Diagnosis, self-help, and maintenance care as key constructs in treatment research for "alcohol use disorders" (AUD).

OBJECTIVE: This study examines a sample of alcohol user treatment outcome studies to determine the amount of attention given to three areas of concern and cost-effectiveness in treatment research: patient diagnosis, use of self-help groups (e.g., Alcoholics Anonymous [AA]), and use of maintenance care services (also known as a "aftercare"). METHOD: A preliminary sample of 40 studies was coded for the degree of specific information provided to each of the three areas of interest. RESULTS: Eight studies in the sample did not mention the diagnostic criteria used to determine patient addiction, 18 did not mention use, referral, or recommendation of AA, and 20 did not mention use, referral, or recommendation of maintenance care services. CONCLUSIONS: As cost-effective additions to primary treatment, AA and maintenance care services deserve greater attention in the treatment of "substance abuse disorders." Researchers should also pay greater attention to patient diagnosis as an integral part of patient care. Finally, journal editors should institute minimum requirements for published reports ensuring that sufficient information on patient care is provided.

Medical student attitudes toward drug addiction policy.

This study explores the attitudes and perceptions of medical students concerning patients with addictions and policy issues related to drugs. Over 1,250 students from 15 medical schools responded to an anonymous survey concerning their experience and training regarding addictions, and their level of support or opposition for various drug policy approaches. Medical students expressed general support for treatment funding and related demand reduction strategies, but the strength of their support was influenced more by their political orientation than their perception of the effectiveness of the strategy. Students who identified themselves as liberals more strongly favored demand reduction and alternatives strategies such as needle exchange programs and drug courts. Conservatives more strongly favored supply reduction strategies including harsher sanctions for users. Need for additional training in medical school was indicated by the fact that 20% reported no training in addictions.

Prediction of treatment outcomes: lifetime depression versus the continuum of care.

We sought to determine the impact of a lifetime diagnosis of major depression on addiction treatment outcome. Structured interviews were conducted upon admission, and consecutive structured interviews were conducted prospectively for treatment outcome at 6 and 12 month follow-up periods. A multisite evaluation study of patients undergoing addiction treatment for alcohol and drug dependence was conducted in private outpatient facilities. Two thousand twenty-nine subjects from 33 independent programs were enrolled in a national registry for addiction treatment outcomes. The patients received abstinence-based addiction treatment with referral to a 12-step recovery program, often Alcoholics Anonymous, and continuing care in the treatment programs. The outcome areas measured were treatment completion, posttreatment substance use, exposure to psychosocial relapse risk factors, involvement with continuing care (formal aftercare and peer support groups), and posttreatment vocational functioning, health care utilization, and legal involvement. The prevalence rate of depressive symptoms over at least a 2-week period (major depression) in our sample was 28%. Multivariate analysis with stepwise multiple regression indicated that the most powerful predictors (relatively) of posttreatment alcohol/drug use were peer support group attendance and program continuing care involvement. Lifetime depression by itself and in interaction with each of these factors accounted for less than 2% of the variance in outcome. Logistic regression yielded similar results in the prediction of abstinence versus relapse. Posttreatment more than pretreatment factors appear to be more decisive in predicting risk for relapse.

Substance abuse treatment cost offsets vary with gender, age, and abstinence likelihood.

The cost-offset effect has been promoted as a way for substance abuse treatment to pay for itself by generating reductions in health care utilization in other areas. Clients (n = 5,434) that were abstinent for 24 months following substance abuse treatment had lower posttreatment utilization than clients that had relapsed. An examination of cost offsets revealed a complex interplay between gender, age, and type of utilization (medical versus psychiatric). Cost offsets were especially pronounced for women over 40 years old.

Cost-effectiveness of substance abuse services. Implications for public policy.

Cost-effectiveness analysis, a technique for allocating resources, examines the relationship between the cost of providing treatment and resulting improvement in health measured in a single, numerical scale. In applying this concept to substance abuse services, the authors expressed effectiveness in terms of additional "abstinent years." To control for differences in clients across modalities, the authors used multivariate cost-effectiveness analysis, estimating results for a typical client at each of three alternative severity levels.

The relationship between pre-, during-, post-treatment factors, and adolescent substance abuse behaviors.

This study examines the relationship between pre-, during-, post-treatment variables, and treatment outcome by using a secondary data analysis of the 6- and 12-months posttreatment follow-up data from 2,317 adolescent subjects. Pre-treatment variables included in this study are psychosocial, family-related, substance abuse, and special event variables. During-treatment variables are length of stay and parental participation in treatment. Post-treatment variables cover the attendance of subsequent treatment/continuing care, such as AA/NA and CD aftercare, and parental attendance of subsequent treatment. Results from discriminant function analyses indicated that during- and post-treatment variables could differentiate the abstinence status at 6- and 12-month follow-ups. It was also shown that the post-treatment variable group exhibited the best classification accuracy among the three variable groups across both follow-up periods. Limitations in applying research findings and their implications for adolescent substance abuse treatment are also discussed.

Lifetime diagnosis of major depression as a multivariate predictor of treatment outcome for inpatients with substance use disorders from abstinence-based programs.

A multisite, longitudinal study of patients undergoing inpatient alcohol and drug dependence treatment was conducted in private inpatient facilities, consisting of 4339 subjects from 38 independent programs enrolled in a national addiction treatment outcomes registry. Structured interviews were conducted upon admission, including documentation of current alcohol/drug disorder (DSM-III-R) and lifetime diagnosis of major depressive syndrome; structured interviews were conducted prospectively at 6- and 12-month follow-up periods. The prevalence rate of lifetime diagnosis of major depression in the sample was 39%. Comorbidity varied according to gender and substance of choice. Lifetime depressive symptoms did not correlate with differential length-of-stay, treatment completion, or follow-up consent and, at best, were very weakly associated with follow-up contact. Patients diagnosed with lifetime depression showed the same frequency of participation in posttreatment continuing care: they also showed statistically significant reductions in job absenteeism, inpatient hospitalizations, and arrest rates pre- vs. posttreatment comparable to those of patients without lifetime depression diagnosis. Lifetime major depressive syndrome was not a predictor of outcome in response to abstinence-based treatment. Involvement in posttreatment continuing care accounted for far greater outcome variance. Posttreatment vs. pretreatment factors may be more decisive in influencing risk for relapse.

Integration of treatment and posttreatment variables in predicting results of abstinence-based outpatient treatment after one year.

A multi-site, longitudinal study of patients undergoing outpatient alcohol and drug dependence treatment was conducted in private outpatient facilities, consisting of 2,029 subjects from 33 independent programs enrolled in a national addiction treatment outcomes registry. Pretreatment demographic and substance variables, treatment utilization variables, and post-treatment continuum of care variables were examined simultaneously in a multivariate prediction context for association with outcome. Upon admission patients provided history information to treatment staff trained in the collection of data for the evaluation efforts. Trained interviewers conducted consecutive structured interviews prospectively for treatment outcome at six- and 12-month follow-up periods. Multivariate analysis with stepwise multiple regression indicated that, relatively speaking, the most powerful predictors of treatment outcome were posttreatment variables: namely, support group attendance and involvement in a continuing care program. Pretreatment and treatment variables contributed proportionately little to the prediction of outcome. Additional sequential-stage analysis showed that the incremental contribution to prediction by posttreatment attendance at Alcoholics Anonymous and involvement in a treatment program following discharge far exceeded the initial predictive validity of the 14 pretreatment and treatment variables examined. Participation in posttreatment continuing care correlated with statistically significant reductions in job absenteeism, inpatient hospitalizations, and arrest rates. Posttreatment more than pretreatment factors may be decisive in influencing risk for relapse.

Prevalence of depression and alcohol and other drug dependence in addictions treatment populations.

The diagnosis of depression has been viewed as an important factor in the treatment response for those who have alcohol and other drug dependence. The objective of the study was to examine the prevalence of a lifetime history of major depression in inpatients with a substance use disorder in addictions treatment. An evaluation study of 6,355 patients was conducted in inpatient and outpatient addictions treatment programs from 41 sites. Subjects were required to have a substance use disorder and to be evaluated for a lifetime diagnosis of major depression according to DSM-III-R criteria. The rate of a lifetime diagnosis of major depression was 43.7%. The most common diagnosis was alcohol dependence, followed by cocaine dependence, and cannabis dependence). Depression was associated in significantly greater numbers with diagnoses involving drugs other than alcohol, in females greater than in males, with number and frequency of use, and in inpatient programs more than outpatient programs. The rates for continuous abstinence at one year did not differ between those with and without a lifetime history of depression.

Screening and diagnosis of "alcohol abuse and dependence" in older adults.

A literature review reveals that research is warranted to improve screening for "alcohol abuse" in older adults and women. An examination of diagnostic criteria for "alcohol abuse dependence" reveals that older adults provide unique challenges to classification systems. There is a need to evaluate the sensitivity and specificity of several new screening instruments for the identification of "alcohol abuse" in the elderly. Routine screening of elderly and women presenting in primary care settings should be a priority for researchers and clinicians.

Prevalence of abuse and dependency in chronic pain patients.

A series of 414 chronic pain patients referred to Are Hospital, Are, Sweden, for evaluation and rehabilitation were administered a structured diagnostic interview to detect alcohol and drug misuse and dependence according to DSM-III-R criteria. A total of 97 (23.4%) met criteria for active alcohol, analgesic, or sedative misuse or dependency; an additional 39 (9.4%) met criteria for a remission diagnosis. Current dependency was most common for analgesics (12.6%) followed by alcohol (9.7%) and sedatives (7.0%).

Adolescent treatment. Implications for assessment, practice guidelines, and outcome management.

Treatment for adolescent substance abuse does work. Not only are there clear improvements in substance use frequency and in the number of substances used 1 year after treatment, but also sharp reductions in school and legal problems are observed. Improvements in treatment and the continuum of care can be made however. Substance abuse treatment cannot end with the formal treatment episode. Continuing attendance at support groups, family support, and proactive re-entry plans at school all help to ensure continued recovery after treatment. Many adolescents receive a large amount of medical care in the year prior to admission; however, very few adolescents or their parents list physicians as referral sources at admission. Adolescent substance abuse should be identified by physicians and thereby treated sooner. Through the use of a three-item screen, physicians can reliably identify high-risk adolescents and confidently refer them for a formal chemical dependency evaluation. The use of FIRM has provided a means of understanding how the interactions of certain pretreatment characteristics best predict treatment outcome. Based on such analyses, patient needs can be identified, and practice guidelines can be empirically derived through an iterative process of implementation and evaluation. As the variability of treatment elements increases, treatment process data will become richer. This trend will enable providers to further refine the patient-treatment match by determining the amounts of exposure to specific treatment elements that are most predictive of a positive outcome for a particular group of patients. Efforts have been made to classify chemically dependent patients through the use of factor and cluster analytic techniques. By first identifying discrete types of patients and then measuring how the many services in the treatment experience interact to produce favorable outcomes, optimal treatment guidelines could potentially be derived for each patient type. Further research in this area would further strengthen the bridge between the domains of clinical assessment, practice guidelines, and treatment outcome, setting the stage for even more effective patient-treatment matching and improved outcomes.

The development and reliability of the Recovery Attitude and Treatment Evaluator-Questionnaire I (RAATE-QI).

A reliability study was performed on a new 94-item true-false report instrument called the Recovery Attitude And Treatment Evaluator-Questionnaire I (RAATE-QI). The RAATE-QI consists of five dimensions which assess a patient's status in five clinically relevant areas for making admission assessment, treatment placement/matching and planning decisions, and discharge/follow-up outcome assessments. The five dimensions measure: resistance to treatment (treatment motivation and denial), resistance to continuing care (long-term denial), biomedical acuity, psychiatric/psychological acuity, and social/family environmental support status. Data on 143 inpatients who completed the RAATE-QI from a public sector chemical dependency/dual diagnosis treatment unit demonstrated test-retest reliabilities in the range from .73 to .87, and internal consistency reliabilities in the range from .63 to .78 across the five dimensions. These preliminary data suggest that the RAATE-QI may be a clinically reliable assessment/placement tool.

Concurrent validation of substance abusers self-reports against collateral information: percentage agreement vs. kappa vs. Yule's Y.

The ability for chemical users to give an accurate self-report of substance use vs. abstinence has been questioned. This study investigated its concurrent validity, against collateral ratings. The results indicated that validity of reports of chemical use must be evaluated in the context of the validity of other types of information. Chemical use items were corroborated about as often as such nonchemical use items as reports of emergency room visits, arrests, and hospitalizations, thus arguing against the presence of a specific denial syndrome or overarching tendency toward self-misrepresentation. Relative concurrent validities seemed more a function of such factors as item salience and specificity. No consistent trend in patient over- or underreporting of chemical use was found. The choice of concurrent validation statistic is important and can influence interpretation of results. Current standards such as percentage agreement and kappa were seen as flawed; comparisons of results based on these two measures, as well as Yule's Y led to the conclusion that Yule's Y is the statistic of choice.

Perspectives of effective treatment for alcohol and drug disorders.

Of the 1918 patients in the follow-up sample used for illustration, 63% reported total abstinence for the year after treatment, and an additional 24% reported at least 6 months of abstinence out of 12. Most relapses occurred during the first 6-month interval; 88% of patients who were abstinent the first 6 months maintained this status for the full year. Patients abusing drugs other than alcohol had much poorer outcomes than those abusing alcohol only, and this finding held up even when drug choice was controlled for sex and age of patients. Intravenous drug use was an important predictor of relapse, as was a history of antisocial behavior. A strong relationship to outcome was seen for patient participation in an aftercare program, and for weekly attendance at peer support group meetings. Emotional distress, relationship difficulties and family problems, financial difficulties, craving, and being around others who use alcohol and drugs are all seen as making the commitment to abstinence more difficult. There is clear evidence also that increased difficulty in these areas is predictive of later relapse. Comparisons of pretreatment and posttreatment measures of patient functioning revealed a decreased need for expensive health care services, such as hospitalization and emergency room care. The motor vehicle accident rate, traffic arrest rate, and criminal offense arrest rate all showed posttreatment declines. On-the-job problems also decreased dramatically following treatment. Posttreatment difficulties were disproportionately higher among patients who had returned to substance use than among patients who remained abstinent, documenting that successful treatment can have an affect in many areas that improve the quality of life for patients themselves (along with their families and communities) as well as reduce the high economic costs associated with alcohol and drug abuse in our society. Cost offsets for chemical dependency treatment are substantial and of broad scope; they also are related directly to the recovery rate. In general, the findings for outpatient programs tend to parallel those of the inpatients. Initial chemical severity and range of other clinical problems are lower, but significant reductions are noted. For both inpatients and outpatients monitored by CATOR, the posttreatment improvement in health care utilizations, reductions in work-related problems, and fewer arrests are related directly to recovery status. That is to say that recovering patients show significantly better improvement than relapsed patients. This means that treatment efficacy must be considered as a key element in estimating treatment benefits.

Medical care utilization as a function of recovery status following chemical addictions treatment.

A sample of 3,572 chemical dependency inpatients aged 25 to 82 years were the subjects of a study to evaluate whether observed reductions in health care costs are associated with successful recovery from alcoholism and other drug dependence, a function of regression to the mean, or ancillary health care during alcoholism/drug abuse treatment. The total number of hospital days were calculated for the year prior to treatment, and one and two years post-treatment. Utilization rates are not significantly different between recovering and relapsed patients prior to treatment; however, the differences between the two groups for the first and second year post-treatment are significant. The recovery patients showed a continued low utilization rate while the relapsed group had considerably higher utilization in both years. Recovery status is an essential factor to consider when determining valid cost-offsets for medical care utilization after alcoholism/drug abuse treatment.

Substance use disorder diagnostic schedule (SUDDS): the equivalence and validity of a computer-administered and an interviewer-administered format.

In order to evaluate the equivalence of interviewer-administered and computer-administered forms of the substance use disorder diagnostic schedule (SUDDS), both forms were presented to 100 substance-dependent inpatients. An additional 101 psychiatric outpatients were administered one form or the other. For patients who received both forms of the SUDDS, the percentage agreement ranged from 96% for the classification of a lifetime diagnosis of alcohol abuse/dependence to 88% for the classification of current diagnosis of alcohol abuse/dependence (kappa coefficients ranged from 0.709 to 0.865). Overall agreement with a clinician diagnosis (validity) and the two forms of administration varied from 100% for computer-generated diagnosis of current alcohol abuse/dependence to 71% for computer-generated lifetime diagnosis of drug abuse/dependence, when stratified by number of symptoms reported. No consistent differences were found in the performances of the two forms of the SUDDS, and we conclude that they may be used interchangeably.

The development and reliability of the RAATE-CE.

The Recovery Attitude And Treatment Evaluator-Clinical Evaluation (RAATE-CE) utilizes a brief, structured clinical interview that assesses five key dimensions that produce a clinically relevant and useful severity profile of the patient for making placement, continued stay, discharge, and treatment-planning decisions. The RAATE-CE also measures treatment progress. These five dimensions are: (A) degree of resistance to treatment (including denial of addiction problems); (B) degree of resistance to continuing care (including self-help groups); (C) acuity of biomedical problems; (D) acuity of psychiatric-psychological problems; and (E) the degree to which the psychosocial environment is supportive or detrimental to recovery. Data on 139 publicly funded, high-severity subjects suggest that the RAATE-CE demonstrates an interrater reliability across the five dimensions between .59 and .77, and an internal consistency reliability range between .65 and .87.

"Crack" use by American middle-class adolescent polydrug abusers.

A 77-item questionnaire on cocaine and "crack" use patterns, and on the addictive, medical, and criminal consequences of such use, was completed by 464 largely white, middle-class, suburban, teenage drug abusers registered in seven geographically disparate outpatient treatment facilities. Of the 130 (28%) who smoked crack, 87 (67%) were designated as "experimenters" (use of crack 1 to 9 times); 20 (15%) were in an intermediate group (smoked crack 10 to 50 times); and 23 (18%) were heavy users (smoked crack more than 50 times). Sixty percent of heavy users progressed from initiation of crack use to its use at least once a week in less than 3 months. Almost 50% of the 87 experimenters and nearly all the 23 heavy users recalled preoccupation with thoughts of crack, rapid loss of the ability to modulate their use of the drug, and rapid development of pharmacologic tolerance. Suspiciousness, mistrust, and depressed mood were associated with the increasing use of crack. Seizures occurred in none of those who used cocaine by snorting it intranasally (without ever smoking crack), in contrast to 1% of the experimenters and 9% of the 43 respondents who had smoked crack at least 10 times. Seven percent of the 87 experimenters versus almost one fourth of the 43 who smoked crack more frequently had injected cocaine intravenously. The use of crack by middle-class adolescents is associated with rapid addiction and with serious behavioral and medical complications.