High utilizers of alcohol and other drug treatment (AODTx) services are a priority for healthcare cost control. We examine characteristics of Medicaid-funded AODTx clients, comparing three groups: individuals <90th percentile of AODTx expenditures (n=41,054); high-cost clients in the top decile of AODTx expenditures (HC; n=5,718); and 1760 enrollees in a chronic care management (CM) program for HC clients implemented in 22 counties in New York State. Medicaid and state AODTx registry databases were combined to draw demographic, clinical, social needs and treatment history data. HC clients accounted for 49% of AODTx costs funded by Medicaid. As expected, HC clients had significant social welfare needs, comorbid medical and psychiatric conditions, and use of inpatient services. The CM program was successful in enrolling some high-needs, high-cost clients but faced barriers to reaching the most costly and disengaged individuals.

One-hundred-thirty-one homeless, substance-dependent MSM were enrolled in a randomized controlled trial to assess the efficacy of a contingency management (CM) intervention for reducing substance use and increasing healthy behavior. Participants were randomized into conditions that either provided additional rewards for substance abstinence and/or health-promoting/prosocial behaviors ("CM-full"; n=64) or for study compliance and attendance only ("CM-lite"; n=67). The purpose of this secondary analysis was to determine the affect of ASPD status on two primary study outcomes: methamphetamine abstinence, and engagement in prosocial/health-promoting behavior. Analyses revealed that individuals with ASPD provided more methamphetamine-negative urine samples (37.5%) than participants without ASPD (30.6%). When controlling for participant sociodemographics and condition assignment, the magnitude of this predicted difference increases to 10% and reached statistical significance (p<.05). On average, participants with ASPD earned fewer vouchers for health-promoting/prosocial behaviors than participants without ASPD ($10.21 [SD=$7.02] versus $18.38 [SD=$13.60]; p<.01). Participants with ASPD displayed superior methamphetamine abstinence outcomes regardless of CM schedule; even with potentially unlimited positive reinforcement, individuals with ASPD displayed suboptimal outcomes in achieving health-promoting/prosocial behaviors.

Methadone has been the most commonly used pharmacotherapy for the treatment of opioid dependence in U.S. public sector treatment, but availability of buprenorphine as an alternative medication continues to increase. Drawing data from two community-based clinical trials that were conducted nearly contemporaneously, this study examined retention in methadone versus buprenorphine treatment over 6months among urban African Americans receiving treatment in one of four publicly-funded programs (N=478; 178 methadone; 300 buprenorphine). Adjusting for confounds related to medication selection, survival analysis revealed that buprenorphine patients are at substantially higher risk of dropout compared to methadone patients (HR=2.43; p<.001). Buprenorphine's retention disadvantage appears to be concentrated in the earlier phases of treatment (approximately the first 50days), after which risk of subsequent dropout becomes similar for the two medications. These findings confirm a retention disparity between methadone and buprenorphine in this population, and suggest potential avenues for future research to enhance retention in buprenorphine treatment.

The goal was to identify factors that predicted sustained cocaine abstinence and transitions from cocaine use to abstinence over 24months. Data from baseline assessments and multiple follow-ups were obtained from three studies of continuing care for patients in intensive outpatient programs (IOPs). In the combined sample, remaining cocaine abstinent and transitioning into abstinence at the next follow-up were predicted by older age, less education, and less cocaine and alcohol use at baseline, and by higher self-efficacy, commitment to abstinence, better social support, lower depression, and lower scores on other problem severity measures assessed during the follow-up. In addition, higher self-help participation, self-help beliefs, readiness to change, and coping assessed during the follow-up predicted transitions from cocaine use to abstinence. These results were stable over 24months. Commitment to abstinence, self-help behaviors and beliefs, and self-efficacy contributed independently to the prediction of cocaine use transitions. Implications for treatment are discussed.

OBJECTIVE:

The Recovery Management paradigm provides a conceptual framework for the examination of joint impact of a focal treatment and post-treatment service utilization on substance abuse treatment outcomes. We test this framework by examining the interactive effects of a treatment for comorbid PTSD and substance use, Seeking Safety, and post-treatment Twelve-Step Affiliation (TSA) on alcohol and cocaine use.

METHOD:

Data from 353 women in a six-site, randomized controlled effectiveness trial within the NIDA Clinical Trials Network were analyzed under latent class pattern mixture modeling. LCPMM was used to model variation in Seeking Safety by TSA interaction effects on alcohol and cocaine use.

RESULTS:

Significant reductions in alcohol use among women in Seeking Safety (compared to health education) were observed; women in the Seeking Safety condition who followed up with TSA had the greatest reductions over time in alcohol use. Reductions in cocaine use over time were also observed but did not differ between treatment conditions nor were there interactions with post-treatment TSA.

CONCLUSIONS:

Findings advance understanding of the complexities for treatment and continuing recovery processes for women with PTSD and SUDs, and further support the chronic disease model of addiction.

We report here on a feasibility study of initiating buprenorphine/naloxone prior to release from incarceration and linking participants to community treatment providers upon release. The study consisted of a small number of Rhode Island (RI) prisoners (N=44) diagnosed with opioid dependence. The study design is a single arm, open-label pilot study with a 6-month follow up interview conducted in the community. However, a natural experiment arose during the study comparing pre-release initiation of buprenorphone/naloxone to initiation post-release. Time to post-release prescriber appointment (mean days) for initiation of treatment outside Rhode Island Department of Corrections (RIDOC) versus inside RIDOC was 8.8 and 3.9, respectively (p=.1). Median post release treatment duration (weeks) for outside RIDOC versus inside RIDOC was 9 and 24, respectively (p=.007). We conclude that initiating buprenorphine/naloxone prior to release from incarceration may increase engagement and retention in community-based treatment.

The purpose of this study was to determine tobacco use and dependence patterns over the course of 12months among an adolescent population entering substance abuse treatment. The sample consisted of intake and 3-, 6-, and 12-month post-intake tobacco use data from 1062 adolescents within 34 substance abuse treatment facilities across the United States. Data were pooled across sites and analyzed utilizing descriptive statistics; repeated measures analyses; multiple regression models; three-level hierarchical linear models; and hierarchical generalized linear modeling. The majority of the sample reported at least weekly tobacco use at intake. Over time, participants increased their total tobacco consumption and days of use while reporting less desire for help with cessation. Race/ethnicity was a factor in differing tobacco use patterns. Tobacco dependence rates remained stable from intake to 3months post-intake, decreased at 6months post-intake, and rose to its highest levels at 12months post-intake. Participants attended one smoking cessation class on average in each 90day time period. Results suggest that adolescents entering substance use treatment may benefit from integrated tobacco cessation interventions that are intensive and occur early in treatment.

MI-based interventions are widely used with a number of different clinical populations and their efficacy has been well established. However, the clinicians' training has not traditionally been the focus of empirical investigations. We conducted a meta-analytic review of clinicians' MI-training and MI-skills findings. Fifteen studies were included, involving 715 clinicians. Pre-post training effect sizes were calculated (13 studies) as well as group contrast effect sizes (7 studies). Pre-post training comparisons showed medium to large ES of MI training, which are maintained over a short period of time. When compared to a control group, our results also suggested higher MI proficiency in the professionals trained in MI than in nontrained ones (medium ES). However, this estimate of ES may be affected by a publication bias and therefore, should be considered with caution. Methodological limitations and potential sources of heterogeneity of the studies included in this meta-analysis are discussed.

Substance abuse treatment providers commonly provide services for men and women involved in sex work. Sex workers often present to treatment with a complicated array of challenges (M. L. Burnette et al., 2008a; D. C. Ling, W. C. W. Wong, E. A. Holroyd, & S. A. Grayson, 2007; M. Young, C. Boyd, & A. Hubbell, 2000), and, while many scholars have posited the need for adapted interventions for sex workers (L. Nuttbrock, A. Rosenblum, S. Magura, C. Villano, & J. Wallace, 2004; A. Weiner, 1996), there is still a lull in the development of comprehensive, tailored services for sex workers seeking substance abuse treatment (L. Nuttbrock et al., 2004). Augmenting this gap is the lack of a clear framework through which to understand the challenges that sex workers endure and how their challenges may differ from treatment-seeking non-sex workers. In order to address this gap, the current study explored the utility of a social justice framework, namely the Capability Approach, in predicting sex work involvement among a substance-abusing sample. We hypothesize that increased challenges to achieving capability will predict sex work involvement among a substance-abusing sample. Results suggest that the Capability Approach is a useful framework that can be used to differentiate between sex workers and their substance-abusing counterparts and that sex workers experience greater challenges to achieving capability. As such, the current findings support recent calls in the literature for the development of tailored services to meet the needs of this population.

Analyses of the effectiveness of substance abuse treatments across racial/ethnic groups should ensure that outcome measures have the same conceptual meaning (i.e., measurement equivalence) across groups. Because racial groups differ in perceptions and experiences of the therapeutic alliance, this study investigated measurement equivalence properties of the Revised Helping Alliance Questionnaire (HAq-II) across racial groups. The sample included 138 African American and 133 non-Latino White participants, age 18-64years, who participated in a randomized clinical trial investigating the effectiveness of Motivational Enhancement Therapy in the National Institute on Drug Abuse Clinical Trials Network. Results demonstrated configural invariance and two forms of metric invariance (weak and strong/scalar), suggesting that conceptualizations of therapeutic alliance and overall levels of endorsement of therapeutic alliance are comparable across racial groups. The groups indicated partial, strict metric nonequivalence. No studies to date reported measurement equivalence properties of the HAq-II. Findings support valid measurement and interpretation of HAq-II outcomes.