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Abstract: Background: The treatment of alcohol and other drugs is now more commonly framed in terms of a chronic condition which requires ongoing monitoring. A model which includes continuing access to health care may optimize outcomes. Most studies of chronic care models have not included health care and have only examined short term effects. Methods: The sample (n =783) included consecutive admissions in ten public and private alcohol and other drug (AOD) treatment programs followed over seven years. The outcome was remission which was defined as alcohol and drug abstinence or non-problem use. Results: In the private sample, receiving health care services predicted remission across the seven years; however this did not occur in the public sample. More patients in the public treatment sample received AOD treatment readmissions each year, while more of those in the private sector received psychiatric and general health visits. Except for drug problem severity, there were no other clinical differences between the samples. There were no differences in the proportions of patients in the two sectors who received the full spectrum of chronic care services. In the final models, 12-step participation was markedly significant for both samples. Conclusions: Models of chronic care for substance use need to consider differences between private and public treatment and should take into account that individuals may not always have access, or avail themselves of services that may optimize long-term outcomes. [Copyright &y& Elsevier]

Abstract: Aim: To evaluate potential mediators of an extended cognitive behavioral smoking cessation intervention. Design: Analysis of data from a randomized clinical trial of smoking cessation. Setting: The Habit Abatement Clinic, University of California, San Francisco. Participants: Participants were older cigarette smokers (≥50 years old). Those receiving Standard Treatment (N =100) were compared to those receiving extended cognitive behavioral treatment (N =99). Measurements: Negative affect was measured with the Profile of Mood States (POMS), the Medical Outcome Studies 36-item Short-Form Health Survey (SF-36), and the Perceived Stress Scale (PSS). Abstinence-specific social support was measured with the Partner Interaction Questionnaire (PIQ). Motivation to quit and abstinence self-efficacy were measured on 1–10 scales with the Thoughts about Abstinence Questionnaire. All were measured at the beginning of treatment and week 52. Results: Analyses revealed that extended CBT increased abstinence self-efficacy over the first 52 weeks postcessation. This effect, in turn, was positively associated with 7-day point prevalence abstinence at week 64 while controlling for treatment condition, and eliminated the independent effect of treatment condition on abstinence. The test of mediation indicated a significant effect, and abstinence self-efficacy accounted for 61% to 83% of the total effect of treatment condition on smoking abstinence. Results failed to support a mediational role of negative affect, abstinence-specific social support, or motivation to quit. Conclusions: The results of the present study are consistent with theories of relapse and studies of more time-limited interventions, and underscore the importance of abstinence self-efficacy in achieving long-term abstinence from cigarettes. [Copyright &y& Elsevier]

Abstract: Background: Important questions remain regarding the necessary duration and intensity for methadone treatment to be effective. Methods: As part of a clinical trial of tuberculosis chemoprophylaxis [Batki, S.L., Gruber, V.A., Bradley, J.M., Bradley, M., Delucchi, K., 2002. A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users. Drug Alcohol Depend. 66 283–293. doi:10.1016/S0376-8716(01)00208-3], patients with opioid dependence were recruited from an outpatient 21-day methadone detoxification program and were randomly assigned to one of three treatment conditions: (1) continuation in 21-day methadone detoxification; (2) transfer to 6-month methadone maintenance with only minimal counseling; or (3) transfer to 6-month methadone maintenance with standard twice monthly counseling and as-needed social work and psychiatric services. Both the 6-month maintenance treatments were followed by 1.5 months of detoxification. Urine drug tests and self-report measures were collected at baseline, months 1–6, and month 8.5. Results: Compared to 21-day methadone detoxification, 6-month methadone maintenance with either minimal or standard counseling resulted in fewer opiate positive urine tests and days of self-reported heroin and alcohol use. There was no change in cocaine use or other outcome measures. The increased counseling available in the standard counseling condition did not appear to reduce heroin use further than the minimal counseling condition, in contrast to the effect found for more structured counseling in long-term methadone maintenance (McLellan et al., 1993). Conclusions: Six months of methadone maintenance, even with minimal counseling, reduces heroin and alcohol use more than 21-day methadone detoxification. [Copyright &y& Elsevier]

Understanding the long-term course of problematic drinking is a fundamental concern for health services research in the alcohol field. The stability of, or change in, the course of drinking—especially heavy drinking—has both theoretical and applied relevance to alcohol research. We explore the application of latent class growth modeling to 5 years of survey data collected from dependent and problem drinkers—some not in treatment at baseline—in an attempt to uncover prototypical longitudinal drinking patterns. Results indicated that five profiles of drinkers can be used to represent their longitudinal course of alcohol consumption: early quitters (N=88), light/non-drinkers (N=76), gradual improvers (N=129), moderate drinkers (N=229), and heavy drinkers (N=572). Significant baseline factors included ASI drug severity, dependence symptoms, and marital status. Attendance at AA meetings, the size of one’s heavy drinking and drug using social network, past treatment, receiving suggestions about one’s drinking, and contacts with the medical system were significant influences. The size of heavy drinking and drug using social networks was noticeably larger for the heavy drinkers. Findings also support the usefulness of a semi-parametric latent group-based approach as a tool for analyzing alcohol-related behaviors. [Copyright &y& Elsevier]

Abstract: Background: This study examined stability of remission in patients who were abstainers and non-problem users at 1-year after entering private, outpatient alcohol and drug treatment. We examined: (a) How does risk of relapse change over time? (b) What was the risk of relapse for non-problem users versus abstainers? (c) What individual, treatment, and extra-treatment characteristics predicted time to relapse, and did these differ by non-problem use versus abstinence? Methods: The sample consisted of 684 adults in remission (i.e., abstainers or non-problem users) 1 year following treatment intake. Participants were interviewed at intake, and 1, 5, 7, 9, and 11 years after intake. We used discrete-time survival analysis to examine when relapse is most likely to occur and predictors of relapse. Results: Relapse was most likely at 5-year, and least likely at 11-year follow-up. Non-problem users had twice the odds of relapse compared to abstainers. Younger individuals and those with fewer 12-step meetings and shorter index treatment had higher odds of relapse than others. We found no significant interactions between non-problem use and the other covariates suggesting that significant predictors of outcome did not differ for non-problem users. Conclusions: Non-problem use is not an optimal 1-year outcome for those in an abstinence-oriented, heterogeneous substance use treatment program. Future research should examine whether these results are found in harm reduction treatment and self-help models, or in those with less severe problems. Results suggest treatment retention and 12-step participation are prognostic markers of long-term positive outcomes for those achieving remission at 1 year. [Copyright &y& Elsevier]

Abstract: Background: Residential therapeutic communities (TCs) have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology that is incompatible with the use of methadone. This study used equivalency testing to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment (MMT) into a TC. Methods: The study compared 24-month outcomes between 125 MMT patients and 106 opioid-dependent drug-free clients with similar psychiatric history, criminal justice pressure and expected length of stay who were all enrolled in a TC. Statistical equivalence was expected between groups on retention in the TC and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviors. Results: Mean number of days in treatment was statistically equivalent for the two groups (166.5 for the MMT group and 180.2 for the comparison group). At each assessment, the proportion of the MMT group testing positive for illicit opioids was indistinguishable from the proportion in the comparison group. The equivalence found for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the MMT group and none in the comparison group tested positive. Regarding injection- and sex-risk behaviors the groups were equivalent at all observation points. Conclusions: Methadone patients fared as well as other opioid users in TC treatment. These findings provide additional evidence that TCs can be successfully modified to accommodate MMT patients. [Copyright &y& Elsevier]

Abstract: This clinical trial evaluated a contingency management intervention designed to improve medication adherence among HIV-positive methadone maintenance patients. After a 4-week baseline observation phase, eligible participants (N =66) were randomly assigned to: (a) medication coaching sessions every other week to assist with adherence strategies (comparison group) or (b) medication coaching plus voucher reinforcement for opening electronic medication caps on time (voucher group). Baseline adherence (percent doses taken/percent total possible doses) was 51% using electronic measurement, 75% using self-report and 75% using pill count. The intervention was provided for 12 weeks, with a 4-week follow-up. The primary outcome results of the clinical trial indicated effectiveness during the intervention, with significant mean adherence differences between voucher and comparison groups using electronic measurement (78% versus 56%), pill count (86% versus 75%), and self-report (87% versus 69%). Differences between groups faded after vouchers were discontinued. Contingency management shows promise as a strategy to promote antiretroviral medication adherence in this population. [Copyright &y& Elsevier]

Background: We evaluated the cost-effectiveness of a hepatitis C (HCV) screening and active linkage to care intervention in US methadone maintenance treatment (MMT) patients using data from a randomized trial conducted in New York City and San Francisco.Methods: We used a decision analytic model to compare 1) no intervention; 2) HCV screening and education (control); and 3) HCV screening, education, and care coordination (active linkage intervention). We also explored an alternative strategy wherein HCV/HIV co-infected participants linked elsewhere. Trial data include population characteristics (67% male, mean age 48, 58% HCV infected) and linkage rates. Data from published sources include treatment efficacy and HCV re-infection risk. We projected quality-adjusted life years (QALYs) and lifetime medical costs using an established model of HCV (HEP-CE). Incremental cost-effectiveness ratios (ICERs) are in 2015 US$/QALY discounted 3% annually.Results: The control strategy resulted in a projected 35% linking to care within 6 months and 31% achieving sustained virologic response (SVR). The intervention resulted in 60% linking and 54% achieving SVR with an ICER of $24,600/QALY compared to no intervention from the healthcare sector perspective and was a more efficient use of resources than the control strategy. The intervention had an ICER of $76,500/QALY compared to the alternative strategy. From a societal perspective, the intervention had a net monetary benefit of $511,000-$975,600.Conclusions: HCV care coordination interventions that include screening, education and active linkage to care in MMT settings are likely cost-effective at a conventional $100,000/QALY threshold for both HCV mono-infected and HIV co-infected patients. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study examined the relationships between treatment fidelity and treatment outcomes in a community-based trial of a 12-Step Facilitation (TSF) intervention. Method: In a prior multi-site randomized clinical trial, 234 participants in 10 outpatient drug treatment clinics were assigned to receive the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention. A secondary analysis reviewed and coded all STAGE-12 sessions for fidelity to the protocol, using the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES). Linear mixed-effects models tested the relationship between three fidelity measures (adherence, competence, empathy) and six treatment outcomes (number of days of drug use and five Addiction Severity Index (ASI) composite scores) measured at 3 months post-baseline. Results: Adherence, competence and empathy were robustly associated with improved employment status at follow up. Empathy was inversely associated with drug use, as was competence in a non-significant trend (p =.06). Testing individual ASI drug composite score items suggested that greater competence was associated with fewer days of drug use and, at the same time, with an increased sense of being troubled or bothered by drug use. Conclusions: Greater competence and empathy in the delivery of a TSF intervention were associated with better drug use and employment outcomes, while adherence was associated with employment outcomes only. Higher therapist competence was associated with lower self-report drug use, and also associated with greater self-report concern about drug use. The nature of TSF intervention may promote high levels of concern about drug use even when actual use is low. [Copyright &y& Elsevier]

Abstract: Background: Addiction treatment programs are increasingly working to address prevalent and comorbid tobacco dependence in their service populations. However at present there are few published measurement tools, with known psychometric properties, that can be used to assess client-level constructs related to tobacco dependence in addiction treatment settings. Following on previous work that developed a staff-level survey instrument, this report describes the development and measurement characteristics of the smoking knowledge, attitudes and services (S-KAS) for use with clients in addiction treatment settings. Method: 250 clients enrolled in residential drug abuse treatment programs were surveyed. Summary statistics were used to characterize both the participants and their responses, and exploratory factor analysis (EFA) was used to examine the underlying factor structure. Results: Examination of the rotated factor pattern indicated that the latent structure was formed by one knowledge factor, one attitude factor, and two “service” factors reflecting program services and clinician services related to tobacco dependence. Standardized Cronbach''s alpha coefficients for the four scales were, respectively, .57, .75, .82 and .82. Conclusions: The proposed scales have reasonably good psychometric characteristics, although the knowledge scale leaves room for improvement, and will allow researchers to quantify client knowledge, attitudes and services regarding tobacco dependence treatment. Researchers, program administrators, and clinicians may find the S-KAS useful in changing organizational culture and clinical practices related to tobacco addiction, help in program evaluation studies, and in tracking and improving client motivation. [Copyright &y& Elsevier]

We examined the prevalence of drug use related infectious complications among opioid using or dependent individuals and service charges associated with medical care received over a 2-year period at a public hospital. A computerized medical record review was used to identify 3147 individuals with diagnoses related to opioid use or dependence. Forty-nine percent of these patients were treated for bacterial infections and 30% presented for treatment of medical problems arising from the effects of the drugs themselves (e.g. drug withdrawal, overdoses, and drug-induced psychiatric symptoms). Mean charges were $13 393 for these patients, nearly 2.5 times the average per patient charges for non-opioid using patients during the study period. Patients with diagnoses related to opioid use or dependence comprised 2% of the total patient population for this period, yet accounted for 5% of total charges. Homeless patients were less likely to have used ambulatory services and were more likely than non-homeless patients to have used emergency and inpatient services. Early detection of patients with opioid use or dependence problems, coupled with effective strategies to engage them in ambulatory preventive services, could allow interventions to reduce morbidity and associated charges in this patient population. The findings suggest that health care providers and policy makers consider polices that promote ambulatory care use among opioid users seeking medical care through the public health care system. [Copyright &y& Elsevier]