Patient and program factors in obtaining supportive services in DATOS

A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes

Objective: The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders? Methods: We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes. Results: This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care. Conclusions: Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.

Predictors of change in the provision of services within outpatient substance abuse treatment programs

The current study examines patterns and predictors of change over a 2-year period in whether outpatient core and wraparound services are offered on-site or by referral. A sample of 69 outpatient nonmethadone programs from 4 US regions provided organizational information across a 2-year period. Services provided within outpatient substance abuse programs were relatively stable over time, particularly with regard to core therapeutic services. The use of referral networks to provide a broader array of wraparound services increased, with programs adding services that reflect recent national initiatives toward program improvement, namely pharmacotherapy, medical diagnosis and treatment, and psychiatric services. Organizational factors such as parent affiliation, counselor caseload, staff size, budget change, and proportion of dually diagnosed clients were related to change in core and wraparound services. Dynamic organizational factors such as staff size and budgets can serve as barriers to and/or facilitate change in service provision over time and have managerial and policy implications.

Sex differences amongst dependent heroin users: histories, clinical characteristics and predictors of other substance dependence

INTRODUCTION AND AIMS

To examine differences in the characteristics and histories of male and female dependent heroin users, and in the clinical characteristics associated with multiple substance dependence diagnoses.

DESIGN AND METHODS

1513 heroin dependent participants underwent an interview covering substance use and dependence, psychiatric history, child maltreatment, family background, adult violence and criminal history. Family background, demographic and clinical characteristics were analysed by sex. Ordinal regression was used to test for a relationship between number of substance dependence diagnoses and other clinical variables.

RESULTS

Women were more likely to experience most forms of child maltreatment, to first use heroin with a boyfriend or partner, to experience ongoing adult violence at the hands of a partner, and to have a poorer psychiatric history than men. Males had more prevalent lifetime substance dependence diagnoses and criminal histories and were more likely to meet the criteria for ASPD. Predictors of multiple substance dependence diagnoses for both sexes were mental health variables, antisocial behaviour, childhood sexual abuse, victim of adult violence, younger age at first cannabis use and overdose. As the number of dependence diagnoses increased, clinical and behavioural problems increased. Childhood emotional neglect was related to increasing dependence diagnoses for females but not males, whereas PTSD was a significant predictor for males but not females.

DISCUSSION AND CONCLUSIONS

Mental health problems, other substance dependence, childhood and adult trauma were common in this sample, with sex differences indicating different treatment needs and possible different pathways to heroin dependence for men and women.

Access to drug and alcohol treatment among a cohort of street-involved youth

BACKGROUND

A number of options for treatment are available to young drug users, but little is known about the youth who actually attempt to access such services. Here we identify characteristics of a cohort of street-involved youth and highlight commonly encountered barriers.

METHODS

From September 2005 to July 2007, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort of 529 drug users aged 14-26 living in Vancouver, Canada. Participants who attempted to access any addiction services in the 6 months prior to enrollment were compared in univariate analyses and multiple logistic regression modeling of socio-demographic and drug-related factors.

RESULTS

Factors positively associated with attempting to access services included Aboriginal ethnicity (adjusted odds ratio [AOR]=1.66 [1.05-2.62]), high school education (AOR=1.66 [1.09-2.55]), mental illness (AOR=2.25 [1.50-3.38]), non-injection crack use (AOR=2.93 [1.76-4.89]), and spending >$50 on drugs per day (AOR=2.13 [1.41-3.22]). Among those who experienced difficulty-accessing services, the most commonly identified barrier was excessively long waiting lists. In a subgroup analysis comparing those who tried to access services but were unsuccessful to those who were successful, risk factors positively associated with failure included drug bingeing (odds ratio [OR]=2.86 [1.22-6.76]) and homelessness (OR=3.86 [1.11-13.4]).

CONCLUSIONS

In light of accumulating evidence that drug use among street youth is associated with risky health-related behaviors, improving access to treatment and other addiction services should remain an important public health priority.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Treatment services and service delivery models for dually diagnosed clients: variations across mental health and substance abuse providers

This paper reports on a survey of administrators (n = 26) and staff (n = 248) in 10 mental health and 16 substance abuse programs in Los Angeles County providing services to individuals with co-occurring disorders. Although half or more of the administrators and staff reported that their programs had some degree of on-site service integration, there was a lack of agreement within most programs as to the extent of integration. Characteristics of services provided and interactions with other service providers are also examined. Future research is needed regarding the divergent perceptions of administrators and staff and their relationship to treatment outcomes.

Predictors of drug treatment re-entry following relapse to cocaine use in DATOS

Many drug abusers have repeated exposure to treatment, yet little is known about the reasons some individuals re-enter treatment following relapse to drug use. This paper examines the predictors of treatment re-entry among cocaine abusers who relapsed to cocaine use (N = 347) within 5 years following their index treatment episode. In-depth assessments were conducted at treatment intake in 1991-93 and at 1 and 5 years following treatment discharge. About 44% of the sample returned to treatment, at an average of 2.6 years following discharge. A logistic regression analysis demonstrated that individuals who were African American, were previously married, used cocaine at least weekly after treatment discharge, and had more service needs at the time of index treatment were more likely to re-enter treatment. The findings suggest that a longer-term perspective on treatment utilization is needed to more fully address chronic substance abuse and the problems typically associated with it.