Gender differences in client-provider relationship as active ingredient in substance abuse treatment

Identifying relative strength of methadone versus health and social services in comprehensive substance use disorder treatment using a variance decomposition approach

BACKGROUND

The purpose of this study is to identify the relative strengths of association of medication and health and social services in comprehensive substance use disorder (SUD) treatment.

OBJECTIVES

The study uses a novel variance decomposition method to assess the relative strength of association of six active ingredients of comprehensive SUD treatment: methadone medication, access services, SUD counseling, matched service ratio, client-provider relationship, and treatment duration.

METHODS

The study uses data from the National Treatment Improvement Evaluation Study (1992-1997), a dataset with an unusual number of services and service strategies measured. The data include 3012 clients from 45 SUD treatment programs. Linear mixed models are used to assess the relation of service variables to the outcome of posttreatment substance use. Variance decomposition methods are used to assess the relative importance of the ingredients in the treatment model.

RESULTS

Along with a random intercept and background variables, receipt of methadone accounted for the greatest relative strength of association at 35.4%, compared with 23.8% for treatment duration, 15.4% for client-provider relationship, and 11.2% for matched service ratio. Access and SUD counseling accounted for modest strengths of association at 1% and 3% each.

CONCLUSION

Findings indicate somewhat greater strength of association of methadone compared with other services and service strategies and overall, reinforce the importance of both medication and services and service strategies in the design and development of effective models of service delivery.

SIGNIFICANCE

This study, among the first to evaluate the relative importance of specific services and service strategies of comprehensive SUD treatment, provides insights relevant to the development of effective models of service delivery.

Trends in Anti-VEGF Injection Medicare Part B Claims among Male and Female Ophthalmologists from 2012-2016

Background: Compared to male ophthalmologists, female ophthalmologists have significantly reduced salaries, fewer faculty roles and authored publications, garnered less federal research funding, and achieved less editorial advancement. We aimed to use the most recently available Centers for Medicare and Medicaid Services data to characterize trends and differences in anti-VEGF reimbursements coded for by male and female ophthalmologists.Methods: We used Medicare Fee-For Service Provider Utilization and Payment Data: Part B Provider public use files for 2012-2016 to quantify service and reimbursement patterns for anti-VEGF injections between male and female ophthalmologists. Five outcome variables were studied: number of providers, average Medicare payment amount, total payment, number of services, and number of Medicare beneficiaries.Results: Number of services performed per female provider was 71.2% that of a male ophthalmologist in 2012, and this percentage did not change from 2012 to 2016 (95%CI [0.63, 0.804], [0.984, 1.04], respectively). Female providers had 76.1% of beneficiaries as males in 2012, and this percentage stayed constant throughout the years (95%CI [0.69, 0.84] and [0.99, 1.03], respectively). The total payment difference between female and males was $102,175 per provider in 2012, and this gap widened by $18,292 yearly (95% CI [-162599.17, -41760.47], [-33060.35, -3524.38], respectively).Conclusion: While male and female providers saw considerable increases in aflibercept services and payments in the 5-year period, the gap between male and female reimbursements widened significantly. Moving forward, analysis of large-scale Medicare datasets provides a tangible report card on how effective our attitudes and policies are in cultivating equal opportunity.

The Feasibility, Appropriateness, Meaningfulness, and Effectiveness of Parenting and Family Support Programs Delivered in the Criminal Justice System: A Systematic Review

Children whose parents are involved in the criminal justice system (CJS) are at increased risk of developing social, emotional, and behavioural difficulties and are more likely than their peers to become involved in the CJS themselves. Parenting behaviour and parent-child relationships have the potential to affect children's outcomes with positive parenting practices having the potential to moderate some of the negative outcomes associated with parental involvement in the CJS. However, many parents in the CJS may lack appropriate role models to support the development of positive parenting beliefs and practices. Parenting programs offer an opportunity for parents to enhance their parenting knowledge and behaviours and improve relationships with children. Quantitative and qualitative evidence pertaining to the implementation and effectiveness of parenting programs delivered in the CJS was included. Five databases were searched and a total of 1145 articles were identified of which 29 met the review inclusion criteria. Overall, programs were found to significantly improve parenting attitudes; however, evidence of wider effects is limited. Additionally, the findings indicate that parenting programs can be meaningful for parents. Despite this, a number of challenges for implementation were found including the transient nature of the prison population and a lack of parent-child contact. Based on these findings, recommendations for the future development and delivery of programs are discussed.

Abstinence at Successful Discharge in Publicly Funded Addiction Health Services

Abstinence at successful discharge in substance use disorder treatment is important to reducing relapse rates and increasing long-term recovery from substance use disorders. However, few studies have examined abstinence as an essential component of successful discharge. This study examined rates and correlates of reported abstinence (nonuse of drugs 30 days prior to successful discharge) among clients attending publicly funded treatment in Los Angeles County, California. Finding show that only 36% of clients who were successfully discharged reported abstinence. Black clients were less likely than non-Hispanic Whites to report abstinence at successful discharge. Clients in methadone treatment programs were less likely than outpatient clients to report abstinence, whereas clients referred to treatment through the legal system (Proposition 36) were more likely to report abstinence compared to self-referred clients. Findings underscore the importance of systematic assessment of abstinence in determining successful discharge and provide a basis for further examination of strategies to improve abstinence and reduce relapse.

Navigating the Alcohol Treatment Pathway: A Qualitative Study from the Service Users' Perspective

AIMS

Provision of effective treatment for dependent drinkers has been identified as a priority in England yet evidence suggests that access is problematic and there are low levels of retention. This qualitative study explores how the alcohol treatment system is experienced by service users, identifying barriers and facilitators that influence treatment outcomes.

METHODS

A total of 20 semi-structured face-to-face interviews were conducted with patients from community alcohol treatment services in three London boroughs in 2012. Interviews were undertaken one year after initially entering treatment. A thematic analysis was conducted, with the results further abstracted to relate them to specific aspects of the treatment journey.

RESULTS

Patients journeys were characterized by a perceived lack of control leading to help-seeking, with treatment outcomes influenced by an individuals' self-efficacy and the capabilities and skills of staff in actively engaging and supporting patients on the journey. A focus of services on the detoxification process and fragmented care pathways impacted negatively on engagement.

CONCLUSIONS

Current alcohol care pathways require significant levels of motivation and self-efficacy to navigate that few patients possess. Pathways need to better reflect the capacity and capabilities of patients to be successful in supporting recovery.

Satisfaction with substance use treatment and 12-step groups predicts outcomes

INTRODUCTION

Satisfaction is a critical component of patient-centered care, yet little is known about the degree to which patient satisfaction is linked to subsequent outcomes, especially in substance use disorder (SUD) treatments and 12-step groups. The current study assessed the degree to which satisfaction with Department of Veterans Affairs (VA) outpatient SUD treatment and with 12-step groups, both measured at 6 months after treatment initiation, was associated with additional treatment utilization and better substance-related outcomes during the next 6 months, that is, up to 1 year after treatment initiation.

METHODS

Participants were 345 patients entering the VA SUD treatment program.

RESULTS

More satisfaction with treatment and with 12-step groups at 6 months was associated with less alcohol use severity and more abstinence at 1 year. More treatment satisfaction was related to less subsequent medical severity, whereas more 12-step group satisfaction was related to less subsequent psychiatric severity. More 12-step group satisfaction was related to subsequent increases in 12-step group attendance and involvement. A single item assessing overall satisfaction appeared best related to subsequent outcomes.

CONCLUSIONS

Satisfied SUD treatment patients and 12-step mutual help members appeared to have better subsequent service utilization patterns and treatment outcomes. SUD treatments can improve outcomes by monitoring and enhancing patient satisfaction.

Gender disparities in utilization and outcome of comprehensive substance abuse treatment among racial/ethnic groups

This study examined gender differences within Black, Latino, and White subgroups in the utilization of comprehensive services and their relation to posttreatment substance use. Survey data were collected during the National Treatment Improvement Evaluation Study (NTIES), a prospective, longitudinal, multisite study of substance abuse treatment programs and their clients in the United States. The analytic sample consisted of 1,812 blacks (734 women and 1,078 men), 486 Latinos (147 women and 339 men), and 844 whites (147 women and 339 men) from 59 service delivery organizations. Results related to service utilization indicated that compared to men, women in all racial and ethnic groups needed and received more services targeted to their needs and reported more positive relations with service providers. Gender was a significant moderator of the relationship between service receipt and treatment outcomes for all racial and ethnic groups, but especially for the Latino subsample. Findings point to the need to consider race-specific gender differences in the development of culturally competent, comprehensive substance abuse treatment.

Disparities in completion of substance abuse treatment between and within racial and ethnic groups

OBJECTIVE

To evaluate disparities in substance abuse treatment completion between and within racial and ethnic groups in publicly funded treatment in Los Angeles County, California.

DATA SOURCE

The Los Angeles County Participant Reporting System with multicross-sectional annual data (2006-2009) for adult participants (n = 16,637) who received treatment from publicly funded programs (n = 276) for the first time.

STUDY DESIGN

Retrospective analyses of county discharge and admission data. Hierarchical linear regressions models were used to test the hypotheses.

DATA COLLECTION

Client data were collected during personal interviews at admission and discharge for most participants.

PRINCIPAL FINDINGS

African Americans and Latinos reported lower odds of completing treatment compared with Whites. Within-group analysis revealed significant heterogeneity within racial and ethnic groups, highlighting primary drug problem, days of drug use before admission, and homelessness as significant factors affecting treatment completion. Service factors, such as referral by the criminal justice system, enabled completion among Latinos and Whites only.

CONCLUSIONS

These findings have implications for reducing health disparities among members of racial and ethnic minorities by identifying individual and service factors associated with treatment adherence, particularly for first-time clients.

Disparities in completion of substance abuse treatment among Latino subgroups in Los Angeles County, CA

RATIONALE

A growing body of research has revealed disparities with respect to drug use patterns within Latino subgroups. However, the extent to which these potential disparities enable different Latino subgroups to respond favorably to treatment is unclear.

METHODS

This study analyzed a subset of multicross-sectional data (2006-2009) on Latinos collected from publicly funded facilities in Los Angeles County, CA (N=12,871). We used multilevel logistic regressions to examine individual and service-level factors associated with treatment completion among subgroups of first-time Latino treatment clients.

RESULTS

Univariate analysis showed that Cubans and Puerto Ricans were less likely to complete treatment than Mexicans and other Latinos. Cubans and Puerto Ricans entered treatment at an older age and with higher formal education than Mexicans, yet they were more likely to report mental health issues and use of cocaine and heroin as primary drugs of choice respectively. Multivariate analysis showed that age, having mental health issues, reporting high use of drugs at intake, and use of methamphetamines and marijuana were associated with decreased odds of completing treatment among all Latino subgroups. In contrast, age at first drug use, treatment duration, and referral monitoring by the criminal system increased the odds of completing treatment for all members.

CONCLUSION

These findings have implications for targeting interventions for members of different Latinos groups during their first treatment episode. Promising individual and service factors associated with treatment completion can inform the design of culturally specific recovery models that can be evaluated in small-scale randomized pilot studies.

Client-Provider relationship in comprehensive substance abuse treatment: differences in residential and nonresidential settings

As the substance abuse service system shifts from primarily residential to primarily nonresidential settings, it becomes important to understand how substance abuse treatment processes and outcomes may vary across service setting. Research increasingly indicates that, along with specific treatment and service strategies, client-provider relationship is an important ingredient in effective substance abuse treatment. This study uses a moderator-mediator analysis of a comprehensive service model to examine how the relation between client-provider relationship and substance abuse treatment outcomes may differ in residential and nonresidential settings. The study used data collected for the National Treatment Improvement Evaluation Study, a prospective, cohort-based study of U.S. substance abuse treatment programs and their clients, with an analytic sample of 59 publicly funded service delivery units and 3,027 clients. Structural equation modeling is used to assess the structural relations and causal connections between treatment process and treatment outcome variables. Results indicate that for nonresidential settings, a better client-provider relationship is directly related to improved outcomes of treatment duration and reduced posttreatment substance use and is indirectly related to both outcomes through provision of services matched to client needs. In residential settings, the quality of the client-provider relationship is unrelated to process or outcome variables. The findings point to the importance of the client-provider relationship in all settings but particularly in outpatient settings where there are limited physical constraints on the treatment process.

Improving health and social outcomes with targeted services in comprehensive substance abuse treatment

BACKGROUND

Improved life functioning along with substance use reduction is increasingly recognized as the definition of effective addiction treatment.

OBJECTIVES

To assess whether targeted health and social services contribute to improved physical/mental health and employment.

METHODS

This study used data from the National Treatment Improvement Evaluation Study (N = 3027) and modeled the improvement in physical/mental health and employment at discharge or 12 months after discharge compared with intake measures as a function of receipts of matched services.

RESULTS

Receiving matched medical service improves physical health only at treatment discharge; receiving matched mental health services improves mental health at discharge and 12 months after discharge; receiving matched vocational services improves employment only 12 months after discharge.

CONCLUSIONS

Need-service matching contributes to improved health and social outcomes when longitudinal assessments of treatment outcomes are used to evaluate treatment effectiveness.

SCIENTIFIC SIGNIFICANCE

Study findings document the value of targeted services for achieving success in health and social functioning in comprehensive substance abuse treatment.

Integrated Substance Abuse and Child Welfare Services for Women: A Progress Review

A review of empirical literature reveals improvements in service utilization and outcomes for women when substance abuse and child welfare services are integrated. The increased use of substances by women involved in the child welfare system has resulted in a call for integrated, coordinated, evidence-based practices. Since the late 1990s, specific system- and service-level strategies have been developed to coordinate and integrate the provision of substance abuse and child welfare services such that women are remaining in treatment longer and are more likely to reduce substance use and be reunited with their children. The strategies reviewed provide useful guidelines for developing components of effective, evidence-based programs for substance-involved women in the child welfare system.