usuarios sobre la atención prestada es en general muy positiva. Mejoraría con pequeños cambios en la labor de los profesionales (información a los pacientes sobre opciones de tratamiento y secundarismos de fármacos) y con grandes cambios estructurales (gestión de recursos humanos, ampliación de horarios y mejora de las instalaciones) (AU)

Risk selection and matching in performance-based contracting.

This paper examines selection and matching incentives of performance-based contracting (PBC) in a model of patient heterogeneity, provider horizontal differentiation and asymmetric information. Treatment effectiveness is affected by the match between a patient's illness severity and a provider's treatment intensity. Before PBC, a provider's revenue is unrelated to treatment effectiveness; therefore, providers supply treatments even if their treatment intensities do not match with the patients' severities. Under PBC, budget allocation is positively related to treatment performance; patient-provider mismatch is reduced because patients are referred more often. Using data from the state of Maine, we show that PBC leads to more referrals and better match between illness severity and treatment intensity. Moreover, we find that PBC has a positive but insignificant effect on dumping.

On-site HIV testing in residential drug treatment units: results of a nationwide survey.

OBJECTIVE: Residential drug treatment units are uniquely situated to provide HIV testing and counseling to their patients. This article examines the extent to which residential drug treatment units in the United States provide HIV testing on-site, and identifies organizational and institutional characteristics that differentiate units in which on-site HIV testing is available from those in which it is not. METHODS: The analyses use data collected in telephone interviews with unit managers from a random nationwide sample (N = 138) of residential drug treatment units in 2001. RESULTS: About half (48.6%) of the residential drug treatment units made HIV testing available to their patients on-site. Residential units were significantly more likely to make on-site testing available if they were larger (i.e., had a greater number of patients treated each month or had a greater number of staff that provided direct patient services) and if they were publicly rather than privately owned. Provision of on-site HIV testing was significantly correlated with having a medical orientation, i.e., with being operated by a hospital, with the unit viewing itself as patients' primary medical provider, or with providing medical care to the patients either on-site or at another part of the same treatment agency. CONCLUSION: In view of the critical importance of HIV testing for individuals who use illicit drugs and the existence of a simplified testing protocol involving saliva samples (eliminating the need for phlebotomy), units that do not have a medical orientation should be encouraged to make HIV testing available on-site.

Determining service variations between and within ASAM levels of care.

The American Society of Addiction Medicine (ASAM) Criteria Validity Study at Massachusetts General Hospital and Harvard Medical School randomized patients between programs in two levels of care. It therefore became critical to determine the extent to which programs met ASAM level of care (LOC) descriptions. Quantitative surveys (checklist) and qualitative case studies (field observation, key informant interviews) documented care variation within and between two ASAM LOCs in 12 substance abuse treatment units. These LOCs were: Level II (Intensive Outpatient Treatment) and Level III (Medically Monitored Residential Treatment). The Level II and Level III programs, as a group, met ASAM LOC criteria, but data showed major within-level variation by hours per day and number and type of skilled treatment services. Observational data suggest considerable within-level variation due to managed care and staff training. In multi-site PPC validity studies, it will be crucial to examine within-LOC variation and take into account payment sources and staff training when assessing patient outcomes.

Managed care and technical efficiency in outpatient substance abuse treatment units.

This article examines (1) the extent to which managed care participation is associated with technical efficiency in outpatient substance abuse treatment (OSAT) organizations and (2) the contributions of specific managed care practices as well as other organizational, financial, and environmental attributes to technical efficiency in these organizations. Data are from a nationally representative sample survey of OSAT organizations conducted in 1995. Technical efficiency is modeled using data envelopment analysis. Overall, there were few significant associations between managed care dimensions and technical efficiency in outpatient treatment organizations. Only one managed care oversight procedure, the imposition of sanctions by managed care firms, was significantly associated with relative efficiency of these provider organizations. However, several organizational factors were associated with the relative level of efficiency including hospital affiliation, mental health center affiliation, JCAHO accreditation, receipt of lump sum revenues, methadone treatment modality, percentage clients unemployed, and percentage clients who abuse multiple drugs.

Drug-user treatment programs in a large metropolitan area.

This paper discusses the results of a comprehensive survey of one of the largest drug-user treatment systems in the United States--the system in Los Angeles County, California, which contains more than 300 programs, covers over 4,000 square miles, and serves clients from a notably heterogeneous population of almost nine million people. The survey reported on here was distinct from similar surveys in that it provided simultaneously comprehensive and in-depth descriptions of formal treatment programs in a defined local area. The authors believe that this survey is the first local drug-user treatment program survey of its scope and magnitude in the United States.

Cost-effectiveness of inpatient substance abuse treatment.

OBJECTIVE: To identify the characteristics of cost-effective inpatient substance abuse treatment programs. DATA SOURCES/STUDY SETTING: A survey of program directors and cost and discharge data for study of 38,863 patients treated in 98 Veterans Affairs treatment programs. STUDY DESIGN: We used random-effects regression to find the effect of program and patient characteristics on cost and readmission rates. A treatment was defined as successful if the patient was not readmitted for psychiatric or substance abuse care within six months. PRINCIPAL FINDINGS: Treatment was more expensive when the program was smaller, or had a longer intended length of stay (LOS) or a higher ratio of staff to patients. Readmission was less likely when the program was smaller or had longer intended LOS; the staff to patient ratio had no significant effect. The average treatment cost $3,754 with a 75.0% chance of being effective, a cost-effectiveness ratio of $5,007 per treatment success. A 28-day treatment program was $860 more costly and 3.3% more effective than a 21-day program, an incremental cost-effectiveness of $26,450 per treatment success. Patient characteristics did not affect readmission rates in the same way they affected costs. Patients with a history of prior treatment were more likely to be readmitted but their subsequent stays were less costly. CONCLUSIONS: A 21-day limit on intended LOS would increase the cost-effectiveness of treatment programs. Consolidation of small programs would reduce cost, but would also reduce access to treatment. Reduction of the staff to patient ratio would increase the cost-effectiveness of the most intensively staffed programs.

A county survey of mental health services in drug treatment programs.

Forty-five administrators of drug treatment programs in Los Angeles County were surveyed about the adequacy of mental health services within their program and the drug treatment system. Approximately half agreed that dually diagnosed clients are not served within the system, and the majority noted that their programs restrict admission of such clients. Administrators of outpatient drug-free programs and methadone maintenance programs were more likely to characterize their mental health services as inadequate or unavailable than were administrators of other types of programs. The findings suggest the need to increase awareness of the treatment needs of dually diagnosed clients in drug treatment programs.

Anuario 92 : antecedentes, investigación, prevención en la comunidad, capacitación, misceláneas / En

El anuario no hace notar en considerable incremento que se ha dado en la producción,el trafico y el consumo de drogas en todo el país

Riesgos macrosociales de farmacodependencia a nivel municipal y red estratégica de atención en México. Plan rector institucional a mediano plazo 1989-1994 / Macrosocial risks of drugdependency in the municcipal level and the strategic net of attention in Mexico. Institutional plan 1989-1994

El presente trabajo es un ensayo metodológico, en el que se aplican una serie de variables indirectas relacionadas con la aparición y propagación del fenómeno de la farmacodependencia en México. Para este fin, se desagrega la población tomando en cuenta las condiciones de riesgo a las que está sujeta, así como las características que inciden en el problema. Mediante esta metodología se logra determinar a aquella población que la Institución considera como objetivo para los servicios que presta, así como identificar regiones de muy alto, alto, medio, y bajo riesgo. Debido a las diferencias que existen entre los Municipios de un Estado y entre estos mismos, el análisis para la totalidad del país se realizó a nivel municipal. De acuerdo con los resultados obtenidos, Centros de Integración Juvenil A.C. determinó su ritmo de crecimiento, los tiempos necesarios para obtener la cobertura óptima en sus servicios a nivel nacional, considerando el papel tan relevante que la comunidad tiene en la prevención de la farmacodependencia. Con este enfoque se pretende potenciar los servicios institucionales, bajo criterios de productividad y eficiencia tanto del personal directivo y técnico como de la propia comunidad a través del voluntariado. El trabajo se compone de ocho capítulos y dos anexos. El primer capítulo comprende las consideraciones básicas sobre cómo se distribuye y concentra la población nacional. En el segundo, se definen los conceptos fundamentales que tienen que ver con las tareas que la Institución realiza. Los capítulos III y IV contienen los aspectos metodológicos para definir el universo de trabajo y las variables que inciden en el fenómeno analizado. En el siguiente, se realiza la aplicación de las variables seleccionadas cualitativa y cuantitativamente, en los diversos municipios seleccionados. En el capítulo VI presenta el universo de trabajo ya adaptado a los objetivos de la Institución, al ordenarlo en forma de Red Operativa. Con esta Red ya estructurada, en el capítulo VII se realizan los cálculos para conocer qué necesidades de personal y qué tiempo se requiere para la adecuada atención de la Población Objetivo Institucional Urbana. En el último capítulo se analizan las potencialidades y la importancia que tiene la participación voluntaria en el modelo de abordaje que la Institución ha desarrollado para la prevención de la farmacodependencia. En el anexo A se presenta la distribución geográfica de los Centros Locales y la identificación de riesgo por municipio a nivel estatal, que son, de acuerdo con los resultados obtenidos, las localidades prioritarias para ser atendidas por los Centros de Integración Juvenil A.C. El anexo B contiene las matrices con información básica por municipios y por entidaded federativa, que sirvió como base para el análisis de la población nacional

Aproximaciones teóricas a la familia del farmacodependiente / Theorical approaches to the family of the drugdependent

La autora anota "Decidí, en virtud de las circunstancias, rescatar el planteamiento de Engels sobre el origen de la familia y poder llegar, partiendo de esta base, a un acercamiento cierto a lo que es y representa la actual estructura familiar" y más adelante comenta "Así pues no es de ningun modo casual que, para hablar de la familia, me refiera al sujeto. Entiendo que la familia es un grupo de individuos interrelacionados estructuralmente, y que cada uno de sus miembros es un universo en relación con otros universos. Ahora bien, cuando se decide el encuentro terapéutico con una familia, es imposible comprender las interrelaciones que sus integrantes sostienen, ya que en términos de roles, comunicación, fantasías o parentescos, por nombrar algunas, si se desconoce, la multiplicidad de factores que intervienen en su estructura. Decir que en una familia el padre mantiene una actitud periférica, que la madre es castradora, que los roles están alterados o que la comunicación se maneja confusamente, creo que no es suficiente; debemos tratar de acceder, por ejemplo, a las razones por las cuales ese padre no puede realizar satisfactoriamente su función, su rol dentro del grupo familiar. Aplicarnos nada más a señalarle que no cumple con lo que se espera de él, es olvidar que la paternidad sólo es una de tantas cosas que le ocurrieron en la vida. Ver únicamente el rol adjudicado como principal, que un individuo desempeña en el grupo familiar (padre,esposo, hijo) es negar en gran parte, quizá la mayor, de su universo"

La farmacodependencia y su prevención dentro de la comunidad / The drugdependency and its prevention in the community

A raíz de la consolidación del derecho a la salud, la necesidad de integración del Sector Salud deviene un proceso que no puede ser pospuesto. Para Centros de Integración Juvenil significa la inscripción en el campo de las instituciones de salud pública, en el marco de una coordinación interinstitucional más ágil y ampliada. En el interior de nuestra institución, se ha generado un especial interés en el análisis del proceso salud-enfermedad, relacionándolo con la farmacodependencia. Este es el tema del estudio del presente artículo en el que, sin llegar a agotar la vasta complejidad que encierra el problema, se aportan líneas de reflexión como para ir construyendo la posibilidad de un análisis más amplio y completo