Assessing Adolescent Substance Abuse Programs with Updated Quality Indicators: The Development of a Consumer Guide for Adolescent Treatment.

When adolescent substance abuse requires treatment, few parents know which treatment features are important and which treatment programs are effective. There are few resources to help them select appropriate care. We describe early work on an evaluation method and comparative treatment guide for parents based upon the premise that the quality of a program and its potential effectiveness is a function of the number and frequency of evidence-based treatment practices (EBPs) delivered. Thus, we describe the development of and measurement approach for a set of EBPs toward the goal of developing a Consumer Guide to Adolescent Substance Abuse Treatment.

National Trends in Adolescent Substance Use Disorders and Treatment Availability: 2003-2010.

This study examines trends in adolescent substance use disorders (SUDs) and treatment utilization in the US using data from the National Household Survey on Drug Use and Health (NSDUH) and data from the National Survey of Substance Abuse Treatment Services (N-SSATS). Results indicate an overall decrease in the percent of adolescents meeting past year criteria for an alcohol or illicit drug disorder between 2003 and 2010, but the percent of adolescents meeting criteria who had not received any treatment in the past year was substantial and has remained stable since 2003. In 2010, less than 30% of facilities participating in the N-SSATS survey indicated that they offered special programming for adolescents, reflecting an overall decrease since 2003.

Effect of patient choice in an adaptive sequential randomization trial of treatment for alcohol and cocaine dependence.

OBJECTIVE: To evaluate the effect of providing choice of treatment alternatives to patients who fail to engage in or drop out of intensive outpatient programs (IOPs) for substance dependence. METHOD: Alcohol- and/or cocaine-dependent patients (N = 500) participated in a sequential, multiple-assignment, randomized trial (SMART). Those who failed to engage in an IOP at Week 2 (N = 189) or who dropped out after engagement (N = 84) were randomized for motivational-interviewing (MI) telephone calls that focused on engagement in an IOP (MI-IOP) or provided a choice of IOP type or 3 treatment options (MI-PC, or patient choice). Those not engaged at both 2 and 8 weeks (N = 102) were re-randomized either to MI-PC or no further outreach. Outcomes were treatment attendance and measures of alcohol and cocaine use obtained at 1, 2, 3, and 6 months. RESULTS: MI-PC produced better attendance than comparison conditions in patients who dropped out after initial engagement and in those re-randomized at 8 weeks. However, contrary to study hypotheses, MI-IOP produced significantly better alcohol-use outcomes than MI-PC in alcohol-dependent patients not engaged at Week 2. There were no other significant differences between treatment conditions on other main-effect analyses with alcohol- or cocaine-outcome measures. CONCLUSION: Providing treatment options via telephone calls to patients who failed to engage in IOP did not produce better substance-use outcomes than outreach calls focused on engagement in IOP. Future researchers should investigate the potential benefits of choice at other points in treatment (e.g., at intake) as well as choice of other combinations of treatments.

A critical component of the continuum of care for substance use disorders: recovery homes in Philadelphia.

For many struggling with addiction, the ability to achieve stable recovery is often jeopardized by untenable housing or unsupportive living environments. Despite promising research on recovery residences, there are still significant gaps in the research on them. Using data collected from a stratified random sample of recovery homes in Philadelphia (N = 25), this study describes the organizational, operational, and programmatic characteristics of these homes and explores potential differences in these characteristics by funding source and gender of residents served. Although not licensed treatment providers, the majority of these homes operated in a recovery-oriented manner and offered a range of different services to their residents-all for a reasonable monthly fee (M = $340.40, SE = 18.60). Few differences emerged between homes that received funding from the Philadelphia Office of Addiction Services and those that did not or between those that served males as opposed to females. More research is needed to address resident outcomes and how Philadelphia recovery homes may compare with recovery residences in other parts of the country.

Using Web searches to track interest in synthetic cannabinoids (a/k/a 'herbal incense').

INTRODUCTION AND AIMS: This article reports a content analysis of Internet websites related to an emerging designer drug, synthetic cannabinoids. The number of synthetic cannabinoids searchers in the USA has steadily increased from November 2008 to November 2011. DESIGN AND METHODS: To determine the information available on the Internet in relation to synthetic cannabinoids, sites were identified using the Google search engine and the search term 'herbal incense'. The first 100 consecutive sites were visited and classified by two coders. The websites were evaluated for type of content (retail, information, news, other). US unique monthly visitor data were examined for the top 10 retail sites, and these sites were coded for the quality of information available regarding the legality of synthetic cannabinoids sale and use. RESULTS: The Google search yielded 2,730,000 sites for 'herbal incense' (for comparison of search terms: 'synthetic marijuana', 1,170,000; 'K2 Spice', 247,000; and 'synthetic weed', 122,000). Moreover, in the Google search, 87% of the sites were retail sites, 5% news, 4% informational and 4% non-synthetic cannabinoid sites. DISCUSSION AND CONCLUSIONS: Many tools found within Google free services hold promise in providing a technique to identify emerging drug markets. We recommend continued surveillance of the Internet using the online tools presented in this brief report by both drug researchers and policy-makers to identify the emerging trends in synthetic drugs' availability and interest.

Providing alcohol for underage youth: what messages should we be sending parents?

OBJECTIVE: There have been conflicting findings in the literature concerning the risks to adolescents when parents provide them with alcohol. Studies have examined various ways in which parents directly affect adolescent alcohol consumption through provision (e.g., parental offers, parental allowance/supervision, parental presence while drinking, and parental supply). This review synthesizes findings on the direct ways parental provision can influence a child's alcohol consumption and related problems in an effort to provide parents with science-based guidance. We describe potential mechanisms of the relationship between these parental influences and adolescent problems, suggest future directions for research, and discuss implications for parents. METHOD: Twenty-two studies (a mix of cross-sectional and longitudinal) that empirically examined the association between parental provision and adolescent drinking outcomes were reviewed. RESULTS: Parental provision was generally associated with increased adolescent alcohol use and, in some instances, increased heavy episodic drinking as well as higher rates of alcohol-related problems. Data in support of the view that parental provision serves as a protective factor in the face of other risk factors were equivocal. CONCLUSIONS: The nature and extent of the risks associated with parental provision, and the potential mechanisms underlying this association, are complex issues. Although more rigorous studies with longitudinal designs are needed, parents should be aware of potential risks associated with providing adolescents with alcohol and a place to drink. It is recommended that parents discourage drinking until adolescents reach legal age.

Addiction Severity Index (ASI) summary scores: comparison of the Recent Status Scores of the ASI-6 and the Composite Scores of the ASI-5.

The characteristics and the validity of the Recent Status Scores (RSSs), the new summary scores generated by the sixth version of the Addiction Severity Index (ASI-6), are compared to the fifth version of the ASI summary scores, the Composite Scores (CSs). A sample of 82 randomly selected patients from substance abuse treatment programs were interviewed with the ASI-6, the ASI-5 and were administered a validity battery of questionnaires that included measures corresponding to each of the ASI domains. Each ASI-6 RSS was significantly correlated with its corresponding ASI-5 CS. The intercorrelations among the RSSs are low and none of these correlations were statistically different from the intercorrelations among CSs. In five of the seven areas, the ASI-6 RSSs were more highly correlated to the corresponding validity measures than were the ASI-5 CSs. The ASI-6 offers more comprehensive content in its scales than do those derived with earlier ASIs.

Development and initial evaluation of the Brief Addiction Monitor (BAM).

This project developed and tested a 17-item monitoring instrument covering important substance use related behaviors to support measurement-based care and outcomes assessment. The study consisted of two phases, an instrument development phase and an initial study to examine its psychometric properties. Participants were 175 patients entering VA outpatient substance abuse treatment. The findings revealed that this Brief Addiction Monitor (BAM) exhibited acceptable characteristics. Exploratory factor analysis yielded three summary factors; recovery protection, physical and psychological problems, and substance use and risk. The root mean square error of approximation estimate was acceptable and the factors had alpha values exceeding or approaching 0.70. All three factors were sensitive to change and had excellent test-retest reliability. Predictive validity was demonstrated for two factors; recovery protection, and substance use and risk. At the item level, there was little indication of inappropriate response patterns. Change over time was significant for most items, and test-retest reliability was acceptable for nearly all items. Additional research is warranted to further establish the BAM's reliability, validity and usefulness.

Comparison of two ASI-based standardized patient placement approaches.

This study evaluated the predictive validity of two automated approaches based on the Addiction Severity Index (ASI) to patient placement criteria. Patients (N = 2,429) in 78 substance abuse treatment programs completed an ASI at intake and were assigned a treatment modality based on availability and clinical considerations. Treatment completion and self-reported abstinence 6 months post-discharge were collected. Two placement approaches were developed using ASI summary score cut points or problem-specific algorithms from ASI items. Both approaches showed evidence of predictive validity. Given the ASI's widespread use in community programs, evidence is provided in support of its ability to inform clinical judgment and implementation of standardized placement.

Psychometric properties of the sixth version of the Addiction Severity Index (ASI-6) in Brazil.

BACKGROUND: There are few research tools in Brazil to assess more broadly the alcohol and other drug related problems. OBJECTIVE: To test the psychometric properties of ASI in its sixth version (ASI-6). METHODS: A multicenter cross-sectional study was conducted in four Brazilian state capitals. Four research centers interviewed 150 adult inpatients or outpatients, and one research center interviewed 140 patients. A total of 740 substance abusers were selected. Training and supervision of interviewers were performed to assure the quality of dada collected. RESULTS: Most areas of the ASI showed good reliability between the instrument and the interviewers, with no statistically significant differences between the ASI-6 Summary Scores for Recent Functioning (SS-Rs) of both interviews. Cronbach's alpha for ASI-6 subscales ranged from 0.64 to 0.95. Correlations between the ASI-6 Alcohol and Drug scores and the concurrent instrument (ASSIST) were high (0.72 and 0.89, respectively). There was a significant negative correlation between the scores in psychiatric, medical and drug areas and the scores of WHOQOL. CONCLUSION: Analysis of the psychometric properties of ASI-6 both in outpatients and inpatients in Brazil indicate a good reliability and validity of this instrument for the Brazilian culture. The development of this instrument in Brazil is an important advancement, which will certainly have implications for the prevention, clinical research, and social rehabilitation fields.

Psychometric properties of the sixth version of the Addiction Severity Index (ASI-6) in Brazil / Propriedades psicométricas da sexta versão da Escala de Gravidade de Dependência (ASI-6) no Brasil

BACKGROUND: There are few research tools in Brazil to assess more broadly the alcohol and other drug related problems. OBJECTIVE: To test the psychometric properties of ASI in its sixth version (ASI-6). METHODS: A multicenter cross-sectional study was conducted in four Brazilian state capitals. Four research centers interviewed 150 adult inpatients or outpatients, and one research center interviewed 140 patients. A total of 740 substance abusers were selected. Training and supervision of interviewers were performed to assure the quality of dada collected. RESULTS: Most areas of the ASI showed good reliability between the instrument and the interviewers, with no statistically significant differences between the ASI-6 Summary Scores for Recent Functioning (SS-Rs) of both interviews. Cronbach's alpha for ASI-6 subscales ranged from 0.64 to 0.95. Correlations between the ASI-6 Alcohol and Drug scores and the concurrent instrument (ASSIST) were high (0.72 and 0.89, respectively). There was a significant negative correlation between the scores in psychiatric, medical and drug areas and the scores of WHOQOL. CONCLUSION: Analysis of the psychometric properties of ASI-6 both in outpatients and inpatients in Brazil indicate a good reliability and validity of this instrument for the Brazilian culture. The development of this instrument in Brazil is an important advancement, which will certainly have implications for the prevention, clinical research, and social rehabilitation fields.

INTRODUÇÃO: Existem poucos instrumentos de pesquisa no Brasil que avaliam de forma mais ampla os problemas relacionados ao álcool e a outras drogas. OBJETIVO: Testar as propriedades psicométricas da ASI, em sua sexta versão (ASI-6). MÉTODOS: Um estudo transversal e multicêntrico foi conduzido em quatro capitais de estados brasileiros. Quatro centros de pesquisa entrevistaram 150 pacientes adultos internados ou em tratamento ambulatorial. Foram selecionados um total de 740 abusadores de substâncias. A qualidade dos dados coletados foi assegurada pelo treinamento e supervisão aos entrevistadores. RESULTADOS: A maioria das áreas da ASI mostraram boa confiabilidade entre o instrumento e os entrevistadores, sem diferenças estatisticamente significativas entre os Escores Sumários de Funcionamento Recente da ASI-6. O alfa de Cronbach para as subescalas da ASI-6 variou de 0,64 a 0,95. Correlações entre os escores da área Álcool e Drogas da ASI-6 e o instrumento concorrente (ASSIST) foram altas (0,72 e 0,89, respectivamente). Existiu uma correlação negativa estatisticamente significativa entre os escores nas áreas psiquiátrica, médica e drogas, e os escores da WHOQOL. CONCLUSÃO: A análise das propriedades psicométricas da ASI-6 tanto em sujeitos internados quanto em tratamento ambulatorial no Brasil apontam para uma boa confiabilidade e validade deste instrumento para a cultura brasileira.

The effect of telephonic patient support on treatment for opioid dependence: outcomes at one year follow-up.

OBJECTIVE: The present study examined the impact of a telephonic patient support program known as HereToHelp™ (HTH) on compliance and treatment outcomes among opioid dependent (OD) patients new to buprenorphine treatment (BUP). METHOD: A total of 1426 OD patients new to BUP were randomized to receive BUP alone (standard care) or BUP plus the HTH patient support program. All patients completed the Addiction Severity Index (ASI) at the time of enrollment, and at 12months post-enrollment. RESULTS: Subjects randomized to the HTH support program who accepted at least 3 care coach intervention calls were more compliant with BUP than the standard care group at month 12 (64.4% vs. 56.1%, χ(2)=5.09, p<.025). Compared to patients who were non-compliant with BUP, compliant patients reported significantly lower scores on all 7 of the ASI composite scores, indicating lower severity on addiction-related problems. CONCLUSIONS: The HTH intervention seemed to improve patient treatment outcomes indirectly by improving compliance with BUP. Supplementing BUP with a structured, telephonic compliance-enhancement program is an effective way to improve compliance with medication which then improves patient outcomes.

Compliance with buprenorphine medication-assisted treatment and relapse to opioid use.

Opioid dependence (OD), often characterized as a chronic relapsing disorder, affects millions of people worldwide. The purpose of this study was to examine the effect of compliance with buprenorphine on reducing relapse among a sample of patients in treatment for OD. Patients new to buprenorphine (N = 703) completed the Addiction Severity Index (ASI) at baseline, and at 1, 2, and 3 months postbaseline. The ASI is a semistructured interview designed to measure problem severity in seven functional areas known to be affected by alcohol and drug dependence. Compliance was defined as taking buprenorphine medication on at least 22 of the past 28 days (80%), while relapse classification was based on resumed use of opioids during the follow-up period (months 2 and 3). Relapse was regressed onto demographic indicators, baseline ASI composite scores, and compliance with buprenorphine. Noncompliant patients were over 10 times more likely to relapse than those who were compliant (exp ß= 10.55; p < .001). Neither demographics nor baseline ASI composite scores were predictive of relapse (p's > .05). Compliance with medication-assisted treatment supports abstinence, essential for patient recovery. Understanding the factors that drive treatment compliance and noncompliance may assist providers in supporting patient compliance and recovery.

Recent status scores for version 6 of the Addiction Severity Index (ASI-6).

AIMS: To describe the derivation of recent status scores (RSSs) for version 6 of the Addiction Severity Index (ASI-6). DESIGN: 118 ASI-6 recent status items were subjected to nonparametric item response theory (NIRT) analyses followed by confirmatory factor analysis (CFA). Generalizability and concurrent validity of the derived scores were determined. SETTING AND PARTICIPANTS: A total of 607 recent admissions to variety of substance abuse treatment programs constituted the derivation sample; a subset (n = 252) comprised the validity sample. MEASUREMENTS: The ASI-6 interview and a validity battery of primarily self-report questionnaires that included at least one measure corresponding to each of the seven ASI domains were administered. FINDINGS: Nine summary scales describing recent status that achieved or approached both high scalability and reliability were derived; one scale for each of six areas (medical, employment/finances, alcohol, drug, legal, psychiatric) and three scales for the family/social area. Intercorrelations among the RSSs also supported the multi-dimensionality of the ASI-6. Concurrent validity analyses yielded strong evidence supporting the validity of six of the RSSs (medical, alcohol, drug, employment, family/social problems, psychiatric). Evidence was weaker for the legal, family/social support and child problems RSSs. Generalizability analyses of the scales to males versus females and whites versus blacks supported the comparability of the findings, with slight exceptions. CONCLUSIONS: The psychometric analyses to derive Addiction Severity Index version 6 recent status scores support the multi-dimensionality of the Addiction Severity Index version 6 (i.e. the relative independence of different life functioning areas), consistent with research on earlier editions of the instrument. In general, the Addiction Severity Index version 6 scales demonstrate acceptable scalability, reliability and concurrent validity. While questions remain about the generalizability of some scales to population subgroups, the overall findings coupled with updated and more extensive content in the Addiction Severity Index version 6 support its use in clinical practice and research.

Relationship of Mental Health and Illness in Substance Abuse Patients.

This study examined the latent structure of a number of measures of mental health (MH) and mental illness (MI) in substance use disorder outpatients to determine whether they represent two independent dimensions, as Keyes (2005) found in a community sample. Seven aspects of MI assessed were assessed - optimism, personal meaning, spirituality/religiosity, social support, positive mood, hope, and vitality. MI was assessed with two measures of negative psychological moods/states, a measure of antisociality, and the Addiction Severity Index's recent psychiatric and family-social problem scores. Correlational and exploratory factor analyses revealed that MH and MI appear to reflect two independent, but correlated, constructs. However, optimism and social support had relatively high loadings on both factors. Antisociality and the family-social problem score failed to load significantly on the MI factor. Confirmatory factor analysis supported the existence of two obliquely related, negatively correlated dimensions. Study findings, although generally supporting the independence of MH and MI, suggest that the specific answers to this question may be influenced by the constructs and assessments used to measure them.

Measurement of mental health in substance use disorder outpatients.

Few studies have examined mental health (MH) attributes of patients with substance use disorder (SUD). This study examines the internal consistency, concurrent validity, and comparative level of MH attributes (i.e., optimism, life attitudes, spirituality/religiousness, social support, positive mood, hope, and vitality) in patients with SUD compared with the instrument development group. The internal consistency of optimism, spirituality/religiousness, positive mood, hope, and vitality were similar in both groups. Some subscales of the social support and life attitude measures had lower internal consistency than was found for the original samples, although internal consistency of more global constructs were comparable. Patients with SUD had higher positive mood, spirituality/religiousness, and hope scores, whereas social support, life attitudes, and optimism scores were lower than in the original sample. Correlations between MH attributes and recent life problems of patients with SUD generally supported the concurrent validity of the MH measures.

A national study of a telephone support service for patients receiving office-based buprenorphine medication-assisted treatment: study feasibility and sample description.

Opioid-dependent (OD) patients seeking treatment have multiple treatment options including abstinence-based and medication replacement therapies. A recent and growing addition to medication replacement therapy is buprenorphine medication-assisted treatment (B-MAT), which may be provided by certified physicians practicing in private offices. Research on OD treatment is often performed on samples of patients recruited from specialty treatment facilities, which may not generalize to B-MAT patients. Thus, B-MAT as a treatment approach has been understudied. The present research describes (a) new methods developed to facilitate sample recruitment and survey data collection from a national B-MAT patient sample and (b) a telephonic support program designed for new B-MAT patients. Results indicate that by using appropriate tools, it is feasible to conduct a clinical study of B-MAT patients, recruited at the point of service, and that telephonic patient support was an acceptable treatment adjunct.

Reliability and validity of the alcohol short index of problems and a newly constructed drug short index of problems.

OBJECTIVE: This study evaluated the psychometric properties of the 15-item alcohol Short Index of Problems (SIP) instrument and those of a newly constructed 15-item drug Short Index of Problems (SIP-D) instrument in 277 newly entered substance-abuse patients. METHOD: The SIP is derived from the longer, 50-item Drinker Inventory of Consequences (DrInC), which was designed to assess adverse consequences of alcohol use. The SIP-D was constructed by substituting the term "drug use" for the term "drinking" in each SIP item. A 3-month recall interval was employed. RESULTS: Factor analyses of each of the instruments revealed similar solutions, with only one main factor accounting for the majority of variance. Nonparametric item response theory methods produced the same finding. Internal consistency reliability estimates for the SIP and SIP-D total scores were .98 and .97, respectively. Concurrent validity was demonstrated by examining the correlations of the total scores for each of the instruments with the recent summary indexes of the newly revised Addiction Severity Index (ASI-Version 6): alcohol, drug, medical, economic, legal, family/social, and psychiatric problems. CONCLUSIONS: This study is the first to confirm the psychometric validity of the SIP when used as an independent instrument unembedded within the DrInC. The study also supports the use of the SIP-D as a brief measure of adverse consequences of drug use. The findings strongly support the unidimensional structure of both measures.

Treatment history: relationship to treatment outcomes.

It is important to understand whether the number of prior treatment episodes relate to treatment completion, discharge status, and 6-month outcomes. The data set contains information on 2,429 clients in treatment. A modified Addiction Severity Index was administered at the time of admission and at 6-months postdischarge. Additionally, length of stay and discharge status data were obtained. ANOVAs, MANOVAs, and chi(2) tests were used. Clients with the most prior treatment episodes had greater baseline substance use and psychosocial severity, and were more likely to be treated in residential settings. Nonetheless, treatment acceptance was greatest for these clients. Clients with no prior treatment reported the least acceptance. Treatment completion rates did not vary as a function of treatment experience. Clients achieved positive changes in multiple life domains regardless of treatment history. Nevertheless, at admission, discharge and follow-up, clients with >or= 2 treatments generally had greater problems than clients with fewer treatments.

Posttraumatic stress disorder and other psychopathology in substance abusing patients.

Studies demonstrating greater problem severity in substance abuse patients with posttraumatic stress disorder (PTSD) versus those without have rarely considered other co-occurring psychiatric disorders. This study of 466 male veterans recently admitted to outpatient substance abuse treatment attempts to identify problems associated with PTSD versus those associated with other nonsubstance use Axis I disorders. Problem severity, particularly psychiatric, was examined across four groups of patients with substance use disorders (SUDs). Those with: 1, SUDs only (SU-Only); 2, PTSD, but no other Axis I disorders (SU+PTSD); 3, PTSD and other Axis I disorders (SU+PTSD+Axis I); and 4, no PTSD, but other Axis I disorders (SU+other Axis I). Results suggested a hierarchy of psychiatric, and to a lesser extent, other life problem severities associated with these diagnostic groupings. The most severe group was SU+PTSD+Axis I, followed in decreasing severity by the SU+other Axis I, SU+PTSD, and SU-Only groups. Additional analyses comparing the SU+PTSD+Axis I patients with a subgroup of Axis I patients with more than one Axis I disorder (SU+multiple Axis I) revealed few group differences except for more lifetime suicide attempts and psychiatric hospitalizations in the SU+PTSD+Axis I group. The findings suggest that it is not PTSD per se, but the frequent co-occurrence of PTSD and other psychopathology that largely accounts for previously reported greater problem severity of SUD patients with PTSD.