Predictors of program completion for women in residential substance abuse treatment

The practitioners' perspective on the upside and downside of applying social capital concept in therapeutic settings

Social capital, and more particularly the social networks that define its existence, is said to benefit health and well-being. In individuals recovering from alcohol and drug addiction, social capital accruing from social networks support treatment, recovery and maintenance. Therefore, the concept of social capital is important for public health practitioners working in recovery interventions. This qualitative study seeks to explore what practitioners perceive as the importance of social capital and how they apply the concept in interventions to support individuals recovering from drug and alcohol addiction. Eight public health practitioners involved in drug and substance abuse interventions in West Yorkshire, England, were interviewed. The results of the interview were then deductively coded using two priori themes of perceived impact of social capital on health outcomes and application of social capital theory in recovery interventions. The findings reveal that practitioners understand the impact of social capital as the effects of social networks on recovery and apply the concept in their interventions. However, the nature of interventions created based on similarities in condition (alcohol and substance addiction) and intended outcome (recovery) create bonding social capital with mixed outcomes. This paper argues that the wider benefits to service users are unintentionally inhibited by the overwhelming downsides of bonding social capital. For instance, closed support groups comprised of individuals with high similarities further exclude the already socioeconomically deprived service users from integrating and accessing resources outside their groups.

The impact of sexual victimization on substance use disorder treatment completion: A systematic review and meta-analysis

Background:A significant proportion of individuals seeking treatment for substance use disorders (SUDs) have experienced sexual victimization, which has been shown to disrupt the efficacy of SUD treatment services. Objective: To evaluate the relationship between lifetime sexual victimization and SUD treatment completion. Methods: Relevant literature was identified through a systematic, computerized search of nine electronic databases (May 2018) and reference harvesting, yielding 15 peer-reviewed articles published between 1992 and 2017. Two authors independently conducted title and abstract screens, full-text reviews, data abstraction, and methodological appraisals. Risk of bias was assessed using a modified mixed-methods appraisal tool. Only nine studies met criteria for the meta-analysis, which used a random-effects model. Results: Included studies yielded mixed results regarding the impact of sexual victimization on treatment completion. The meta-analysis yielded a non-significant trend of survivors of sexual victimization having slightly lower odds of completing treatment. Conclusions: Findings from this systematic review and meta-analysis did not support the impact of sexual victimization on treatment completion. Methodological limitations of the extant literature limit cross-study comparisons. Future studies should document program-related factors to improve the ability to understand relationships affecting treatment completion.

Gender-specific participation and outcomes among jail diversion clients with co-occurring substance use and mental health disorders

Men and women with co-occurring substance use disorders and mental illness are at relatively high risk for becoming involved in the criminal justice system. Programs, such as post-booking jail diversion, aim to connect these individuals to community-based treatment services in lieu of pursuing criminal prosecution. Gender appears to have an important influence on risk factors and pathways through the criminal justice system, which in turn may influence how interventions like jail diversion work to engage men and women in treatment services and reduce recidivism. Different circumstances, levels of engagement, and outcomes by gender may be related to both person-level characteristics and external factors such as availability of gender-specific services and resources. This mixed-methods study identified specific ways in which men and women use services and reoffend after being diverted, and complemented those findings with in-depth insights from program clinicians about how program experiences and resources differ in important ways by gender. We matched and merged administrative records from 2007 to 2009 for 16,233 adults from several state agencies in Connecticut, and included data on demographic characteristics, clinical diagnoses, outpatient and inpatient behavioral health treatment utilization, arrest, and incarceration. Using propensity analysis, the 1693 men and women who participated in the statewide jail diversion program were matched to respective comparison groups of nondiverted men and women. We used longitudinal multivariable regression analyses to estimate the effects of jail diversion participation on treatment utilization, arrest, and incarceration, separately for men and women. We conducted three focus groups with jail diversion clinicians from around the state (n = 21) to gain in-depth insight from them about how circumstances, program experiences, and resources differ by gender in important ways; these subjective clinician insights complement the quantitative analyses of diversion outcomes for men and women. For both men and women, diversion was associated with reductions in risk for incarceration and increases in utilization of outpatient treatment services. For men only, diversion was associated with higher utilization of inpatient mental health care. No differences in treatment or criminal justice outcomes were observed in models that compared men and women directly. Major themes from the focus groups included: the existence of too few inpatient and residential resources for women with co-occurring disorders; different challenges to treatment engagement that men and women face; and a need for more effective, gender-specific services for all program participants. Results from this mixed-methods study offer information on gender-specific program outcomes and surrounding circumstances that can help programs to better understand and address unique risks and needs for men and women with co-occurring substance use and mental health disorders who are involved in the criminal justice system.

The Assessment of Recovery Capital (ARC) predicts substance abuse treatment completion

Recovery from addiction requires various personal and environmental resources. The purposes of this study were to determine if the Assessment of Recovery Capital (ARC) scores measured at admission could predict substance abuse treatment (SAT) completion and to identify personal and environmental factors associated with ARC scores. Participants (N = 2265) comprised clients entering a Midwestern SAT facility (August 2015 - June 2017). Logistic regression was used to predict SAT completion using ARC scores. Nonparametric group comparisons were used for personal and environmental covariates. ARC scores significantly predicted successful SAT completion (OR = 1.05, 95% CI = 1.04, 1.05, Wald z = 12.9, p < 0.001). Employment had a positive relationship with ARC scores (Kruskal-Wallis χ² = 215.96, df = 8, p < 0.001). ARC scores varied according to primary substance (Kruskal-Wallis χ² = 101.10, df = 6, p < 0.001); alcohol and marijuana showed the highest scores and heroin the lowest. ARC scores decreased as number of problem substances increased (Kruskal-Wallis χ² = 70.57, df = 2, p < 0.001, r_S = -0.163, p < 0.001). Living arrangement was also significant (Kruskal-Wallis χ² = 146.36, df = 8, p < 0.001); clients who were homeless had the lowest ARC scores. A number of personal and environmental covariates were associated with the ARC scores and potentially with the outcome. After adjustment, the ARC remained a strong predictor of SAT completion. The ARC should be used in SAT facilities to guide treatment decisions and to create individualized treatment plans for clients.

Engaging mothers with substance use issues and their children in early intervention: Understanding use of service and outcomes

Mothers who use substances need integrated, multi-sectoral intervention services to support substance use discontinuation. We explored mothers' service use at Breaking the Cycle, an early intervention and prevention program for pregnant and parenting women and their young children in Toronto, Canada. We conducted retrospective analyses of families' service records and client charts (N = 160). Aims were to 1) describe women's use of service, 2) examine how early engagement of pregnant women related to postnatal service use, and 3) examine the circumstances in which women ended their service relationship with Breaking the Cycle. Specifically, we examined circumstances at service ending relating to women's service goals; custody status with children; and global substance-use, parent-child relationship, and child development outcomes. We found that these vulnerable women were actively engaged in many services and for a long duration, early engagement was associated with greater service use, and greater service use was associated with more positive circumstances upon ending service. Results provide support for a relational approach to service that promotes not only the relationship between mother and child, and mother and service provider, but also highlights relationships among staff, between staff and management, and between community partners as integral to effective service delivery. Integrating positive relationships at all levels is critical to support vulnerable families with complex needs.

Qualitative exploration of relationships between peers in residential addiction treatment

Relationships between peers are often considered central to the therapeutic process, yet there is relatively little empirical research either on the nature of peer-to-peer relationships within residential treatment or on how those relationships generate positive behaviour change or facilitate recovery. In this paper, we explore relationships between peers in residential addiction treatment, drawing upon the concept of social capital to frame our analyses. Our study was undertaken during 2015 and 2016 in two English residential treatment services using the same therapeutic community-informed model of treatment. We conducted 22 in-depth interviews with 13 current and 9 former service residents. All interviews were audio-recorded, transcribed verbatim, coded in MAXQDA, and analysed using Iterative Categorisation. Residents reported difficult relationship histories and limited social networks on entry into treatment. Once in treatment, few residents described bonding with their peers on the basis of shared experiences and lifestyles. Instead, interpersonal differences polarised residents in ways that undermined their social capital further. Some senior peers who had been in residential treatment longer acted as positive role models, but many modelled negative behaviours that undermined others' commitment to treatment. Relationships between peers could generate feelings of comfort and connectedness, and friendships developed when residents found things in common with each other. However, residents more often reported isolation, loneliness, wariness, bullying, manipulation, intimidation, social distancing, tensions and conflict. Overall, relationships between peers within residential treatment seemed to generate some positive but more negative social capital; undermining the notion of the community as a method of positive behaviour change. With the caveat that our data have limitations and further research is needed, we suggest that residential treatment providers should more routinely open the "black box" of "community as method" to consider the complex and dynamic nature of the relationships and social capital inside.

Predictors of Inpatient Treatment Completion among Females with Opioid Use Disorder: Findings from a Tertiary Care Drug Dependence Treatment Centre of India

INTRODUCTION

Studies have reported that females who drop out prematurely from inpatient treatment have poor treatment outcome. However, literature from India is limited in this regard.

METHODS

We reviewed case records of female patients admitted with opioid use disorder at NDDTC, Ghaziabad between January 1, 2008 and December 31, 2012 to study the predictors of inpatient treatment completion among female patients with opioid use disorder in relation to their sociodemographic and clinical profile.

RESULTS

Over the 5 years, 72 female patients were admitted with opioid dependence. During the study period, out of 72 patients, 44 (61.1%) were inpatient treatment completers and 28 (38.9%) were noncompleters. Mean length of ward stay was 5.1 ± 3.8 days and 16.2 ± 11.8 days for inpatient treatment noncompleters and completers, respectively, the difference being statistically significant (t = 4.845, P < 0.001). The multivariable analysis (adjusted for selected demographic characteristics as marital status, education, and employment) revealed that most women taking drug for relief from pain, having medical morbidity, and onset of opioids at age 25 years or more had a significantly greater likelihood for being treatment completers.

CONCLUSION

Certain factors can help in identification of women opioid users who are at risk of leaving the treatment.

Formal and Informal Concrete Support and Discharge Disposition among Women in Substance Abuse Treatment in the U.S

The purpose of this study is to examine the relative contribution and the relationships between formal (treatment related members) • informal (family members) concrete support and discharge disposition. A total of 172 women interviewed upon intake in one of 3 counties funded substance abuse treatment programs in Cleveland, Ohio. Hierarchical logistic regression was performed to assess the impact of formal concrete support and informal concrete support on the likelihood of a discharge disposition of completed treatment. Formal concrete support showed a statistically significant contribution to discharge disposition, while informal concrete support did not. Findings of this study highlight the importance of formal concrete support. Future research should continue to expand our knowledge of how support from formal treatment services interacts with support from informal (family) networks.

Trust and other Characteristics Associated with Health Care Utilization by Injection Drug Users

This article examines health care utilization among injection drug users. Based on previous health care models, we identify various attitudes and personal characteristics that have been found to affect health care utilization in the general population, and we examine their effect with this at-risk group. They include trust in physicians, self-esteem, self-efficacy, social isolation, and depression. We examined survey data collected from 374 injection drug users in New Haven, Connecticut. Our findings indicated that trust in physicians significantly increased health care utilization, and depression decreased it. We also found that HIV+ respondents as well as those with health insurance utilized health care more often. These findings broaden the generalizability of existing health care utilization models, and they inform efforts to increase health care among vulnerable populations such as injection drug users.

Gender Differences in Treatment Outcomes over a Three-Year Period: A Path Model Analysis

Gender differences in longitudinal patterns of treatment utilization and outcomes over three yearly time points 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 one-year follow-up. Retrospectively recalled natural history data were collected at the follow-up interview. Over the three observational years, compared to men, women generally reported greater involvement in drug abuse treatment, lower levels of drug use and employment, and higher levels of drug use by their spouses. The path model showed that women's drug use and criminality were negatively related to formal treatment and self-help group participation, but positively related to their spouse's drug use. Fewer factors significantly impacted men's drug use and crime over time. Implications of these gender differences are discussed.

Where are the Children? An Examination of Children's Living Arrangements When Mothers Enter Residential Drug Treatment

Although providing child care and family residency options has become central to substance abuse treatment for women with dependent children, research documenting status of child coresidence prior to, during, and following treatment is currently unavailable. The purpose of this study is to examine the degree to which mothers are successful in maintaining or reestablishing their role as parents during the course of treatment. The sample included 152 female clients admitted to a residential drug treatment program for women with dependent children. Findings document an increase in child coresidency from admission to follow-up. Women who entered treatment with all children or who were reunited with children previously in others' care at admission were over five times more likely to coreside with all children at follow-up. At follow-up, mothers who reported complete coresidence were more likely to be 30 years old or younger, live independently, and have fewer than two parenting challenges.

Retention in medication-assisted treatment for opiate dependence: A systematic review

Retention in medication-assisted treatment among opiate-dependent patients is associated with better outcomes. This systematic review (55 articles, 2010-2014) found wide variability in retention rates (i.e., 19%-94% at 3-month, 46%-92% at 4-month, 3%-88% at 6-month, and 37%-91% at 12-month follow-ups in randomized controlled trials), and identified medication and behavioral therapy factors associated with retention. As expected, patients who received naltrexone or buprenorphine had better retention rates than patients who received a placebo or no medication. Consistent with prior research, methadone was associated with better retention than buprenorphine/naloxone. And, heroin-assisted treatment was associated with better retention than methadone among treatment-refractory patients. Only a single study examined retention in medication-assisted treatment for longer than 1 year, and studies of behavioral therapies may have lacked statistical power; thus, studies with longer-term follow-ups and larger samples are needed. Contingency management showed promise to increase retention, but other behavioral therapies to increase retention, such as supervision of medication consumption, or additional counseling, education, or support, failed to find differences between intervention and control conditions. Promising behavioral therapies to increase retention have yet to be identified.

Predictors of stimulant abuse treatment outcomes in severely mentally ill outpatients

BACKGROUND

Severe mental illness is often exclusionary criteria for studies examining factors that influence addiction treatment outcome. Therefore, little is known about predictors of treatment response of individuals receiving psychosocial treatments for addictions who suffer from co-occurring severe mental illness.

METHODS

The impact of demographic, substance abuse severity, psychiatric severity, and service utilization variables on in-treatment performance (i.e., longest duration of abstinence) in a 12-week contingency management (CM) intervention for stimulant abuse in 96 severely mentally ill adults was investigated. A 4-step linear regression was used to identify independent predictors of in-treatment abstinence.

RESULTS

This model accounted for 37.4% of variance in the longest duration of abstinence outcome. Lower levels of stimulant use (i.e., stimulant-negative urine test) and psychiatric severity (i.e., lower levels of psychiatric distress), as well as higher rates of outpatient treatment utilization at study entry were independently associated with longer duration of drug abstinence.

CONCLUSION

These data suggest that individuals with low levels of stimulant use and psychiatric severity, as well as those actively engaged in services are most likely to succeed in a typical CM intervention. For others, modifications to CM interventions, such as increasing the value of reinforcement or adding CM to evidence based psychiatric interventions may improve treatment outcomes.

The Impact of Acculturation, Motivation and the Therapeutic Alliance on Treatment Retention and Outcomes for Hispanic Drug Involved Probationers

Factors associated with retention and outcomes for Hispanic offenders mandated to treatment for substance use disorders have been overlooked in the literature resulting in an impediment to providing evidence-based, culturally relevant treatment services. This project examined the roles of motivational factors, the therapeutic relationship, and acculturation in predicting treatment retention and recidivism among Hispanic male probationers mandated to residential treatment. By following a treatment cohort over one hundred and twenty days, this research identifies factors that may be targeted to improve interventions and policies. The following conclusions are supported: among Hispanic offenders, the number of days in treatment is positively related to motivation to change and level of acculturation.

Does mandating offenders to treatment improve completion rates?

While it is known that community-based outpatient treatment for substance abusing offenders is effective, treatment completion rates are low and much of the prior research has been conducted with offenders in residential treatment or therapeutic communities. The aim of the present study was to assess whether offenders who are mandated to community-based outpatient treatment have better completion rates compared to those who enter treatment voluntarily. The 160 research participants were a heterogeneous group of substance abusers who were under various levels of criminal justice supervision (CJS) in the community. The participants were enrolled in an intensive outpatient program and were recruited into the study between July 2007 and October 2010. All offenders received weekly therapy sessions using a cognitive problem solving framework and 45% completed the 6 month treatment program. Interestingly, those who were mandated demonstrated less motivation at treatment entry, yet were more likely to complete treatment compared to those who were not court-ordered to treatment. While controlling for covariates known to be related to treatment completion, the logistic regression analyses demonstrated that court-ordered offenders were over 10 times more likely to complete treatment compared to those who entered treatment voluntarily (OR=10.9, CI=2.0-59.1, p=.006). These findings demonstrate that stipulated treatment for offenders may be an effective way to increase treatment compliance.

"Everyone deserves services no matter what": defining success in harm-reduction-based substance user treatment

This article reports qualitative interview data from a study of participant-generated outcomes of two harm reduction programs in the United States. We address the question:"What does success in harm-reduction-based substance user treatment look like?" Providers in this study understood harm reduction to adhere to notions of "any positive change," client centeredness, and low-threshold services. Participants reported changes in demarginalization, engagement in the program, quality of life, social functioning, changes in substance use, and changes in future goals and plans. The nature of these changes is difficult to articulate within traditional notions of success (i.e., abstinence, program completion, etc.). We conclude that participants in harm reduction programs experience tangible positive changes but that legitimation of these changes calls for a reconceptualization of "outcomes" and "success" in the current context of substance user treatment and research.

Structural Ecosystems Therapy for HIV+ African-American women and drug abuse relapse

This report examines the effect of Structural Ecosystems Therapy (SET) for (n=143) HIV+ African-American women on rate of relapse to substance use relative to both a person-centered approach (PCA) to therapy and a community control (CC) group. A prior report has shown SET to decrease psychological distress and family hassles relative to these 2 comparison groups. In new analyses, SET and CC had a significant protective effect against relapse as compared with PCA. There is evidence that SET's protective effect on relapse was related to reductions in family hassles, whereas there was not a direct impact of change in psychological distress on rates of relapse. Lower retention in PCA, perhaps caused by the lack of a directive component to PCA, may have put these women at greater risk for relapse. Whereas SET did not specifically address substance abuse, SET indirectly protected at-risk women from relapse through reductions in family hassles.

Factors Associated with Treatment Compliance and its Effects on Retention among Participants in a Court-Mandated Treatment Program

Drug treatment court (DTC) programs have been implemented and promoted in American as well as Canadian judicial systems as an effective tool for reducing criminal recidivism rates. An evaluation of the program in Toronto revealed that the drug court participants' substance abuse and criminal behaviors are reduced while they are under the drug courts' jurisdiction, and to some extent recidivism is reduced after participants leave the program. However, while we know from the literature that there are positive effects of the program, the characteristics of drug-dependent offenders who benefit the most from the DTC are less clear. The main purpose of this study was to understand where the prediction from literature, that compliance determines success in treatment, fails. Thus, study participants were divided into two groups: 1) those who might normally be expected to not comply yet who do in the long run (unexpected retention, UR); and 2) those who might normally be expected to comply, but who do not (unexpected expulsions, UE). Discriminant function analysis showed that participants considered UR were subject to conditions of social disadvantage yet quite motivated; whereas UE participants had no housing concern, no indication of family problems, but had additional criminal justice involvement at an early stage of the program. Implications for strengthening DTCs as well as suggestions for future research in the drug treatment and drug court fields are discussed.

Client and program factors associated with dropout from court mandated drug treatment

To examine why court mandated offenders dropout of drug treatment and to compare their characteristics, treatment experiences, perceptions, and outcomes with treatment completers, we analyzed self-reported and administrative data on 542 dropouts (59%) and 384 completers (41%) assessed for Proposition 36 treatment by thirty sites in five California counties during 2004. At intake, dropouts had lengthier criminal histories, lower treatment motivation, more severe employment and psychiatric problems, and more were using drugs, especially heroin. Relatively fewer dropouts received residential treatment and their retention was much shorter. A similar proportion of dropouts received services as completers and the mean number of services received per day by dropouts was generally more, especially to address psychiatric problems, during the first three months of treatment. The most commonly offender-reported reasons for dropout included low treatment motivation (46.2%) and the difficulty of the Proposition 36 program (20.0%). Consequences for dropout included incarceration (25.3%) and permission to try treatment again (24.0%). Several factors predicting drug treatment dropout were identified. Both groups demonstrated improved functioning at one-year follow-up, but fewer dropouts had a successful outcome (34.5% vs. 59.1%) and their recidivism rate was significantly higher (62.9% vs. 28.9%) even after controlling for baseline differences. Understanding factors associated with drug treatment dropout can aid efforts to improve completion rates, outcomes, and overall effectiveness of California's Proposition 36 program. Findings may also aid a broader audience of researchers and policy analysts who are charged with designing and evaluating criminal-justice diversion programs for treating drug-addicted offenders.

Mental Health as a Mediator of Gender Differences in Employment Barriers among Drug Abusers

Employment has been identified as an important drug abuse treatment outcome, but drug abusers often face a wide variety of barriers to securing stable employment. The employment barriers literature also reports that women and people with mental health problems have difficulty in obtaining employment. The current study examined gender differences in mental health and employment barriers in a sample of drug court participants. Hierarchical regression analyses were conducted to test the hypothesis that differences in employment barriers among drug-abusing males and females are mediated by differences in mental health problems. Women were found to have more mental health problems and employment barriers, and support for the mediation hypothesis was found. Implications for drug treatment providers are discussed.

The Impact of Foster Care and Temporary Assistance for Needy Families (TANF) on Women's Drug Treatment Outcomes

This study assesses the impact of having a child in foster care and receiving cash benefits through Temporary Assistance for Needy Families (TANF) on women's completion of a residential drug treatment program. The study's hypothesis was that drug treatment completion rates for women who had children in foster care and/or who were receiving TANF would differ from women who did not receive these services. The sample included 117 women age 19 to 54, in a Midwestern state. Findings suggest that women with a child or children in foster care were less likely to complete treatment. Women receiving cash benefits were also somewhat less likely to complete treatment than women not receiving these services. Women with children in foster care had similar levels of psychological, employment, and drug and alcohol concerns as other women, as measured by the Addiction Severity Index. Future research should focus on identifying strategies that enhance retention rates of these vulnerable women. Implications for improving treatment retention are discussed in light of the Adoption and Safe Families Act of 1997 and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

Client retention in residential drug treatment for Latinos

Client drop out from treatment is of great concern to the substance abuse field. Completion rates across modalities vary from low to moderate, not ideal since length of stay has been positively and consistently associated with better client outcomes. The study explored whether client characteristics shown to be related to retention were associated with treatment completion and treatment duration for a sample of 164 Latino substance users who entered a culturally focused residential program. In-person client interviews were conducted within a week of program admission. Logistic regression analysis was used to examine research questions. Clients most likely to drop out had self-reported co-occurring psychiatric diagnoses; they were 81% less likely to complete the program, suggesting that clients with mental health problems have a more difficult time remaining in residential treatment. Clients using drugs in the three months prior to entry were three and a half times more likely to be in the shorter stay group, and clients who lived in institutions prior to program entry were three times more likely to be in the longer-stay group. Factors contributing to drop out for this Latino sample were similar to those identified in the literature for non-Latino samples. Methods for addressing the needs of clients with co-occurring disorders are discussed.

Individual and program predictors of attrition from VA substance use treatment

The study investigated patient- and program-level variables associated with attrition from intensive outpatient (IOP) substance use treatment in a national VA sample. National databases were used to identify a recent cohort of veterans receiving intensive IOP substance use treatment. Attrition was defined as receiving less than five visits of IOP treatment. Patient-level variables examined included age, gender, race, and psychiatric and medical comorbidities. Program-level variables examined included the number of hours of treatment offered, the percentage of patients living on-campus, and extent of staff cuts in the past year. Twenty-seven percent of veterans left treatment early. Being older, female, and having a psychotic disorder was associated with attrition. Program-level factors associated with attrition were the number of hours the program offered treatment, in that more treatment offered was associated with higher attrition. Focus on individual and program level factors associated with attrition is crucial to retaining individuals in treatment.

Predictors of substance abuse treatment entry for crime-involved, cocaine-dependent women

A health services utilization model was used to examine predictors of treatment entry among a large sample (N=659) of crime-involved, cocaine-dependent women. Previous research in this area has focused on women already in treatment and resultantly excluded a critical population of drug-dependent women who are actively using but not in treatment. Thus, interviews were completed with women who were participating in substance abuse treatment programs and with women who were not currently in treatment to examine what factors may have inhibited or facilitated their entering treatment. The predisposing characteristics, enabling resources, and service needs of these women were assessed in relation to their treatment utilization status. Findings indicated that variables within each of the three categories of the health services model were related to treatment entry including race/ethnicity and education (predisposing characteristics), and alcohol use and having multiple chronic health problems (need). But, overall, enabling factors, such as being legally employed, having health insurance, having custody of children, and knowing where to go to get treatment, appeared to be the most influential predictors. Implications of this research include employing multiple tactics for increasing the likelihood of treatment entry such as aggressive outreach efforts focusing on at-risk women who have the fewest social ties and who are the least integrated into mainstream society.

Substance abuse in pregnant women. Experiences from a special child welfare clinic in Norway

BACKGROUND

Substance abuse during pregnancy may harm the foetus and can cause neonatal abstinence syndrome. Exposure to alcohol and other substances can influence the child for the rest of its life. A special child welfare clinic was set up in 1994 in Kristiansand, Norway, targeting pregnant women with substance abuse problems in the county of Vest-Agder. Pregnancy is not an indication for opioid replacement therapy in Norway, and one of the clinic's aims was to support the drug dependent women through their pregnancy without any replacements. The object of this paper is to describe concurrent health and social problems, as well as the predictors for stopping drug abuse, in the clinic's user group.

METHODS

Retrospective cohort study. Data was gathered from the medical records of all 102 women seen in the clinic in the period between 1992 and 2002. The study includes 59 out of 60 women that were followed until their children were two years old or placed in alternative care, and a comparison group of twice the size. Both groups were presented with a questionnaire concerning both the pregnancy and health and socio-economic issues.

RESULTS

Four (4.5 percent) of the women that completed their pregnancies did not manage to reduce their substance abuse. All the others reduced their substance abuse considerably. The odds ratio for stopping substance abuse within the first trimester was significantly associated with stopping smoking (O.R. 9.7) or being victims of rape (O.R. 5.3).

CONCLUSION

A low cost and low threshold initiative organised as a child welfare clinic may support women with substance abuse problems in their efforts to stop or reduce their substance abuse during pregnancy.

Organizational- and individual-level correlates of posttreatment substance use: a multilevel analysis

In addressing the need to study the effects of organizational factors on individual-level treatment outcomes, this study used hierarchical models to examine the organizational- and individual-level correlates of posttreatment substance use. Risk for posttreatment use varied significantly across organizations. Factors in the external institutional environment of facilities significantly influenced risk for use: managed care regulation increased the risk, whereas Joint Commission on the Accreditation of Healthcare Organizations accreditation decreased it (p < .01 for both). On the individual level, longer treatment episodes and treatment completion reduced the risk (p < .01 for both) after controlling for client characteristics. The benefits of length of stay in treatment were modified by elements of the external institutional environment and organizational treatment technology. The ameliorative effects of prolonged treatment were reduced by higher levels of managed care regulation, organizational monitoring, caseload size (p < .01 for all), and proportion of degreed staff (p < .05). The results highlight the influence of organizational factors on posttreatment use.

Gender, mental health, and treatment motivation in a drug court setting

The current study examined differences in motivation for drug treatment in a sample of 500 (327 males and 173 females) drug court participants. It was hypothesized that females would report higher levels of treatment motivation, as indicated by measures of problem recognition and desire for help, and that this difference would be moderated by mental health. After controlling for selected factors related to treatment motivation, females were found to have higher levels of problem recognition and desire for help. A significant gender x mental health interaction was also found, suggesting that females with more mental health problems have the highest levels of desire for help.

Completing substance abuse treatment in child welfare: the role of co-occurring problems and primary drug of choice

A significant number of substance-abusing parents in the child welfare system do not complete substance abuse treatments. Consequently, their children experience longer stays in substitute care settings, and the risk of the termination of parental rights is increased. This study identifies and determines the specific factors that explain the completion of substance abuse treatment for substance-abusing caregivers in child welfare. The sample includes 871 caregivers enrolled in the Illinois Alcohol and Other Drug Abuse waiver demonstration. Approximately 22% of these caregivers successfully completed all required levels of substance abuse treatment. The multivariate models indicate that age, employment status, and legal involvement were significantly associated with the likelihood of completing substance abuse treatment. Heroin users were significantly less likely to complete treatment as compared with alcohol, cocaine, and marijuana users. The findings are discussed in terms of policy and practice implications for public child welfare systems.

Does gender-specific substance abuse treatment for women promote continuity of care?

Research has stressed the value of providing specialized services to women and suggests the importance of treatment duration. This quasi-experimental retrospective study reports on the continuity of care for women with children who were admitted to long-term residential substance abuse treatment. Women were admitted to 7 agencies offering specialized, women's only treatment (SP, n = 747) or to 9 agencies that provided standard mixed-gender treatment (ST, n = 823). Client and treatment data were gathered from administrative sources. We hypothesized that women in specialized treatment would demonstrate higher continuing care rates after controlling for treatment completion and length of stay. Women in SP programs (37%) were more likely than those in ST programs (14%) to continue care. Multivariate analyses revealed that SP clients who completed treatment with longer stays were most likely to continue care. The findings show that specialized treatment for women promotes continuing care and demonstrate the importance of treatment completion.

ENHANCING THE EFFECTIVENESS OF RESIDENTIAL TREATMENT FOR SUBSTANCE ABUSING PREGNANT AND PARENTING WOMEN: FOCUS ON MATERNAL REFLECTIVE FUNCTIONING AND MOTHER-CHILD RELATIONSHIP

Substance abuse during early motherhood has become a significant problem and has led to accelerated efforts to develop specific treatment facilities for these mothers and children. Despite the often intensive treatment efforts in residential settings, there is surprisingly little evidence of their efficacy for enhancing the quality of caregiving. The situation of these mother-child pairs is exceptionally complex and multilevel, and has to be taken into account in the content and structuring of treatment. Intensive work in the "here and now" focusing on the mother-child relationship from pregnancy onwards in an effort to enhance maternal reflective capacity and mindedness is considered a key element for better treatment prognosis, in terms of both abstinence and quality of parenting. Pioneering work with such a focus is described in this article.

Predictors of participation in an HIV risk reduction intervention for socially deprived Latino women: A cross sectional cohort study

BACKGROUND

Little is known about predictors of participation and attrition in HIV prevention programs for socially deprived Latino women.

OBJECTIVES

The purpose of this study was to examine factors that predict program participation and attrition among Latino women in a community-based, culturally specific HIV risk reduction intervention.

DESIGN

This was a cross-sectional comparison of baseline data drawn from a randomized HIV risk reduction trial.

SETTINGS

Information was drawn from study subjects residing in a predominately Latino low-income community in Chicago.

PARTICIPANTS

Among 404 study subjects in the intervention group, 214 of Latino women who had attended at least 5 of 6 intervention sessions were considered participants. One hundred and twelve women who never attended and 29 of women who attended fewer than 3 sessions were considered dropouts.

METHODS

The baseline data of program participants were compared to those of dropouts. The influence of the following factors on program participation was examined: sociodemographic characteristics, self-esteem, HIV knowledge, intimate partner violence, depression, and communication with partner.

RESULTS

Logistic regression analysis showed that Mexican women were more likely to participate in the intervention program than Puerto Rican women (odds ratio (OR)=1.88, 95% confidence interval (CI)=1.64, 4.23). Other significant predictors of program participation included: being older (OR=1.08, 95% CI=1.03, 1.14), unemployed (OR=0.46, 95% CI=0.25, 0.83), having higher risk reduction behavior intentions score (OR=1.16, 95% CI=1.06, 1.26), and lower level of depressive symptoms (OR=0.97, 95% CI=0.95, 0.99).

CONCLUSIONS

The recruitment and retention strategies should be developed by considering those important predictors of intervention participation to prevent Latino women from dropping out of the HIV prevention program.

Mutual moral caring actions: a framework for community nursing practice

A community practice framework is presented as the synthesis of research findings from the analysis of a critical ethnonursing study of women in recovery from chemical dependence. Critical Social Theory is used to examine the paradoxical experiences of women from their lifeworld and system within the community. The framework focuses on the mutual moral caring actions of the community nurse and the women in the recovery. It is supported by the concepts of transcultural nursing ethics. The utility of the framework is to promote clarity of speech and parity of community membership for women in recovery from chemical dependence and their return to the community.

Substance abuse treatment and the recurrence of maltreatment among caregivers with children living at home: A propensity score analysis

Policy and programmatic initiatives of the last decade have focused on increased coordination of services and expansion of prompt substance abuse treatment for mothers initially involved with child welfare services (CWS). Yet, little evidence has been amassed concerning the implications of this approach on the recurrent need for CWS. Data are from a large national probability sample of children and their caregivers involved with CWS following an allegation of maltreatment. Data include the recurrence of maltreatment reports for this group of children who remain at home. Selected from 1,101 caregivers with an indicated substance abuse problem, a group of 224 clients who did not receive services were compared with 224 treated clients. Event history analyses showed that clients who received substance abuse treatment were nearly twice as likely to have another child abuse report within 18 months. Reasons why participation in substance abuse treatment may result in greater involvement with CWS are posited.

Factors associated with lifetime history of drug treatment among substance dependent women

There is extensive research on factors related to substance use treatment retention and completion but less is known about factors related to treatment initiation, particularly for women. This paper examines factors associated with a lifetime history of substance abuse treatment among women with drug abuse or dependence. Baseline interview data, using the Addiction Severity Index (ASI) that obtained during a randomized clinical trial was analyzed comparing women with no history of drug treatment with women with a history at least one drug treatment episode. Of the 153 women, 47.4% had a lifetime history of drug treatment compared to 52.6% who have never enrolled in drug treatment. After multiple logistic regression, craving drugs at least 15 days in the past month, using cocaine at least 15 days in the past month, ASI alcohol composite score, perceived seriousness of legal problems, history of at least 3 pregnancies, and history of physical abuse by a known person, were independently associated with drug treatment.

Problem severity profiles of clients in European therapeutic communities: gender differences in various areas of functioning

The BIOMED II 'Improving Psychiatric Treatment in Residential Programmes for Emerging Dependency Groups' project provided a relatively large sample (n = 863) of men (77%) and women (23%) in therapeutic community treatment in nine European countries. This paper's aim is to search for gender differences in profiles of therapeutic community clients on the basis of the different areas of functioning of the EuropASI. A binary logistic regression model was used to avoid the confounding effects of country and age. Our findings confirm what is found in the American literature: compared to men, women have a much worse profile in various areas of functioning when entering treatment. In response, they may require a gender-adapted set of therapeutic interventions at the moment they enter treatment.

Development and initial demonstration of a community-based intervention for homeless, cocaine-using, African-American Women

Drug abstinence is difficult to achieve and maintain, especially when clients return to their pretreatment environment. Forging ties with the natural helping networks in the community, such as religious organizations, may reinforce abstinent behaviors established during treatment. This study evaluated Bridges to the Community, a supplemental component to an intensive residential treatment program. Bridges uses members of African-American churches as mentors for recovering women. This demonstration project included 118 female participants with primary cocaine dependence who received either standard treatment or Bridges plus standard treatment. Participants in both groups reduced substance use, risk-taking behaviors, depression, and increased self-esteem. Participants who received Bridges had greater treatment retention, reported 100% cocaine abstinence at follow-up, and were more satisfied with their treatment.

Collaboration between child welfare and substance-abuse fields: combined treatment programs for mothers

OBJECTIVE

To review collaboration between child welfare and drug-abuse fields in providing treatment to mothers who abuse drugs and maltreat their children.

METHODS

Literature review of studies examining effects of maternal drug abuse on parenting skills and outcomes of interventions for both maternal drug abuse and parenting skills.

RESULTS

Parenting skills differ between mothers who do and do not abuse drugs, but these studies are primarily limited to mothers of infants and preschoolers. The evidence base for interventions to address both substance use and parenting in these mothers is growing, but more well-controlled studies are needed. Opportunities for improved collaboration between fields are presented.

CONCLUSION

Progress has been made toward collaboration to address drug abuse and parenting skills of mothers who abuse drugs, but more integrated strategies are needed, especially for mothers who use drugs and maltreat their children.

Identifying pregnant women at risk for early attrition from substance abuse treatment

Greater treatment retention among pregnant substance abusers is associated with improved pregnancy and neonatal outcomes, so early identification of clients most at risk for early attrition is essential. Participants were 152 pregnant women enrolled in the initial 7-day residential component of a comprehensive substance abuse treatment program for pregnant women. Twenty-nine (19%) women left treatment within the first 5 days, primarily within the first 2 days. Clinical staff identified many, but not all, patients who eventually left treatment early as many indicated their desire to leave and were troubled by drug craving and withdrawal. Other predictors of attrition included not receiving methadone maintenance, being Caucasian, and reporting more prior drug treatment episodes, fewer medical problems and, to a lesser extent, more family/social and psychiatric and fewer drug problems on the Addiction Severity Index. Interventions are needed to target pregnant clients most at risk for early treatment attrition.

Gender differences in substance use treatment entry and retention among prisoners with substance use histories

OBJECTIVES

We examined gender similarities and differences in the predictors of substance use treatment entry and of the combination of treatment entry and completion.

METHODS

The sample consisted of 2219 male and female program participants. Maximum likelihood probit estimation was used to identify background and attitudinal characteristics predictive of substance use treatment entry and retention.

RESULTS

We observed gender similarities and differences in predictors of treatment entry and the combination of treatment entry and completion. Many of the factors that attract individuals to treatment are the same ones that keep individuals in treatment.

CONCLUSIONS

Attitudinal predictors-namely, motivation to change-showed the greatest consistency between genders and between predictors of treatment entry and predictors of treatment entry and completion.

Problem severity profiles of substance abusing women in European Therapeutic Communities: Influence of psychiatric problems

This article aims to search for a specific female, psychiatric profile based on a large European sample of substance dependent clients (828) entering therapeutic communities. First, all six areas of functioning of the EuropASI were included, using the composite scores to search for gender differences. Next, the 'psychiatric' status section was selected for further study. A binary logistic regression was performed with gender as the dependent variable, and nine individual psychiatric items, country, and age as predictors. According to this model a number of problem variables could be identified as being reported more often by women than by men in therapeutic community treatment. Women are more likely to report serious depression, problems in understanding, concentrating or remembering, being prescribed medication, and serious thoughts about suicide; they have also attempted suicide more often than men. Women find treatment for these psychological problems more important than their male counterparts. They also have a more severe history of abuse. Women in therapeutic communities may need specific treatment interventions for their more severe psychiatric needs.

Staying in treatment: how much difference is there from prison to prison?

This is the 1st study to examine the effects of individual- and program-level characteristics on treatment attrition within a prison-based setting. The sample of 1,446 men and women were from 19 programs. Differences were found in both individual- and program-level predictors of disciplinary discharges and dropouts. Dropouts were more likely to be women and enter treatment with lower levels of motivation. Individuals who were disciplinary discharges from treatment were more likely to be young, have a history of violence, and have a diagnosis of antisocial personality. Only 1 program factor--an emphasis on disciplinary discharge for violation of program rules--was associated with disciplinary discharge. The clinical implications of these findings are discussed.