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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. [ABSTRACT FROM AUTHOR]

While it is known that community-based outpatient treatment for substance abusing offenders is effective, treatment completion rates are low and much of the prior research has been conducted with offenders in residential treatment or therapeutic communities. The aim of the present study was to assess whether offenders who are mandated to community-based outpatient treatment have better completion rates compared to those who enter treatment voluntarily. The 160 research participants were a heterogeneous group of substance abusers who were under various levels of criminal justice supervision (CJS) in the community. The participants were enrolled in an intensive outpatient program and were recruited into the study between July 2007 and October 2010. All offenders received weekly therapy sessions using a cognitive problem solving framework and 45% completed the 6 month treatment program. Interestingly, those who were mandated demonstrated less motivation at treatment entry, yet were more likely to complete treatment compared to those who were not court-ordered to treatment. While controlling for covariates known to be related to treatment completion, the logistic regression analyses demonstrated that court-ordered offenders were over 10 times more likely to complete treatment compared to those who entered treatment voluntarily (OR=10.9, CI=2.0-59.1, p=.006). These findings demonstrate that stipulated treatment for offenders may be an effective way to increase treatment compliance., (Copyright © 2013 Elsevier Inc. All rights reserved.)

This study is a secondary data analysis of a clinical trial assessing the effectiveness of outreach case management (OCM) in linking discharged methadone patients back into treatment. The original trial assessed the effectiveness of the OCM intervention compared to a passive referral among methadone clients who needed treatment postdischarge but had not reengaged. The purpose of this study was to assess the characteristics and long-term outcomes of all clients who were discharged from methadone maintenance treatment including those who had reengaged in treatment. A total of 230 methadone clients were interviewed 3 months and then again at 9 months following discharge from treatment. Compared with participants who needed treatment but had not reengaged (NoTx: 56%), those who had successfully reenrolled in treatment (Tx; 44%) were more likely to be female, not married, and unemployed; had a longer history of sedative use; reported more psychiatric hospitalizations; and were originally enrolled in a community-based rather than a Veterans Administration program. Despite having more severe problems, the Tx group had fewer opioid-positive urines and reported less IV drug use at 9 months postdischarge compared to the NoTx group. The findings highlight the importance of rapid treatment reengagement., (Copyright © 2011 Elsevier Company. All rights reserved.)

Objective: To evaluate 3-month tobacco quit rates of young adult tobacco users randomized to 2 intervention conditions., Methods: Overall 192 non-treatment-seeking 18-to-24-year-old tobacco users received educational information and advice to quit smoking. Participants were then block randomized to 2 brief intervention conditions: (1) a telephone quitline (TQ) N = 90; or (2) a brief direct treatment intervention (BDTI) N = 102., Results: A 90-day follow-up evaluation found that 19.6% of BDTI and 10.2% of TQ participants reported 30-day point prevalence tobacco quit rates (chi-square = 2.37, P = .09)., Conclusions: BDTI can help non-treatment-seeking, low SES, young adult tobacco users quit smoking.

After drug use stabilization, employment has long been considered an important goal for clients enrolled in Methadone Maintenance Treatment Programs (MMTPs). The integrated counseling and employment intervention described here is a manualized treatment based on interpersonal cognitive problem solving (ICPS) theory. The six-month intervention utilized a problem-solving framework to help methadone clients obtain a job and manage employment within the context of drug treatment. In this pilot study, 23 subjects were randomly assigned to either integrated ICPS drug and employment counseling (n = 12) or to an ICPS drug counseling control condition (n = 11). While there were no differences between the integrated and control conditions, both groups showed a significant improvement in employment outcomes and reduction in HIV risk behaviors at the six-month follow-up. Although there may be concerns regarding the generalizability of the findings, overall, the problem solving framework may be an improvement over standard methadone counseling. The intervention may be beneficial when implemented with a larger group of motivated ex-offenders who are mandated to drug treatment as a condition of their parole.

This study examined the predictors of treatment completion among 380 state parole violators consecutively admitted to a comprehensive 12-month drug treatment program in lieu of reincarceration. Offenders were placed on intensive parole supervision throughout the 12-month treatment protocol and received three months of residential substance abuse treatment followed by nine months of outpatient counseling. Overall 123 (32.4%) of the offenders completed the 12-month treatment protocol. The primary reason for noncompletion was a positive drug screen. Bivariate analyses were performed to determine independent predictors of program completion. Four variables (age, past 30-day heroin use, total months incarcerated, and significant problems with mother) from the baseline Addiction Severity Index were found to be correlated with treatment completion (p <.10). These factors and other demographics (race, marital status, education) and variables found predictive of program completion in previous studies were entered into a multiple logistic regression model. Overall the final model found that only two factors--older age (p < .03) and no heroin use in the past 30 days (p < .02) significantly predicted treatment completion. These findings suggest that among parolees with moderate to extensive criminal justice histories younger individuals and those with recent heroin use respond less favorably to comprehensive substance abuse treatment services and intensive parole supervision.

A survey of 184 young, rural, tobacco users found that healthcare professionals often assessed tobacco use, although there was significant variability by professional type (physician vs. dentist) and tobacco service (advise vs. referral). Females reported significantly higher levels of receiving tobacco services (advice to quit) than males.

Background: Heroin dependence is a chronic relapsing disease often requiring multiple treatment experiences. Despite this knowledge, few methadone programs follow-up with discharged patients who frequently continue to engage in risky behaviors. The aim of this project was to evaluate the effectiveness of outreach case management for post-discharged methadone patients., Methods: At 90 days post-discharge 128 active out of treatment heroin users were randomly assigned to receive either a passive referral (PR) for drug treatment (n=52) or were provided with 6 weeks of outreach case management (OCM), an intervention designed to help motivate and coach patients to re-enter treatment (n=76)., Results: At 6 months post-baseline 29% of the OCM participants had successfully re-enrolled in drug treatment compared to 8% of the PR participants (chi(2)=7.6, d.f.=1, p=0.006). A logistic regression analysis showed that OCM participants were nearly six times more likely than PR participants to re-engage in MMT (OR=5.8, CI=1.6-20.8, p=0.008). Moreover, OCM subjects had fewer opiate and cocaine positive urines at the 6-month follow-up compared to PR subjects., Conclusions: The findings highlight the importance of engaging former patients in treatment and actively assisting in treatment re-entry. OCM is a simple approach to reduce the number of out-of-treatment drug users, although availability of treatment funding limits enrollment opportunities.

Approximately 80% of parolees have a history of substance abuse and nearly all are unemployed following release from prison. Common stipulations of parole require offenders to obtain employment and to not use mood-altering substances. This article explores a series of strategies implemented from 1999 to 2001 to help offenders paroled to substance user treatment to gain employment. A total of 245 paroled offenders enrolled in an outpatient substance abuse treatment program voluntarily agreed to participate in one of four different vocational intervention programs (Job Skill Development and Supported Work, Life Skill Development, Job Training, and Welfare to Work). Programmatic data (e.g., attendance, completion, job acquisition, and wage) were collected and reported for each of the vocational programs. Additionally, a 12-month pilot study examined criminal justice, substance use, and employment outcomes of 36 offenders referred to the job skill development and supported work project. Overall, 78% of the offenders enrolled in the vocational services completed the program and 134/245 (55%) were able to obtain employment. The data showed that completion of vocational services was strongly associated with obtaining employment 12 months postenrollment. Offenders identified the employment services as an integral part of their improved overall functioning. A series of practice recommendations and policy suggestions is offered to develop and manage vocational services for substance-using offenders. Employment services for parolees require considerable coordination of activities with parole officers, vocational programs, substance abuse treatment professionals, and funding systems.

This study examined the relationship between familial history of substance use and addiction severity and treatment outcomes of opiate-dependent patients. The sample was comprised of 281 methadone maintenance patients at a VA or community-based clinic. Using the family history section of the Renard Diagnostic Interview, three familial risk groups were identified based on patients' self-report of their relatives' substance use. The three groups considered both the number and type (e.g., first vs. second degree) of biological relatives with a substance use problem. These three risk groups included: (1) high risk (HR, n = 111), (2) medium risk (MR, n = 80), and (3) low risk (LR, n = 90). HR patients reported a history of more severe asocial behavior at baseline and they reported more medical problems and a greater degree of concurrent alcohol use both prior to and after 6 months of treatment compared to LR patients. In addition, the HR group reported more family/social problems at baseline compared to the MR and LR group and both HR and MR patients reported more psychological problems than LR patients after 6 months of treatment. However, when accounting for baseline differences, the regression analyses demonstrated that familial risk was not predictive of drug treatment outcomes after 6 months of methadone maintenance treatment.

Most research on employment interventions focuses on job acquisition as the sole outcome measure, despite the fact that there are many intermediate steps to obtaining work. This article examines the impact of a vocational problem solving skills (VPSS) intervention to increase motivation and action step activities that lead to employment. Over a 1-year period between 1995 and 1996, a sample of 109 methadone maintained treatment clients were randomly assigned to either a 10-session vocational problem solving intervention (N= 62) or a time and attention control condition (N=47). The Addiction Severity Index (ASI) and a Vocational Motivational Assessment Checklist (VMAC) were administered upon enrollment in the study and at 6 months postbaseline. The VMAC was completed on a biweekly basis over the 12-week intervention period. The VMAC measures both the behavioral actions to obtain employment (e.g., reading want ads, completing job applications) and client perceived motivation to obtain a job. There were no differences by condition in the level of motivation to secure employment and the number of job seeking activities during the intervention period. However, motivation to work and number of action steps did predict obtaining employment for the sample as a whole at the 6-month follow-up. Although the intervention did not increase motivation and job seeking activities, information regarding reasonable outcomes for this population of chronically unemployed persons was identified. Also, practical and methodological implications are discussed.

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.

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.

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 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.

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.

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.

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).

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.

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.

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.

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.

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.

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.