Linkage to medical services in the Drug Abuse Treatment Outcome Study

HIV/HCV Co-infection: Burden of Disease and Care Strategies in Appalachia

PURPOSE OF REVIEW

The purpose of this review is to address infection with HIV and hepatitis C in the Appalachian region of the USA and the driving forces underlying this epidemic. We seek to discuss epidemiology of disease and the possible interventions to reduce incidence and burden of disease in this resource-limited area.

RECENT FINDINGS

The rise of the opioid crisis has fueled a rise in new hepatitis C infection, and a rise in new HIV infection is expected to follow. Injection drug use has directly contributed to the epidemic and continues to remain a risk factor. Men who have sex with men remains a significant risk factor for HIV acquisition as well. Progress has been made in the battle against HIV and, to a lesser extent, hepatitis C, but much more can be done. Limited data on co-infection with HIV/HCV are currently available for this at-risk region, but it is clear that Appalachia is highly vulnerable to co-infection outbreaks. A multipronged approach that includes advances in assessment of co-infection and education for both patients and clinicians can help to recognize, manage, and ideally prevent these illnesses.

Place and Attrition from Substance Abuse Treatment

High rates of attrition are one of the greatest problems interfering with the effectiveness of substance abuse treatment programs. Though unexamined to date, this paper argues that where a client lives, where treatment is delivered, and the relationship between these locations may influence both voluntary and involuntary dropout. The notion of a “treatment ecology” is presented, and theories of mechanisms by which location may impact attrition are developed through a review of related literature. In other fields, lack of attention to theory prior to empirical investigations of contextual effects has prompted criticism and made interpretation of empirical results difficult. Neighborhood disadvantage, drug availability, community resources, restorative qualities of the neighborhood, and travel burden are identified as promising areas for study. Current conceptual models of treatment outcomes are first reviewed to identify how they might accommodate attention to place. Policy implications and special considerations for future empirical work on this topic are discussed briefly.

Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare

Substance abusers often face substantial systematic and personal barriers to receiving required substance abuse treatment services as well as other services; hence, various linkage mechanisms have been proposed for drug abuse treatment programs to overcome such barriers. Although there is a growing interest in the use of case management with a substance abuse background, its effectiveness in child welfare has yet to be explored. In this study the author attempts to investigate the effectiveness of case management in service utilization by systematically evaluating the five-year Alcohol and Other Drug Abuse (AODA) waiver demonstration project with Recovery Coaches in Illinois. A classic experimental design with a control group was used. Random assignment occurs at the agency level. Parents in the experimental group (N = 1562) received recovery coaches in addition to traditional child welfare services while parents in the control group (N = 598) only received traditional child welfare services. Bivariate and multivariate analyses (Ordinary Last Square regressions) were used. Compared to parents in the control group, parents in the experimental group were more likely to utilize substance abuse treatment. The results suggest that gender, education level, employment status, and the number of service needs were significantly associated with service utilization. Controlling other factors, recovery coaches improved overall service utilization. Because the outcome of child welfare often depends on the improvement of risks or resolution, it is important for parents to utilize the needed services. Future studies need to address what aspects of recovery coaches facilitate the services utilization.

A pilot study of a distress tolerance treatment for opiate-dependent patients initiating buprenorphine: rationale, methodology, and outcomes

Buprenorphine, an opioid that is a long-acting partial opiate agonist, is an efficacious treatment for opiate dependence that is growing in popularity. Nevertheless, evidence suggests that many patients will lapse within the first week of treatment and that lapses are often associated with withdrawal-related or emotional distress. Recent research suggests that individuals' reactions to this distress may represent an important treatment target. In the current study, we describe the development and outcomes from a preliminary pilot evaluation (N = 5) of a novel distress tolerance (DT) treatment for individuals initiating buprenorphine. This treatment incorporates exposure-based and acceptance-based treatment approaches that we have previously applied to the treatment of tobacco dependence. Results from this pilot study establish the feasibility and acceptability of this approach. We are now conducting a randomized controlled trial of this treatment that we hope will yield clinically significant findings and offer clinicians an efficacious behavioral treatment to complement the effects of buprenorphine.

The case for chronic disease management for addiction

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care-elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

Organizational correlates of service availability in outpatient substance abuse treatment programs

In pursuit of quality care for drug abuse treatment programs, researchers continue to monitor program characteristics related to service provision. The current study examines 115 outpatient drug-free programs in four U.S. regions and documents typical methods of offering an array of services and the relationship between program characteristics and services offered onsite and by referral. Core services (e.g., comprehensive assessments) are offered primarily onsite, whereas delivery methods of wraparound services are mixed with transitional services offered generally onsite and medical services traditionally offered offsite. Accredited programs offered more core services onsite, while those providing case management offered more core and wraparound services onsite. Programs with a higher proportion of dually diagnosed clients offered more core services onsite and fewer wraparound services by referral. Programs with a higher concentration of criminal justice-referred clients offered fewer core services onsite. These findings suggest ways of improving access to services.

Substance use and the quality of patient-provider communication in HIV clinics

The objective of this study was to estimate the influence of substance use on the quality of patient-provider communication during HIV clinic encounters. Patients were surveyed about unhealthy alcohol and illicit drug use and rated provider communication quality. Audio-recorded encounters were coded for specific communication behaviors. Patients with vs. without unhealthy alcohol use rated the quality of their provider's communication lower; illicit drug user ratings were comparable to non-users. Visit length was shorter, with fewer activating/engaging and psychosocial counseling statements for those with vs. without unhealthy alcohol use. Providers and patients exhibited favorable communication behaviors in encounters with illicit drug users vs. non-users, demonstrating greater evidence of patient-provider engagement. The quality of patient-provider communication was worse for HIV-infected patients with unhealthy alcohol use but similar or better for illicit drug users compared with non-users. Interventions should be developed that encourage providers to actively engage patients with unhealthy alcohol use.

Improving adherence to HIV quality of care indicators in persons with opioid dependence: the role of buprenorphine

BACKGROUND

Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients.

METHODS

We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants.

RESULTS

One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (β 8.55; 95% confidence interval, 2.06-15.0).

CONCLUSIONS

In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.

Workforce professionalism in drug treatment services: impact of California's Proposition 36

This article investigates whether California's Proposition 36 has promoted the workforce professionalism of drug treatment services during its first 5 years of implementation. Program surveys inquiring about organizational information, Proposition 36 implementation, and staffing were conducted in 2003 and 2005 among all treatment providers serving Proposition 36 clients in five selected California counties (San Diego, Riverside, Kern, Sacramento, and San Francisco). A 1-hour self-administered questionnaire was completed by 118 treatment providers representing 102 programs. This article examines five topics that are relevant to drug treatment workforce professionalism: resources and capability, standardized intake assessment and outcome evaluation, staff qualification, program accreditation, and information technology. Results suggest that Proposition 36 had a positive influence on the drug treatment workforce's professionalism. Improvements have been observed in program resources, client intake assessment and outcome evaluation databases, staff professionalization, program accreditation, and information technology system. However, some areas remain problematic, including, for example, the consistent lack of adequate resources serving women with children.

Psychosocial factors associated with successful transition into HIV case management for those without primary care in an urban area

The purpose of this study was to identify the psychosocial factors which influence transitioning HIV positive clients without primary medical care to a case management agency within 6 weeks by a city brokerage agency. People living with HIV who reported being in a social support group and those who requested assistance with meeting their basic needs were significantly more likely to attend their first case management appointment within 6 weeks (adjusted OR 1.91 95% CI 1.22-2.97 and OR 1.24 95% CI 1.01-1.54, respectively). Individuals requesting medical care or substance abuse treatment were less likely to accomplish transitioning (adjusted OR 0.75 95% CI 0.59-0.95 and adjusted OR 0.70 95% CI 0.53-0.91, respectively). The implications of this study for improving the effectiveness of brokering case management for those with HIV are discussed.

Measuring collaboration and integration activities in criminal justice and substance abuse treatment agencies

Individuals with substance abuse problems who are involved in the criminal justice system frequently need community-based drug and alcohol abuse treatment and other services. To reduce the risk of relapse to illicit drugs and criminal recidivism, criminal justice agencies may need to establish collaborations with substance abuse treatment and other community-based service providers. Although there are many variations of interorganizational relationships, the nature of these interagency collaborations among justice agencies and treatment providers has received little systematic study. As a first step,we present an instrument to measure interagency collaboration and integration activities using items in the National Criminal Justice Treatment Practices Surveys conducted as part of the Criminal Justice Drug Abuse Treatment Studies(CJ-DATS). Collaboration and integration activities related to drug-involved offenders were examined between substance abuse treatment providers, correctional agencies, and the judiciary. The measurement scale reliably identified two levels of collaboration: less structured, informal networking and coordination and more structured and formalized levels of cooperation and collaboration. An illustration of the use of the systems integration tool is presented.

Substance abuse treatment in human immunodeficiency virus: the role of patient-provider discussions

Substance abuse treatment is associated with decreases in human immunodeficiency virus (HIV) risk behavior and can improve HIV outcomes. The purpose of this study was to examine factors associated with substance abuse treatment utilization, including patient-provider discussions of substance use issues. We surveyed 951 HIV-infected adults receiving care at 14 HIV Research Network primary care sites regarding drug and alcohol use, substance abuse treatment, and provider discussions of substance use issues. Although 71% reported substance use, only 24% reported receiving substance abuse treatment and less than half reported discussing substance use issues with their HIV providers. In adjusted logistic regression models, receipt of substance abuse treatment was associated with patient-provider discussions. Patient-provider discussions of substance use issues were associated with current drug use, hazardous or binge drinking, and Black race or ethnicity, though substance use was comparable between Blacks and Whites. These data suggest potential opportunities for improving engagement in substance abuse treatment services.

Organizational characteristics of drug abuse treatment programs for offenders

This article examines the association between the organizational characteristics of drug abuse treatment programs for offenders and the provision of wraparound services and three types of treatment orientations. Data are from the National Criminal Justice Treatment Practices Survey, which was conducted with program directors (N = 217). A greater number of wraparound services provided were associated with inpatient treatment, specialized treatment facilities, community setting (vs. correctional), services provided for more types of client populations, college-educated staff, and planned treatment for > 180 days. Therapeutic community orientation was associated with prison-based treatment and specialized treatment facilities. Cognitive-behavioral therapy orientation was associated with higher perceived importance of community treatment, more perceived staff influence on treatment, and treatment for 91-180 days. The 12-step orientation was most strongly associated with having staff specialized in substance abuse. Study findings have implications for developing effective reentry programs for offenders that bridge correctional and community treatment.

The effect of individual, program, and neighborhood variables on continuity of treatment among dually diagnosed individuals

This study reviewed the medical charts of 271 patients diagnosed with co-morbid mental health and substance-use disorders who were discharged from a hospital acute inpatient unit to various outpatient treatment programs in Philadelphia. Geographic Information Systems (GIS) technology and logistic regression modeling were employed to investigate the effects of individual, neighborhood, and program-level variables on arrival to the first treatment appointment within 30 days of discharge. Four models are presented. The results of the study suggest that having had three or more treatment episodes prior to inpatient hospitalization, and living in a neighborhood in which temporary or transitional, and presumably, other low income housing is located, increased the likelihood of patients continuing with treatment in the community. Discharge to the preadmission address, a chief complaint of bizarre behavior, close proximity of two or more liquor and/or beer stores, a high density of narcotics anonymous (NA) and/or alcoholics anonymous (AA) meetings within the neighborhood, an axis I diagnosis of substance-induced mood disorder, and a urine drug screen positive for heroin reduced the likelihood of attending outpatient treatment. We conclude that geographic and community variables as they relate to substance abuse may add an important dimension to our understanding of patient functioning and well being in the community following inpatient treatment.

A multilevel decomposition approach to estimate the role of program location and neighborhood disadvantage in racial disparities in alcohol treatment completion

Large racial disparities in completion rates from substance abuse treatment programs in urban settings remain largely unexplained, although evidence is accumulating that neighborhood conditions may influence individual substance abuse patterns and consequences. Understanding racial disparities in alcohol treatment completion, in particular, is crucial to resolving health disparities because racial/ethnic minorities bear a disproportionate burden of alcohol-related health consequences. Patient records for all non-homeless African American (N=1677), Hispanic (N=1635), and white (N=1216) alcohol outpatients, ages 18 or older, discharged during 1998-2000 from publicly funded treatment programs in Los Angeles County, the second largest system of publicly funded substance abuse treatment in the United States, were combined with census data. We tested the hypothesis that racial differences in treatment completion are related to differences in neighborhood context, particularly neighborhood-level disadvantage. Estimates from multilevel statistical models indicate that treatment neighborhood disadvantage is independently associated with treatment completion after controlling for patient characteristics and facility- and zip code-level random effects. Results of a Oaxaca decomposition of the regression estimates indicate that racial differences in treatment neighborhood disadvantage account for 32.3% of African American-white differences in treatment completion. Hispanic-white differences in completion, and the effect of home neighborhood disadvantage on completion, were non-significant. We conclude that the location of publicly funded alcohol treatment programs is related to racial disparities in treatment completion, but additional research is necessary to understand the mechanism behind this association.

Access to treatment-related and support services in methadone treatment programs

This study examines whether the mechanism through which a methadone maintenance treatment site offers seven treatment-related and support services is related to whether a patient receives such services. Mechanisms include the provision of services on-site, at another program site, or through formal or informal linkage arrangements. Analysis was conducted on a nationally representative sample of methadone treatment sites. Providing services on-site was found to be positively related to patient access to a majority of services, whereas, in general, offering services at another program site or through formal or informal linkages was not found to be effective. Not-for-profit or public ownership of treatment sites was also found to be positively related to patient access.

Do drug treatment facilities increase clients' exposure to potential neighborhood-level triggers for relapse? A small-area assessment of a large, public treatment system

Research on drug treatment facility locations has focused narrowly on the issue of geographic proximity to clients. We argue that neighborhood conditions should also enter into the facility location decision and illustrate a formal assessment of neighborhood conditions at facilities in a large, metropolitan area, taking into account conditions clients already face at home. We discuss choice and construction of small-area measures relevant to the drug treatment context, including drug activity, disadvantage, and violence as well as statistical comparisons of clients' home and treatment locations with respect to these measures. Analysis of 22,707 clients discharged from 494 community-based outpatient and residential treatment facilities that received public funds during 1998-2000 in Los Angeles County revealed no significant mean differences between home and treatment neighborhoods. However, up to 20% of clients are exposed to markedly higher levels of disadvantage, violence, or drug activity where they attend treatment than where they live, suggesting that it is not uncommon for treatment locations to increase clients' exposure to potential environmental triggers for relapse. Whereas on average both home and treatment locations exhibit higher levels of these measures than the household locations of the general population, substantial variability in public treatment clients' home neighborhoods calls into question the notion that they hail exclusively from poor, high drug activity areas. Shortcomings of measures available for neighborhood assessment of treatment locations and implications of the findings for other areas of treatment research are also discussed.

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement

BACKGROUND

Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California.

METHODS

Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews.

RESULTS

On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients.

CONCLUSIONS

SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

Do mechanisms that link addiction treatment patients to primary care influence subsequent utilization of emergency and hospital care?

BACKGROUND

Patients with drug use disorders are heavy users of emergency department (ED) and inpatient hospital care. This study examines whether formal mechanisms to link addiction treatment patients to primary medical care, either directly on site or by off-site referral-when compared with an absence of said mechanisms-might reduce these patients' use of ED and hospital services after substance abuse treatment.

METHODS

We used longitudinal data from 6 methadone maintenance programs with 232 patients, 24 outpatient nonmethadone programs with 1202 patients, and 14 long-term residential programs with 679 patients in the National Treatment Improvement Evaluation Study. Multivariate logistic models controlling for health status and medical service utilization before treatment examined whether provision of medical services on- or off-site during treatment linkage led to reduced use of ED and hospital services in the year after treatment compared with no such provision.

RESULTS

On-site delivery of primary care reduced subsequent ED and hospital use among patients in methadone maintenance and long-term residential compared with the nonlinkage condition but not in outpatient nonmethadone programs. Off-site referral for medical care reduced subsequent ED visits but not hospitalizations in long-term residential programs.

CONCLUSIONS

These findings suggest that for some treatment modalities, stronger primary care linkage mechanisms decrease subsequent utilization of expensive ED and hospital services. Future study should examine the cost implications of these strong linkage mechanisms and ways to strengthen linkages to off-site medical care.

Availability of medical care services in drug treatment clinics associated with lower repeated emergency department use

BACKGROUND

Drug users rely heavily on emergency departments (EDs) for care. Medical and other services in outpatient drug treatment clinics may reduce demand for ED care.

OBJECTIVE

The objective of this study was to examine the association of services in drug treatment clinics with repeated ED use by clinic patients.

DESIGN

This study consisted of telephone interviews of directors of a stratified random sample of 125 New York state outpatient drug treatment clinics linked to Medicaid claims for patients with long-term (>or=6 months) treatment at these clinics.

PATIENTS

This study comprised a total of 8397 Medicare enrollees in surveyed clinics in 1996 to 1997.

MEASUREMENTS

The surveys addressed drug treatment; general medical, HIV, alcohol, and social support services; location of selected services; primary care, HIV specialty, and mental health provider staffing levels; accessibility; and academic affiliation. From Medicaid claims, we defined patient demographic, clinical, and healthcare variables. Logistic regression models examined associations of availability of onsite medical services with repeated (2 or more) ED visits in 1997, adjusted for patient characteristics and patient clustering in clinics.

RESULTS

Repeated ED visits occurred in 15% of the cohort and were less likely when medical services were all onsite versus more distant (12.9% vs 16.8%, P<0.001). An interaction showed that onsite medical care was associated with less ED use only in low-volume (<or=1350 visits/wk, adjusted odds ratio [AOR] 0.64 [0.47-0.88]) and moderate volume (1351-2500 visits/wk, AOR 0.79 [0.64-0.97]) clinics. The availability of preventive services and HIV specialists onsite appear to mediate the beneficial effect of onsite medical care.

CONCLUSIONS

Greater onsite medical care in low- and moderate-volume drug treatment clinics was associated with less repeated ED use.

Managed Care's Dual Impact on Outpatient Substance Abuse Treatment: Methadone Maintenance vs. Drug Free

The number and type of services offered at substance abuse treatment (SAT) facilities are important aspects of the quality of care. Managed care (MC) is a growing presence in SAT and has been shown to affect the provision of treatment. We expand on earlier work and examine the impact of managed care on the number and type of services offered by methadone maintenance (MM) and drug-free (DF) outpatient treatment facilities. We use the econometric technique of instrumental variables to address the issue of endogeneity of MC and service offerings, thereby allowing a causal interpretation of results. Using data from the 2000 National Survey of Substance Abuse Treatment Services, we find that MC significantly increases the total number of services offered in MM outpatient facilities by four, yet decreases the number by two in DF outpatient facilities. We also show how the impact on specific services differs by modality and provide explanations for our findings.

A model to provide comprehensive testing for HIV, viral hepatitis, and sexually transmitted infections at a short-term drug treatment center

Substance users are at high risk for blood-borne infections as well as those that are transmitted sexually. Substance abuse treatment centers present an opportunity to offer comprehensive counseling and testing (CCT) for HIV, viral hepatitis, and sexually transmitted infections (STIs) to this high-risk population. We examined the feasibility and acceptability of one model of CCT among substance users. CCT was offered to 145 consecutive inpatients; study participants completed a risk factor questionnaire and selected from a menu of testing options. Thirty-six percent of those approached agreed to participate and accepted at least one biologic test. Sixty-two percent of participants accepted all tests that were offered. While beneficial to those who accept testing, the described model of CCT is feasible in a drug treatment center, but acceptable to only a minority of inpatients.

Patient and program factors in obtaining supportive services in DATOS

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients (N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.

Establishment of a Multidisciplinary Health Evaluation and Linkage to Primary Care (HELP) Clinic in a Detoxification Unit

We evaluated the feasibility of establishing a multidisciplinary Health Evaluation and Linkage to Primary care (HELP) clinic at an urban residential detoxification unit. Patients received a clinical evaluation and facilitated linkage to primary medical care including personalized referral, reminders, and appointment rescheduling. Of 235 adults reporting alcohol, cocaine or heroin as first or second drug of choice and without a primary care physician, 178 (76%) received a full HELP clinic evaluation, 35 (15%) some clinic components, and 7 (3%) only a primary care appointment. Of those with a full evaluation, 28% received pneumococcal vaccination, and most received health behavior counseling. Over the subsequent 2 years, 131 (60%) of the 220 patients whom had any contact with the HELP clinic had at least one primary care visit. A multidisciplinary health clinic to evaluate patients during detoxification is feasible and can link patients with substance dependence to primary medical care.

The impact of managed care on substance abuse treatment services

OBJECTIVE

To examine the impact of managed care on the number and types of services offered by substance abuse treatment (SAT) facilities. Both the number and types of services offered are important factors to analyze, as research shows that a broad range of services increases treatment effectiveness.

DATA SOURCES

The 2000 National Survey of Substance Abuse Treatment Services (NSSATS), which is designed to collect data on service offerings and other characteristics of SAT facilities in the United States. These data are merged with data from the 2002 Area Resource File (ARF), a county-specific database containing information on population and managed care activity. We use data on 10,513 facilities, virtually a census of all SAT facilities.

STUDY DESIGN

We estimate the impact of managed care (MC) on the number and types of services offered by SAT facilities using instrumental variables (IV) techniques that account for possible endogeneity between facilities' involvement in MC and service offerings. Due to limitations of the NSSATS data, MC and specific services are modeled as binary variables.

PRINCIPAL FINDINGS

We find that managed care causes SAT facilities to offer, on average, approximately two fewer services. This effect is concentrated primarily in medical testing services (i.e., tests for TB, HIV/AIDs, and STDs). We also find that MC increases the likelihood of offering substance abuse assessment and relapse prevention groups, but decreases the likelihood of offering outcome follow-up.

CONCLUSION

Our findings raise policy concerns that managed care may reduce treatment effectiveness by limiting the range of services offered to meet patient needs. Further, reduced onsite medical testing may contribute to the spread of infectious diseases that pose important public health concerns.

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

Designated case managers as facilitators of medical and psychosocial service delivery in addiction treatment programs

This study examines whether having designated case management staff facilitates delivery of comprehensive medical and psychosocial services in substance abuse treatment programs. A multilevel, prospective cohort study of 2829 clients admitted to selected substance abuse treatment programs was used to study clients from long-term residential, outpatient, and methadone treatment modalities. Program directors reported whether the program had staff designated as case managers. After treatment discharge, clients reported their receipt of 9 supplemental services during the treatment episode. In multivariate models controlling for multiple program-level and client-level factors, program-level availability of designated case managers increased client-level receipt of only 2 of 9 services, and exerted no effect on service comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs.

Health Services Research: Drug Use and Human Immunodeficiency Virus in the United States

Major research findings show gaps in health services research on the prevalence and outcomes of patient- and organization-level human immunodeficiency virus (HIV) and drug abuse prevention and treatment services. The latest thrust of health services research on translational research issues includes informing and training practitioners about new, proven drug abuse treatment interventions; changing treatment organizations (creating a climate for change and building a culture to sustain change); and financing new treatments. Findings defining the direct relationship between the quality of drug abuse treatment and the patients' program completion, the perception of the staff by the patient, feelings of self-empowerment and mitigation of patient and organizational readiness, the superiority of integrated care, and the primary reasons for delays in HIV-infected substance-using patients seeking care are included. More needs to be done to increase the participation of substance abuse programs in teaching about and implementing HIV prevention and developing means to modulate or eliminate barriers to the integration of HIV and substance abuse care.

The impact of smoking cessation on drug abuse treatment outcome

Although cigarette smoking is endemic among illicit drug users, drug abuse treatment programs rarely encourage smoking cessation and often discourage it. The purpose of this study was to determine whether smoking cessation after entering drug abuse treatment influenced drug use 12 months after drug abuse treatment. We analyzed 2316 cigarette smokers in the Drug Abuse Treatment Outcome Study (DATOS), a national, longitudinal study of drug abuse treatment. Heckman probit selection models assessed the association of self-reported smoking cessation while in drug abuse treatment on self-reported drug abstinence in the year after treatment completion, while simultaneously accounting for possible nonparticipation bias. Controlling for multiple factors, smoking cessation was associated with greater abstinence from drug use after completion of drug abuse treatment (P=.04). Despite drug abuse treatment programs' hesitance to encourage smokers to quit, smoking cessation does not negatively impact drug use outcomes.

Transportation and retention in outpatient drug abuse treatment programs

To determine whether certain types of transportation assistance improve outpatient treatment retention beyond thresholds shown to have therapeutic benefits, we analyzed data from 1,144 clients in 22 outpatient methadone maintenance (OMM) programs and 2,031 clients in 22 outpatient drug-free (ODF) programs in the Drug Abuse Treatment Outcomes Study (DATOS), a national, 12-month, longitudinal study of drug abuse treatment programs. Directors' surveys provided information about provision of car, van, or contracted transportation services or individual vouchers/payment for public transportation. Chart-abstracted treatment retention was dichotomized at 365 days for OMM and 90 days for ODF. Separate multivariate hierarchical linear models revealed that provision of car, van, or contracted transportation services improved treatment retention beyond these thresholds for both OMM and ODF, but individual vouchers or payment for public transportation did not. Future research should validate whether car, van, or contracted transportation services improve retention and other treatment outcomes in outpatient drug abuse treatment.