The working alliance inventory - short version: psychometric properties of the patient and therapist form in youth mental health and addiction care.

The therapeutic alliance is considered to play an important role in youth treatment. The commonly used versions of the Working Alliance Inventory (WAI) are based on Bordin's three-dimensional alliance model. However, previous psychometric studies of the WAI did not find this three-dimensional structure in youth psychotherapy. These earlier findings may indicate different perceptions of the alliance by adolescent versus adult patients, but may also be due to methodological shortcomings. The current study aims to address previous study limitations by evaluating the factor structure of the short version of the WAI (WAI-S) in youth treatment in multilevel analysis to address the hierarchical structure of the alliance data. We examined the psychometric properties of the patient (n = 203) and therapist (n = 62) versions of the WAI-S in youth mental health and addiction care and tested four multilevel models of alliance at start of treatment and 2-month follow-up. Our results suggests a two-factor model for youth and a three-dimensional model for their therapist at both time points. Since this is the first study that finds a best fit for a two-dimensional construct of alliance in youth, more research is needed to clarify whether the differences in alliance dimensions are due to measurement differences between the WAI-S for youth and therapists or whether youth and their therapists truly differ in their perceptions of the concept of alliance.

[The therapeutic alliance as predictor in the treatment of young people]. / De therapeutische alliantie als voorspeller in de behandeling van jongeren.

BACKGROUND: The quality of the therapeutic alliance is an important factor in the treatment of both adult and adolescent patients in psychiatry. Little is known about the importance of the therapeutic alliance among youths who seek help for their substance abuse problems in addiction treatment. AIM: We investigated the importance of first treatment session therapeutic alliance for outcome in youth mental health and addiction treatment, considering both the youths' and therapists' perspective. METHOD: 127 adolescents participated in a prospective clinical cohort study, with favorable or unfavorable treatment outcome after 4 months as primary outcome measure. At the end of the first treatment session, youths and their therapists were asked to rate the therapeutic alliance. RESULTS: Youths' and therapists' perceptions about the therapeutic alliance at the start of treatment were predictive of treatment outcome at four months follow-up. In particular, the combined perspective on first-session alliance by both youths and therapists appeared a strong predictor for treatment outcome. If both youths and therapists rated the therapeutic alliance as weak, the percentage of youths showing a favorable treatment outcome was much lower (23%), than if youths and therapists rated the alliance as strong (70%). CONCLUSION: The present study confirms the importance of a combined perspective on the therapeutic alliance for predicting treatment outcome among patients in youth mental health and addiction treatment.

[Multidimensional family therapy and cognitive behavioral therapy in adolescents with a cannabis use disorder: a randomised controlled study]. / Multidimensionele gezinstherapie en cognitieve gedragstherapie bij adolescenten met een stoornis in het gebruik van cannabis; een gerandomiseerd onderzoek.

BACKGROUND: More and more adolescents with cannabis problems are seeking treatment at addiction clinics. There is an urgent need for new types of treatment in this field. AIM: To evaluate the effectiveness of multidimensional family therapy (MDFT) and cognitive behavioral therapy (CBT) in adolescents with a cannabis use disorder. METHOD: One hundred and nine adolescents were randomly assigned to outpatient MDFT or CBT. Both types of therapy groups had a planned treatment course lasting 5 to 6 months. After 12 months the two groups were compared in terms of changes in cannabis use and in terms of secondary outcome measures, including delinquency. RESULTS: Adolescents in both treatment groups showed significant and relevant reductions in cannabis use and delinquency over 12 months. Although the MDFT treatment lasted longer and was more intensive than the CBT treatment, there was no difference in the key outcome measures of the treatments. Secondary analyses indicated that older adolescents and those without comorbid psychiatric problems derived considerably more benefit from CBT, whereas younger adolescents and those with comorbid psychiatric problems benefited much more from MDFT. CONCLUSION: MDFT and CBT are equally effective in reducing cannabis use and delinquent behavior in adolescents with a cannabis use disorder. Age and comorbid psychiatric problems turned out to be important moderators of the treatment results of MDFT and CBT and could therefore be used as a starting point for matching adolescent substance abusers to the most appropriate type of treatment.

Heroin self-administration by means of 'chasing the dragon': pharmacodynamics and bioavailability of inhaled heroin.

In this controlled clinical study, the bioavailability and pharmacodynamics of inhaled heroin are evaluated and compared between 'chasing the dragon' and inhalation from a heating device, and at three dose levels, 25, 50 and 100 mg heroin, in two separate study phases. In study phase 1, no differences between the inhalation methods were detected on any of the physiological or behavioral measures, nor in bioavailability. Subjectively, the participants had a strong preference for the method of chasing, which was therefore used in study phase 2. In phase 2, heroin produced a dose-related increase in subjective drug-liking, body temperature and heart rate, and a clear, dose-related decline in reaction time. Linearly dose-related differences were found in the amount of total morphine in urine, amounting to an average of 45% of the parent heroin base received. Based on these findings, it is concluded that chasing is quite an effective route of heroin administration, producing rapid, dose-related subjective and objective effects and a sufficiently high and reproducible bioavailability.

[Dutch research on the effectiveness of medical prescription of heroin; background, research design and preliminary results]. / Het Nederlandse onderzoek naar de effectiviteit van heroïne op medisch voorschrift; achtergronden, onderzoeksopzet en eerste ervaringen.

In the Netherlands the total number of heroin addicts amounts to approximately 25,000. Of these about 70% is in contact with the treatment system. The remaining 30% have not been seeking help, believes that no help is needed or has lost faith in a better future altogether. Of those who are in treatment, 30% attempt to stop the use of opiates through participation in drug free abstinence oriented outpatient or inpatient treatment programs. The remaining 70% have given up the outlook of a drug free existence at least temporarily, and they participate in a methadone maintenance program directed at stabilizing drug use, harm minimization and social integration. In two-thirds these goals are not or only partially achieved. For these patients additional treatment options are needed. Medical prescription of heroin is such an option. However, currently no data are available on the effectiveness of this option. The Dutch study on the effectiveness of medical prescription of heroin is an attempt to obtain these data. In the study, simultaneously two randomized trials are being executed: one with inhalable and one with injectable heroin. In these trials, 625 (375 inhalers and 250 injectors) chronic treatment-resistant heroin addicts who are currently enrolled in a methadone maintenance program are offered heroin (in combination with oral methadone) seven days per week, three times per day for a period of six to twelve months. It is a multi-center study with eight treatment units in six cities in the Netherlands (Amsterdam, The Hague, Groningen, Heerlen, Rotterdam, Utrecht). At this moment 180 patients have been randomized. During the treatment no medical complications have been observed and no serious public order or safety problems have occurred. Study participants have been very compliant both with the treatment regimen and the research requirements. The latter is indicated by the fact that 85% of all the two-monthly assessments have been completed.

[Anticipated effects of experimental heroin prescription on the method of administration and the use of other drugs]. / Te verwachten effecten van experimentele heroïneverstrekking op de toedieningswijze en het gebruik van andere middelen.

OBJECTIVE: Pending a Dutch heroin prescription trial (intended to regulate drug abuse), preliminary research was conducted into client factors that may influence the course and outcome, notably into administration patterns and changes in concomitant use of other drugs. DESIGN: Interview. SETTING: Methadone programme Baan in Rotterdam, the Netherlands. METHOD: In a Rotterdam methadone programme, 60 clients were identified matching the target group of a heroin prescription trial; 42 respondents were interviewed. Using a semistructured questionnaire, data were collected on characteristics of drug use in the preceding month. RESULTS: In addition to their methadone supply, the majority (90%) of the respondents used both heroin and cocaine. Heroin and cocaine were smoked as well as injected by 22% and 31% respectively. In the choice of a route of administration individually experienced effects played a major part, which suggests that participation in a prescription trial will not lead to shifts in employed routes of administration. Cocaine was often found to have a central position in polydrug use, while the function of heroin was mostly that of a modulator. This suggests that no direct effect on the use of cocaine can be expected from the prescription of heroin. On the contrary, the relationship between the available amount of money and the cocaine used was such that, considering that participants in a prescription trial may be left with more money, a prescription trial might lead to an increased use of cocaine. CONCLUSION: The prescription of heroin does not seem to have a direct effect on the use of cocaine. Indirectly the use of cocaine might increase.

A research perspective on drug related nuisance--Dutch experiences.

The Dutch policy on drugs has yielded positive results from the public health point of view. Drug related nuisance, however, is an enduring problem and society's acceptance of this nuisance is diminishing. This article discusses the concept of drug-related nuisance and addresses the question how this nuisance can be measured. Next to it, attention is paid to the question whether the so-called Dutch "harm reduction policy" will survive.

Reaching the unreached: targeting hidden IDU populations with clean needles via known user groups.

Needle exchange is a practical and important part of the Dutch prevention strategy to check the spread of HIV among injecting drug users (IDUs). However, needle-exchange programs are often tied to drug treatment programs that only reach a limited number of IDUs. To overcome this limitation, alternative designs are considered and initiated. This article describes a community-based approach to needle exchange that is built on empowerment of, and intense participation by, known IDUs to target unknown IDUs for delivery of clean needles. The needle-exchange patterns of the IDUs participating in this collective scheme are compared to those of other users who exchanged needles on an individual basis. It was found that this approach extended the reach of the program to a great degree and that it was well received in the IDU community. However, the results were negatively influenced by police activities aimed at closing down places where drugs were used and sold. It is concluded that engaging IDUs in peer-group-directed prevention efforts is both feasible and promising.

Drug sharing and HIV transmission risks: the practice of frontloading in the Dutch injecting drug user population.

Injecting drug users may now be the largest group at risk for contracting HIV, mainly through the sharing of drug injection equipment (including lending, borrowing, and renting). This article presents the results of an ongoing ethnographic study into the drug-taking rituals of heroin addicts. A possible additional route of HIV contamination is presented, namely the ritual sharing of drugs through a practice termed "frontloading," which is embedded in a broader pattern of the sharing of resources among addicts. It is hypothesized that in the Netherlands this practice may be responsible for a substantial proportion of HIV spread among injecting drug users.