A community-based trial of vocational problem-solving to increase employment among methadone patients.

UNLABELLED: Unemployment remains a common problem among methadone patients. This study examined the effectiveness of the Vocational Problem-Solving Skills (VPSS) intervention to help unemployed methadone patients obtain employment. METHODS: 109 patients were randomly assigned to receive 10 sessions of either VPSS (n=62) or Interpersonal Problem-Solving (IPS) (n=47). Fourteen counselors from two methadone programs were trained to deliver both the VPSS and IPS counseling sessions. RESULTS: Overall, 93% (101/109) of the patients completed a 6-month follow-up assessment which revealed that 58.6% (34/58) of patients in the VPSS condition were employed, whereas 37.2% (16/43) in the comparison condition worked (chi-square=4.53, 1 df, p<0.05). However, a multinomial regression equation found that the VPSS intervention did not significantly contribute to the prediction of employment. Other factors such as longer length of previous work experience, 40 years of age or older, treatment site, and baseline patient motivation to work emerged as significant predictors. CONCLUSION: Although VPSS alone was not a strong independent predictor of improved employment functioning, improvements in employment functioning were detected at one of the two sites as a function of VPSS.

A case study of employment case management with chronically unemployed methadone maintained clients.

Employment interventions implemented in drug treatment programs have been marginally successful, but few interventions have been found to address the needs of chronically unemployed clients. Employment case management (ECM) is a comprehensive employment intervention strategy designed to motivate chronically unemployed persons to engage in work, assist in job placement, and provide post employment support through workforce integration, while maintaining progress in drug treatment. This clinical case study reports on a convenience sample of 10 chronically unemployed methadone maintained clients who voluntarily enrolled in the ECM project. Clients received individual ECM services for a period of 26 weeks. Clients were assessed at two- and eight-month follow-up intervals. Nine of the 10 clients were employed at the two-month follow-up assessment and six maintained employment at the eight-month follow-up. Moreover, three clients were able to successfully transition from welfare to competitive private sector employment. Preliminary data suggest that ECM may be an effective intervention strategy to help chronically unemployed methadone clients obtain and maintain employment. Qualitatively, clients reported that post employment intervention services such as motivational counseling, problem solving, and employer advocacy helped sustain employment.

The effectiveness of two intensities of psychosocial treatment for cocaine dependence.

Structured treatments for cocaine dependence have been shown to be effective despite high attrition rates. What is unclear is what level of treatment intensity is needed to improve and sustain patient outcomes, especially among low SES urban residents. This study evaluated whether there were differences between two levels of treatment intensities for cocaine dependence in reducing substance use and improving health and social indicators. Ninety-four cocaine dependent predominantly African-American male veterans were randomly assigned to either a 12 h/week day hospital program (DH12) or a 6 h/week outpatient program (OP6) and were evaluated at baseline, during treatment and at 4 and 7 months post-treatment. Both treatments stressed abstinence, behavior change and prosocial adjustment and only differed in level of treatment intensity. During treatment measures included urine toxicologies, program attendance, treatment completion and aftercare attendance. Participants reported a 52% reduction in days of cocaine use and experienced significant improvements in employment and psychiatric functioning at seven months post-treatment. However, there was no significant difference between the DH12 and OP6 programs in terms of abstinence during treatment, treatment completion, treatment or aftercare attendance or any Addiction Severity Index (ASI)-related variable assessing level of functioning at 4 and 7 months. While future research with a larger community-based sample that includes female clients is necessary, the current findings demonstrate that a 6 h/week program is just as effective and thus has a significant cost savings compared to a 12 h/week treatment modality for cocaine dependence.

Assessing the needs of substance abusing women. Psychometric data on the psychosocial history.

The Psychosocial History (PSH) is a comprehensive multidisciplinary interview designed to assess the status, history, and needs of women in substance abuse treatment. The PSH retains the fundamental scoring structure of the Addiction Severity Index (ASI), while adding supplemental questions considered clinically useful and relevant for predicting outcomes. The present study examined the psychometric properties and general utility of both instruments with a sample of women enrolled in substance abuse treatment. Initially, the instruments were tested independently and found to have excellent test-retest reliability and acceptable internal consistency. A reliability trial between the instruments found that the composite scores (CS) of the ASI and PSH yielded satisfactory correlations among four of the six CS domains. The PSH had higher CS scores than the ASI across domains, which may reflect the comprehensive nature of the PSH items that prompt greater disclosure of problems and needs. Validity analyses showed significant correlations of PSH and ASI psychiatric CSs with Symptom Checklist-90-Revised totals. These results suggest that the PSH yields reliable and valid assessment data similar to the ASI. Moreover, the PSH provides a more comprehensive assessment than the ASI in the area of pregnancy, family issues, and victimization.

Characterizing "nonresponsive" methadone patients.

A review of records at a large urban methadone clinic revealed a substantial group of patients with treatment tenures of at least 6 months whose urinalysis results indicated continued regular use of opiates. In an attempt to characterize these "nonresponsive" patients and to identify their specific treatment needs, we compared them to a group of patients with comparable treatment tenures but whose urinalysis results indicated little or no recent illicit opiate use. Contrary to expectations, opiate use itself was virtually the only feature that clearly distinguished the two groups. "Responders" and "nonresponders" did not differ significantly on measures of psychosocial problem severity in any other area, nor did they differ in their treatment service utilization. Moreover, examination of admission data indicated that the two groups showed similar rates of improvement in the severity of their psychosocial problems in all seven measured areas. The implications of these results for treatment and clinic administration are discussed.

One-year mortality rates following methadone treatment discharge.

OBJECTIVES: Mortality among 507 patients in a methadone program over a 1-year period was assessed. METHODS: Mortality was determined for patients in treatment (n = 397), and 12 months later for those discharged (n = 110). RESULTS: Of discharged patients, 8.2% (9/110) had died, of which six were caused by heroin overdose. None of the discharged clients were in treatment at the time of death. All deaths were among clients who either dropped out of treatment or were discharged unfavorably from the program. Comparatively, only 1% (4/397) of patients died while enrolled in treatment. CONCLUSION: Death rates, especially overdose, are high among patients who are unfavorably discharged or drop out of methadone treatment. Efforts should be made to retain these at-risk patients in methadone treatment even though treatment response may be suboptimal.

Is the Addiction Severity Index a reliable and valid assessment instrument among clients with severe and persistent mental illness and substance abuse disorders?

OBJECTIVE: This study examined aspects of reliability, validity and utility of Addiction Severity Index (ASI) data as administered to clients with severe and persistent mental illness (SMI) and concurrent substance abuse disorders enrolled in a publicly-funded community mental health center. METHODS: A total of 62 clients with SMI volunteered to participate in an interobserver and test-retest reliability study of the ASI. Spearman-Brown and Pearson correlation coefficients were calculated to examine the extent of agreement among client responses. RESULTS: Overall 16% of the composite scores could not be calculated due to missing data and 31% of the clients misunderstood or confused items in at least one of the seven ASI domains. As a whole, the interobserver reliability of the ASI composite scores for those subjects where sufficient data were available was satisfactory. However, there was more variance in the stability of client responses, with four composite scores producing test-retest reliability coefficients below .65. CONCLUSION: Evidence from this study suggests that the ASI has a number of limitations in assessing the problems of clients with severe and persistent mental illness, and it is likely that other similar instruments based on the self-reports of persons with severe and persistent mental illness would also encounter these limitations.

HIV risks among homeless men differentiated by cocaine use and psychiatric distress.

This study examined the relationship among cocaine use, psychiatric distress, and HIV risk behaviors of homeless men. A 3 x 2 ANOVA was computed to determine overall mean HIV risk behavior, with the first factor representing three levels of psychiatric distress (low, moderate, and high) and the second factor representing use or no use of cocaine. Overall, homeless men who used cocaine had significantly higher HIV risk scores than did noncocaine users. Among the homeless men who used cocaine, those men who reported high psychiatric distress had significantly higher HIV risk scores than did noncocaine users and cocaine users with low psychiatric distress. Moreover, these risk scores predominantly represented three high risk sexual behaviors; lack of condom use, multiple sex partners, and participation in commercial sex. Outreach efforts that target both substance use and especially high-risk sexual practices are urged for this population.

A comparison of three methods of measuring the type and quantity of services provided during substance abuse treatment.

This study examined three data collection methods of quantifying and categorizing treatment services provided in a publicly funded methadone program. All three approaches were research technician implemented: (1) bi-weekly patient interview with the Treatment Services Review (TSR); (2) weekly counselor interview by the Counselor Services Interview (CSI); and (3) data abstraction from clinical patient records (REC). Fifty patients were followed over 28 days using each method to assess the services received/provided within the program. Five service domains were assessed: medical, employment, alcohol/drug, family, and psychiatric. Correlations were calculated among the three methods of data collection across each of the five service domains. Overall, low to moderate correlations were found with the highest rates of agreement detected between the TSR and the REC in the employment domain (0.48) and the REC and CSI in the family domain (0.48). Post hoc focus groups with the counselors and patients found that: (1) counseling sessions rarely focused on specific problem domains; (2) counselors and patients disagreed about the quality of treatment services; and (3) counselors 'rounded-up' time spent counseling. These findings suggest that measuring treatment service delivery varies markedly based on who provides the information (e.g. patient or treatment staff) and what procedures are used for data collection (e.g. chart abstraction or self-report).

Efficacy of enhanced outreach counseling to reenroll high-risk drug users 1 year after discharge from treatment.

OBJECTIVE: Because discharged methadone maintenance patients represent a population at particularly high public health risk, the authors studied such patients 1 year after their discharge from a methadone program. METHOD: The locations of 94 of 110 discharged patients were successfully determined 1 year after discharge. Nine (10%) of these patients had died, 37 (39%) were already reenrolled in treatment, and 7 (7%) did not require treatment. The 41 remaining subjects were randomly assigned to either the enhanced outreach counseling condition (N = 27) or a standard referral condition (N = 14). RESULTS: Within 2 weeks following this intervention, 17 (63%) of the 27 patients in the enhanced outreach counseling program and one (7%) of the 14 patients not in the program had reenrolled in treatment. CONCLUSIONS: These data suggest that enhanced outreach counseling may be an effective outreach strategy as well as a risk-reduction for discharged methadone maintenance patients.

DSM-III-R alcohol dependence criteria in Russian and American men.

Data on the alcohol drinking patterns of U.S. and Russian men currently enrolled in alcohol treatment programs are described in terms of quantity of alcohol consumed, patterns of alcohol use, withdrawal symptoms, and biopsychological problems experienced. Using the criterion standards of DSM-III-R to determine alcohol dependence diagnoses as measured by the CIDI-SAM, we found that 99% of the U.S. and 97% of the Russian sample met DSM-III-R dependence criteria. In general, these data offer some validity for use of the DSM-III-R criteria and CIDI-SAM to determine alcohol dependence in a Russian sample. Although differences in the patterns and symptoms of alcohol use were found, they may be reflective of cultural, social, and economic factors, in addition to methodological limitations.

Reliability and validity of the Addiction Severity Index with a homeless sample.

The Addiction Severity Index (ASI) is an instrument widely used to assess the treatment problems of substance users. Its psychometric properties have been tested and found satisfactory for many types of substance abusers entering treatment. However, there are many other subgroups of substance users not in formal treatment, such as homeless substance users. While the ASI has been used with this subgroup, its psychometric properties remain questionable. This study examined the reliability and validity of the ASI in a sample of 98 homeless substance users awaiting temporary housing placement. Test-retest reliability found the ASI to have moderate to high reliability coefficients in each of the seven domains assessed. Both composite score and severity rating measures were found to be quite independent with low intercorrelations. Three of the seven ASI composite scores were tested for and found to have moderate concurrent validity: alcohol (r = .31 to .36), drug (r = .46), and psychiatric (r = .53 to .66). Composite score interitem correlations were .70 or greater in each of the domains except for employment (.50) and family (.52). These data suggest that, although there are some limitations in using the ASI with homeless substance users, it demonstrated acceptable reliability and validity.

Factors associated with employment among methadone patients.

We examined the patient characteristics of 340 subjects in methadone treatment to determine if these characteristics could differentiate among three "stages" of work during the past year (stable unemployment, intermittent work, and stable employment). A multiple discriminant function analysis was able to classify correctly 14% of the cases beyond chance. Results of these analyses found lower depression scores, cocaine abstinence, education, and marital status correlated with stable employment conditions. Interventions designed to change these characteristics may improve employment conditions among methadone patients.

Can you trust patient self-reports of drug use during treatment?

This study compared two frequently used measures of drug use, urine testing and self-report in a sample of subjects currently enrolled in methadone treatment for a minimum of six months. A comparison between the percentage of positive opiate urine screens and subjects' self-reported opiate use indicated that more patients self-reported opiate use (80%) than had been detected by urinalysis (57%). Similar results were found for cocaine use. We present arguments that a more inclusive method of measuring drug use during treatment should include the combination of both urinalysis and self-reports.

Psychometric analyses of the Alcohol Dependence Scale among United States and Russian clinical samples.

This project explores the cross-national construct validity of the Alcohol Dependence Syndrome. The investigation also examines basic psychometric properties of the Alcohol Dependence Scale (ADS), an instrument commonly employed to measure dependence. Subjects consisted of inpatients and outpatients in American and Russian alcoholism treatment programs. Despite some variations, an orthogonal four factor structure of the ADS appears similar across the two cultural samples, thus lending support to the alcohol dependence construct. Analyses of psychometric properties of the Scale generally support its value in future cross-cultural research on alcohol dependence.