Professor, Psychiatry and Behavioral Sciences
Member, Stanford Neurosciences Institute
CIGH Fellow, Stanford Center for Innovation in Global Health (2015 - Present)
Affiliated faculty, Stanford Law School (2014 - Present)
Member, Provost's Task Force on Binge Drinking on Campus (2011 - 2013)
Acting Director, VA Center for Health Care Evaluation (2010 - 2011)
Senior Policy Advisor, White House Office of National Drug Control Policy (2009 - 2010)
Chairman, Faculty Advisory Committee, Stanford Health Policy Forum (2007 - Present)
Affiliate, Center for Health Policy, Stanford University (2003 - Present)
Director, VA Program Evaluation and Resource Center (2001 - 2009)
Honors & Awards
Distinguished Contribution to the Public Interest, American Psychological Association (2009)
Honorary Member, Psychiatry Journal Club, Ibn Rushd Hospital, Baghdad (2008)
Public Health Book of the Year, British Medical Association (2010)
Honorary Professor of Psychiatry, Institute of Psychiatry at the Maudsley, King's College London (2009-)
Boards, Advisory Committees, Professional Organizations
Member, Advisory Board, Recovery Research Institute, Harvard University (2012 - Present)
Ph.D., University of Illinois, Psychology (1993)
A.M., University of Illinois, Clinical/Community Psychology (1991)
B.A., Michigan State University, Psychology (1988)
Current Research and Scholarly Interests
Dr. Humphreys researches interventions for substance abuse and psychiatric disorders. He focuses particularly on evaluating the outcomes of professionally-administered treatments and peer-operated self-help groups (e.g., Alcoholics Anonymous), developing health services research-related applications for innovative qualitative and quantitative research techniques, and analyzing national mental health policy.
Web-based Intervention to Reduce Alcohol Use in Veterans With Hepatitis C
Many people who are infected with Hepatitis C misuse alcohol, which is even more dangerous for them than it is for a non-infected person. In this VA study, such individuals will be screened and given feedback on their drinking using an Internet-based program which has been shown to reduce drinking in other populations. The research team will evaluate whether the program helps Veterans drink less over time and thereby improve their health.
- Independent Studies (5)
Prior Year Courses
- Policy Practicum: Designing a Social Impact Bond for Santa Clara County Mental Health
LAW 413X (Aut, Win, Spr)
- Policy Practicum: Designing a Social Impact Bond for Santa Clara County Mental Health
PSYC 213 (Aut, Win)
- Policy Practicum: Designing a Social Impact Bond for Santa Clara County Mental Health
Postdoctoral Faculty Sponsor
Graduate and Fellowship Programs
Pain Management (Fellowship Program)
- Reconciling the Present and the Future in Opioid Prescription Policy: An Ethical Dilemma. Pain medicine (Malden, Mass.) 2018
- An experimental method for assessing whether marijuana use reduces opioid use in patients with chronic pain. Addiction (Abingdon, England) 2018
- How Medicaid Can Strengthen the National Response to the Opioid Epidemic. American journal of public health 2018; 108 (5): 589–90
Opioids of the Masses Stopping an American Epidemic From Going Global
2018; 97 (3): 118–29
View details for Web of Science ID 000430264700011
Medical Marijuana Users are More Likely to Use Prescription Drugs Medically and Nonmedically.
Journal of addiction medicine
OBJECTIVES: Previous studies have found a negative population-level correlation between medical marijuana availability in US states, and trends in medical and nonmedical prescription drug use. These studies have been interpreted as evidence that use of medical marijuana reduces medical and nonmedical prescription drug use. This study evaluates whether medical marijuana use is a risk or protective factor for medical and nonmedical prescription drug use.METHODS: Simulations based upon logistic regression analyses of data from the 2015 National Survey on Drug Use and Health were used to compute associations between medical marijuana use, and medical and nonmedical prescription drug use. Adjusted risk ratios (RRs) were computed with controls added for age, sex, race, health status, family income, and living in a state with legalized medical marijuana.RESULTS: Medical marijuana users were significantly more likely (RR 1.62, 95% confidence interval [CI] 1.50-1.74) to report medical use of prescription drugs in the past 12 months. Individuals who used medical marijuana were also significantly more likely to report nonmedical use in the past 12 months of any prescription drug (RR 2.12, 95% CI 1.67-2.62), with elevated risks for pain relievers (RR 1.95, 95% CI 1.41-2.62), stimulants (RR 1.86, 95% CI 1.09-3.02), and tranquilizers (RR 2.18, 95% CI 1.45-3.16).CONCLUSIONS: Our findings disconfirm the hypothesis that a population-level negative correlation between medical marijuana use and prescription drug harms occurs because medical marijuana users are less likely to use prescription drugs, either medically or nonmedically. Medical marijuana users should be a target population in efforts to combat nonmedical prescription drug use.
View details for DOI 10.1097/ADM.0000000000000405
View details for PubMedID 29664895
State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder.
Psychiatric services (Washington, D.C.)
2018; 69 (4): 448–55
OBJECTIVE: As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine.METHODS: This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs.RESULTS: State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049).CONCLUSIONS: State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.
View details for DOI 10.1176/appi.ps.201700196
View details for PubMedID 29241428
- What can treatment research offer general practice? LANCET PSYCHIATRY 2018; 5 (4): 295–97
- Of moral judgments and sexual addictions ADDICTION 2018; 113 (3): 387–88
Exclusion criteria and generalizability in bipolar disorder treatment trials
CONTEMPORARY CLINICAL TRIALS COMMUNICATIONS
2018; 9: 130–34
The current paper reviews the English-language research on exclusion criteria in bipolar disorder treatment trials and discusses how study samples compare to the general bipolar patient population.& Results: Across 8 identified studies of exclusion criteria and their impact, between 55% and 96% of people with bipolar disorder would be excluded from treatment research. The number of exclusion criteria varies across bipolar disorder treatment research, with one study estimate of a median of 7 criteria used across studies. The criteria that excluded the greatest number of potential participants were comorbid substance use disorder, suicidal risk, and comorbid medical conditions. Both studies that compared treatment responses among participants who met and did not meet exclusion criteria found no statistically significant differences.Most potential participants are excluded from outcome research, which creates challenges for recruitment and limits generalizability of study findings. Common exclusionary practices lead to unrepresentative samples that limit generalizability and reduce the confidence of clinicians that findings can be translated to front-line practice with bipolar disorder patients.
View details for DOI 10.1016/j.conctc.2018.01.009
View details for Web of Science ID 000431064200019
View details for PubMedID 29696235
View details for PubMedCentralID PMC5898491
- Our Other Prescription Drug Problem NEW ENGLAND JOURNAL OF MEDICINE 2018; 378 (8): 693–95
A public health approach to opioid addiction in North America Reply
2018; 391 (10117): 202
View details for Web of Science ID 000423867000018
Benefit requirements for substance use disorder treatment in state health insurance exchanges
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2018; 44 (4): 426–30
Established in 2014, state health insurance exchanges have greatly expanded substance use disorder (SUD) treatment coverage in the United States as qualified health plans (QHPs) within the exchanges are required to conform to parity provisions laid out by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA). Coverage improvements, however, have not been even as states have wide discretion over how they meet these regulations.How states regulate SUD treatment benefits offered by QHPs has implications for the accessibility and quality of care. In this study, we assessed the extent to which state insurance departments regulate the types of SUD services and medications plans must provide, as well as their use of utilization controls.Data were collected as part of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment. Data were obtained from state Departments of Insurance via a 15-minute internet-based survey.States varied widely in regulations on QHPs' administration of SUD treatment benefits. Some states required plans to cover all 11 SUD treatment services and medications we assessed in the study, whereas others did not require plans to cover anything at all. Nearly all states allowed the plans to employ utilization controls, but reported little guidance regarding how they should be used.Although some states have taken full advantage of the health insurance exchanges to increase access to SUD treatment, others seem to have done the bare minimum required by the ACA. By not requiring coverage for the entire SUD continuum of care, states are hindering client access to appropriate types of care necessary for recovery.
View details for DOI 10.1080/00952990.2017.1411934
View details for Web of Science ID 000432219800003
View details for PubMedID 29261341
View details for PubMedCentralID PMC5940489
Predictive Validity of Outpatient Follow-up After Detoxification as a Quality Measure.
Journal of addiction medicine
2017; 11 (3): 205-210
Care coordination for substance use disorder (SUD) treatment is a persistent challenge. Timely outpatient follow-up after detoxification from alcohol and opiates is associated with improved outcomes, leading some care systems to attempt to measure and incentivize this practice. This study evaluated the predictive validity of a 7-day outpatient follow-up after detoxification quality measure used by the Veterans Health Administration (VHA).A national sample of patients who received detoxification from alcohol or opiates (N = 25,354) was identified in VHA administrative data. Propensity score-weighted mixed-effects regressions modeled associations between receiving an outpatient follow-up visit within 7 days of completing detoxification and patient outcomes, controlling for facility-level performance and clustering of patients within facilities.Baseline differences between patients who did (39.6%) and did not (60.4%) receive the follow-up visit were reduced or eliminated with propensity score weighting. Meeting the quality measure was associated with significantly more outpatient treatment for SUD (b = 1.07 visits) and other mental health conditions (b = 0.58 visits), and higher inpatient utilization for SUD (b = 0.75 admissions) and other mental health conditions (b = 0.76 admissions). Notably, meeting the quality measure was associated with 53.3% lower odds of 2-year mortality (P < 0.001 for all).These findings support the predictive validity of 7-day follow-up after detoxification as a care coordination measure. Well-coordinated care may be associated with higher outpatient and inpatient utilization, and such engagement in care may be protective against mortality in people who receive detoxification from alcohol or opiates.
View details for DOI 10.1097/ADM.0000000000000298
View details for PubMedID 28282324
Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis
BMJ-BRITISH MEDICAL JOURNAL
Objectives To identify trends in concurrent use of a benzodiazepine and an opioid and to identify the impact of these trends on admissions to hospital and emergency room visits for opioid overdose.Design Retrospective analysis of claims data, 2001-13.Setting Administrative health claims database.Participants 315 428 privately insured people aged 18-64 who were continuously enrolled in a health plan with medical and pharmacy benefits during the study period and who also filled at least one prescription for an opioid.Interventions Concurrent benzodiazepine/opioid use, defined as an overlap of at least one day in the time periods covered by prescriptions for each drug. Main outcome measures Annual percentage of opioid users with concurrent benzodiazepine use; annual incidence of visits to emergency room and inpatient admissions for opioid overdose.Results 9% of opioid users also used a benzodiazepine in 2001, increasing to 17% in 2013 (80% relative increase). This increase was driven mainly by increases among intermittent, as opposed to chronic, opioid users. Compared with opioid users who did not use benzodiazepines, concurrent use of both drugs was associated with an increased risk of an emergency room visit or inpatient admission for opioid overdose (adjusted odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001) among all opioid users. The adjusted odds ratio for an emergency room visit or inpatient admission for opioid overdose was 1.42 (1.33 to 1.51; P<0.001) for intermittent opioid users and 1.81 (1.67 to 1.96; P<0.001) chronic opioid users. If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).Conclusions From 2001 to 2013, concurrent benzodiazepine/opioid use sharply increased in a large sample of privately insured patients in the US and significantly contributed to the overall population risk of opioid overdose.
View details for DOI 10.1136/bmj.j760
View details for Web of Science ID 000397014900002
View details for PubMedID 28292769
Adapting a computer-delivered brief alcohol intervention for veterans with Hepatitis C.
Informatics for health & social care
This study adapted an existing computer-delivered brief alcohol intervention (cBAI) for use in Veterans with the hepatitis C virus (HCV) and examined its acceptability and feasibility in this patient population.A four-stage model consisting of initial pilot testing, qualitative interviews with key stakeholders, development of a beta version of the cBAI, and usability testing was used to achieve the study objectives.In-depth interviews gathered feedback for modifying the cBAI, including adding HCV-related content such as the health effects of alcohol on liver functioning, immune system functioning, and management of HCV, a preference for concepts to be displayed through "newer looking" graphics, and limiting the use of text to convey key concepts. Results from usability testing indicated that the modified cBAI was acceptable and feasible for use in this patient population.The development model used in this study is effective for gathering actionable feedback that can inform the development of a cBAI and can result in the development of an acceptable and feasible intervention for use in this population. Findings also have implications for developing computer-delivered interventions targeting behavior change more broadly.
View details for DOI 10.1080/17538157.2016.1255628
View details for PubMedID 28068154
Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial.
Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice.To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation.A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings.Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours.Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year.Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]).Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research.clinicaltrials.gov Identifier: NCT01067144.
View details for DOI 10.1001/jamasurg.2017.4915
View details for PubMedID 29238824
Predictive validity of a quality measure for intensive substance use disorder treatment.
Measures of substance use disorder (SUD) treatment quality are essential tools for performance improvement. The Veterans Health Administration (VHA) developed a measure of access to and engagement in intensive outpatient programs (IOPs) for SUD. However, predictive validity, or associations between this measure and treatment outcomes, has not been examined.Data on veterans with SUD came from 3 samples: the Outcomes Monitoring Project (N = 5436), a national evaluation of VHA mental health services (N = 339,887), and patients receiving detoxification services (N = 23,572). Propensity score-weighted mixed-effects regressions modeled associations between receiving at least 1 week of IOP treatment and patient outcomes, controlling for facility-level performance and a random effect for facility.Propensity score weighting reduced or eliminated observable baseline differences between patient groups. Patients who accessed IOPs versus those who did not reported significantly reduced alcohol- and drug-related symptom severity, with significantly fewer past-month days drinking alcohol (b = 1.83, P < .001) and fewer past-month days intoxicated (b = 1.55, P < .001). Patients who received IOP after detoxification services had higher 6-month utilization of SUD outpatient visits (b = 2.09, P < .001), more subsequent detoxification episodes (b = 0.25, P < .001), and lower odds of 2-year mortality (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.61-0.75; P < .001).Receiving at least 1 week of SUD treatment in an IOP was associated with higher follow-up utilization, improved health outcomes, and reduced mortality. These associations lend support to the predictive validity of VHA's IOP quality measure. Future research should focus on measure feasibility and validity outside of VHA, and whether predictive validity is maintained once this quality measure is tied to performance incentives.
View details for PubMedID 27435754
- Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States ANNALS OF INTERNAL MEDICINE 2016; 165 (1): 10-?
Governmental standard drink definitions and low-risk alcohol consumption guidelines in 37 countries
2016; 111 (7): 1293-1298
One of the challenges of international alcohol research and policy is the variability in and lack of knowledge of how governments in different nations define a standard drink and low-risk drinking. This study gathered such information from governmental agencies in 37 countries.A pool of 75 countries that might have definitions was created using World Health Organization (WHO) information and the authors' own judgement. Structured internet searches of relevant terms for each country were supplemented by efforts to contact government agencies directly and to consult with alcohol experts in the country.Most of the 75 national governments examined were not identified as having adopted a standard drink definition. Among the 37 that were so identified, the modal standard drink size was 10 g pure ethanol, but variation was wide (8-20 g). Significant variability was also evident for low-risk drinking guidelines, ranging from 10-42 g per day for women and 10-56 g per day for men to 98-140 g per week for women and 150-280 g per week for men.Researchers working and communicating across national boundaries should be sensitive to the substantial variability in 'standard' drink definitions and low-risk drinking guidelines. The potential impact of guidelines, both in general and in specific national cases, remains an important question for public health research.
View details for DOI 10.1111/add.13341
View details for Web of Science ID 000379951700027
View details for PubMedID 27073140
Weighing the Risks and Benefits of Chronic Opioid Therapy
AMERICAN FAMILY PHYSICIAN
2016; 93 (12): 982-990
Evidence supports the use of opioids for treating acute pain. However, the evidence is limited for the use of chronic opioid therapy for chronic pain. Furthermore, the risks of chronic therapy are significant and may outweigh any potential benefits. When considering chronic opioid therapy, physicians should weigh the risks against any possible benefits throughout the therapy, including assessing for the risks of opioid misuse, opioid use disorder, and overdose. When initiating opioid therapy, physicians should consider buprenorphine for patients at risk of opioid misuse, opioid use disorder, and overdose. If and when opioid misuse is detected, opioids do not necessarily need to be discontinued, but misuse should be noted on the problem list and interventions should be performed to change the patient's behavior. If aberrant behavior continues, opioid use disorder should be diagnosed and treated accordingly. When patients are discontinuing opioid therapy, the dosage should be decreased slowly, especially in those who have intolerable withdrawal. It is not unreasonable for discontinuation of chronic opioid therapy to take many months. Benzodiazepines should not be coprescribed during chronic opioid therapy or when tapering, because some patients may develop cross-dependence. For patients at risk of overdose, naloxone should be offered to the patient and to others who may be in a position to witness and reverse opioid overdose.
View details for Web of Science ID 000377633800003
View details for PubMedID 27304767
- Excellent Patient Care Processes in Poor Hospitals? Why Hospital-Level and Patient-Level Care Quality-Outcome Relationships Can Differ JOURNAL OF GENERAL INTERNAL MEDICINE 2016; 31: 74-77
Excellent Patient Care Processes in Poor Hospitals? Why Hospital-Level and Patient-Level Care Quality-Outcome Relationships Can Differ.
Journal of general internal medicine
2016; 31: 74-77
Studies finding weak or nonexistent relationships between hospital performance on providing recommended care and hospital-level clinical outcomes raise questions about the value and validity of process of care performance measures. Such findings may cause clinicians to question the effectiveness of the care process presumably captured by the performance measure. However, one cannot infer from hospital-level results whether patients who received the specified care had comparable, worse or superior outcomes relative to patients not receiving that care. To make such an inference has been labeled the "ecological fallacy," an error that is well known among epidemiologists and sociologists, but less so among health care researchers and policy makers. We discuss such inappropriate inferences in the health care performance measurement field and illustrate how and why process measure-outcome relationships can differ at the patient and hospital levels. We also offer recommendations for appropriate multilevel analyses to evaluate process measure-outcome relationships at the patient and hospital levels and for a more effective role for performance measure bodies and research funding organizations in encouraging such multilevel analyses.
View details for DOI 10.1007/s11606-015-3564-3
View details for PubMedID 26951280
- Pain Duration and Resolution following Surgery: An Inception Cohort Study PAIN MEDICINE 2015; 16 (12): 2386-2396
Pain Duration and Resolution following Surgery: An Inception Cohort Study.
2015; 16 (12): 2386-2396
Preoperative determinants of pain duration following surgery are poorly understood. We identified preoperative predictors of prolonged pain after surgery in a mixed surgical cohort.We conducted a prospective longitudinal study of patients undergoing mastectomy, lumpectomy, thoracotomy, total knee replacement, or total hip replacement. We measured preoperative psychological distress and substance use, and then measured pain and opioid use after surgery until patients reported the cessation of both opioid consumption and pain. The primary endpoint was time to opioid cessation, and those results have been previously reported. Here, we report preoperative determinants of time to pain resolution following surgery in Cox proportional hazards regression.Between January 2007 and April 2009, we enrolled 107 of 134 consecutively approached patients undergoing the aforementioned surgical procedures. In the final multivariate model, preoperative self-perceived risk of addiction predicted more prolonged pain. Unexpectedly, anxiety sensitivity predicted more rapid pain resolution after surgery. Each one-point increase (on a four point scale) of self-perceived risk of addiction was associated with a 38% (95% CI 3-61) reduction in the rate of pain resolution (P = 0.04). Furthermore, higher anxiety sensitivity was associated with an 89% (95% CI 23-190) increased rate of pain resolution (P = 0.004).Greater preoperative self-perceived risk of addiction, and lower anxiety sensitivity predicted a slower rate of pain resolution following surgery. Each of these factors was a better predictor of pain duration than preoperative depressive symptoms, post-traumatic stress disorder symptoms, past substance use, fear of pain, gender, age, preoperative pain, or preoperative opioid use.
View details for DOI 10.1111/pme.12842
View details for PubMedID 26179223
- The exclusion of people with psychiatric disorders from medical research JOURNAL OF PSYCHIATRIC RESEARCH 2015; 70: 28-32
Griffith Edwards' rigorous sympathy with Alcoholics Anonymous
2015; 110: 16-18
Griffith Edwards made empirical contributions early in his career to the literature on Alcoholics Anonymous (AA), but the attitude he adopted towards AA and other peer-led mutual help initiatives constitutes an even more important legacy. Unlike many treatment professionals who dismissed the value of AA or were threatened by its non-professional approach, Edwards was consistently respectful of the organization. However, he never became an uncritical booster of AA or overgeneralized what could be learnt from it. Future scholarly and clinical endeavors concerning addiction-related mutual help initiatives will benefit by continuing Edwards' tradition of 'rigorous sympathy'.
View details for DOI 10.1111/add.12900
View details for Web of Science ID 000355769700005
View details for PubMedID 26042562
Examining the Specification Validity of the HEDIS Quality Measures for Substance Use Disorders
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2015; 53: 16-21
Accurate operationalization is a major challenge in developing quality measures for substance use disorder treatment. Specification validity is a term used to describe whether a quality measure is operationalized such that it captures the intended care processes and patients. This study assessed the specification validity of the 2009 Healthcare Effectiveness Data and Information Set (HEDIS®) substance use disorder initiation and engagement measures by examining whether encounters assumed to include relevant treatment have corroborating evidence in the clinical progress notes. The positive predictive values were excellent (>90%) for residential and outpatient records selected from addiction treatment programs but more modest for records generated in non-addiction settings, and were highly variable across facilities. Stakeholders using these measures to compare care quality should be mindful of the clinical composition of the data and determine if similar validation work has been conducted on the systems being evaluated.
View details for DOI 10.1016/j.jsat.2015.01.002
View details for Web of Science ID 000354505900003
View details for PubMedID 25736624
- What ecologic analyses cannot tell us about medical marijuana legalization and opioid pain medication mortality. JAMA internal medicine 2015; 175 (4): 655-656
- State-level relationships cannot tell us anything about individuals. American journal of public health 2015; 105 (4)
Addiction Treatment Professionals Are Not the Gatekeepers of Recovery
SUBSTANCE USE & MISUSE
2015; 50 (8-9): 1024-1027
Addiction treatment is beneficial to many individuals who have substance use disorders. However, only a minority of individuals who recover from addiction receive it. Despite this, addiction treatment is sometimes granted the status of the "gatekeeper of recovery." The myth that treatment is necessary for recovery has no empirical support. It also undermines the confidence of individuals in their ability to change on their own and is unduly dismissive of the efforts of nonprofessional helpers.
View details for DOI 10.3109/10826084.2015.1007678
View details for Web of Science ID 000361331800020
View details for PubMedID 25774891
Predictive validity of two process-of-care quality measures for residential substance use disorder treatment.
Addiction science & clinical practice
2015; 10: 22-?
In order to monitor and ultimately improve the quality of addiction treatment, professional societies, health care systems, and addiction treatment programs must establish clinical practice standards and then operationalize these standards into reliable, valid, and feasible quality measures. Before being implemented, quality measures should undergo tests of validity, including predictive validity. Predictive validity refers to the association between process-of-care quality measures and subsequent patient outcomes. This study evaluated the predictive validity of two process quality measures of residential substance use disorder (SUD) treatment.Washington Circle (WC) Continuity of Care quality measure is the proportion of patients having an outpatient SUD treatment encounter within 14 days after discharge from residential SUD treatment. The Early Discharge measure is the proportion of patients admitted to residential SUD treatment who discharged within 1 week of admission. The predictive validity of these process measures was evaluated in US Veterans Health Administration patients for whom utilization-based outcome and 2-year mortality data were available. Propensity score-weighted, mixed effects regression adjusted for pre-index imbalances between patients who did and did not meet the measures' criteria and clustering of patients within facilities.For the WC Continuity of Care measure, 76 % of 10,064 patients had a follow-up visit within 14 days of discharge. In propensity score-weighted models, patients who had a follow-up visit had a lower 2-year mortality rate [odds ratio (OR) = 0.77, p = 0.008], but no difference in subsequent detoxification episodes relative to patients without a follow-up visit. For the Early Discharge measure, 9.6 % of 10,176 discharged early and had significantly higher 2-year mortality (OR = 1.49, p < 0.001) and more subsequent detoxification episodes.These two measures of residential SUD treatment quality have strong associations with 2-year mortality and the Early Discharge measure is also associated with more subsequent detoxification episodes. These results provide initial support for the predictive validity of residential SUD treatment quality measures and represent the first time that any SUD quality measure has been shown to predict subsequent mortality.
View details for DOI 10.1186/s13722-015-0042-5
View details for PubMedID 26520402
View details for PubMedCentralID PMC4672518
Estimating the Efficacy of Alcoholics Anonymous without Self-Selection Bias: An Instrumental Variables Re-Analysis of Randomized Clinical Trials
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH
2014; 38 (11): 2688-2694
Observational studies of Alcoholics Anonymous' (AA) effectiveness are vulnerable to self-selection bias because individuals choose whether or not to attend AA. The present study, therefore, employed an innovative statistical technique to derive a selection bias-free estimate of AA's impact.Six data sets from 5 National Institutes of Health-funded randomized trials (1 with 2 independent parallel arms) of AA facilitation interventions were analyzed using instrumental variables models. Alcohol-dependent individuals in one of the data sets (n = 774) were analyzed separately from the rest of sample (n = 1,582 individuals pooled from 5 data sets) because of heterogeneity in sample parameters. Randomization itself was used as the instrumental variable.Randomization was a good instrument in both samples, effectively predicting increased AA attendance that could not be attributed to self-selection. In 5 of the 6 data sets, which were pooled for analysis, increased AA attendance that was attributable to randomization (i.e., free of self-selection bias) was effective at increasing days of abstinence at 3-month (B = 0.38, p = 0.001) and 15-month (B = 0.42, p = 0.04) follow-up. However, in the remaining data set, in which preexisting AA attendance was much higher, further increases in AA involvement caused by the randomly assigned facilitation intervention did not affect drinking outcome.For most individuals seeking help for alcohol problems, increasing AA attendance leads to short- and long-term decreases in alcohol consumption that cannot be attributed to self-selection. However, for populations with high preexisting AA involvement, further increases in AA attendance may have little impact.
View details for DOI 10.1111/acer.12557
View details for Web of Science ID 000345620400001
View details for PubMedID 25421504
- Addiction editors respond to Mr. Leverton. Addiction 2014; 109 (7): 1209-1211
- Self-Loathing Aspects of Depression Reduce Postoperative Opioid Cessation Rate PAIN MEDICINE 2014; 15 (6): 954-964
Self-loathing aspects of depression reduce postoperative opioid cessation rate.
2014; 15 (6): 954-964
We previously reported that increased preoperative Beck Depression Inventory II (BDI-II) scores were associated with a 47% (95% CI 24%-64%) reduction in the rate of opioid cessation following surgery. We aimed to identify the underlying factors of the BDI-II (affective/cognitive vs somatic) associated with a decreased rate of opioid cessation after surgery.We conducted a secondary analysis of the data from a previously reported prospective, longitudinal, observational study of opioid use after five distinct surgical procedures (total hip replacement, total knee replacement, thoracotomy, mastectomy, and lumpectomy) in 107 patients. The primary endpoint was time to opioid cessation. After exploratory factor analysis of the BDI-II, mean summary scores were calculated for each identified factor. These scores were evaluated as predictors of time to opioid cessation using Cox proportional hazards regression.The exploratory factor analysis produced three factors (self-loathing symptoms, motivational symptoms, emotional symptoms). All three factors were significant predictors in univariate analysis. Of the three identified factors of the BDI-II, only preoperative self-loathing symptoms (past failure, guilty feelings, self-dislike, self-criticalness, suicidal thoughts, worthlessness) independently predicted a significant decrease in opioid cessation rate after surgery in the multivariate analysis (HR 0.86, 95% CI 0.75-0.99, P value 0.037).Our results identify a set of negative cognitions predicting prolonged time to postoperative opioid cessation. Somatic symptoms captured by the BDI-II were not primarily responsible for the association between preoperative BDI-II scores and postoperative prolonged opioid use.
View details for DOI 10.1111/pme.12439
View details for PubMedID 24964916
Representativeness of patients enrolled in influential clinical trials: a comparison of substance dependence with other medical disorders.
Journal of studies on alcohol and drugs
2013; 74 (6): 889-893
ABSTRACT. Objective: The purpose of this study was to determine whether randomized trials of treatments for substance dependence differ from those for other medical disorders on quality of enrollment information reporting and sample representativeness. Method: Twenty highly cited clinical trials (publication date 2002-2010) of treatments for each of 14 prevalent disorders were identified by structured literature search. The disorders were alcohol dependence, drug dependence, nicotine dependence, Alzheimer's disease, breast cancer, colorectal cancer, chronic obstructive pulmonary disease, depression, diabetes, HIV/AIDS, hypertension, ischemic heart disease, lung cancer, and schizophrenia. The 280 clinical trials were coded for number of individuals screened for eligibility, number of screened individuals meeting eligibility criteria, and number of eligible individuals refusing to participate. Results: Substance-dependence treatment trials were significantly more likely to track and report enrollment information (75% vs. 45% of clinical trials for other disorders, p < .001). Substance-dependence trials did not differ from trials focused on other disorders on mean rate of non-enrollment. Across disorders, the primary driver of non-enrollment appeared to be clinical trial exclusion criteria rather than eligible patients refusing to enroll. Conclusions: Relative to other disorders, trials in the substance-dependence field do a better (although imperfect) job of tracking and reporting enrollment information. Low enrollment rates and unrepresentative samples are not challenges unique to treatment outcome studies in the substance-dependence field. Across a range of disorders, clinical trials that use eligibility criteria judiciously are more likely to produce findings that generalize to front-line clinical practice than are trials that restrict enrollment to a small and unrepresentative subset of patients. (J. Stud. Alcohol Drugs, 74, 889-893, 2013).
View details for PubMedID 24172115
View details for PubMedCentralID PMC3817050
Promoting recovery in an evolving policy context: What do we know and what do we need to know about recovery support services?
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2013; 45 (1): 126-133
As both a concept and a movement, "recovery" is increasingly guiding substance use disorder (SUD) services and policy. One sign of this change is the emergence of recovery support services that attempt to help addicted individuals using a comprehensive continuing care model. This paper reviews the policy environment surrounding recovery support services, the needs to which they should respond, and the status of current recovery support models. We conclude that recovery support services (RSS) should be further assessed for effectiveness and cost-effectiveness, that greater efforts must be made to develop the RSS delivery workforce, and that RSS should capitalize on ongoing efforts to create a comprehensive, integrated and patient-centered health care system. As the SUD treatment system undergoes its most important transformation in at least 40years, recovery research and the lived experience of recovery from addiction should be central to reform.
View details for DOI 10.1016/j.jsat.2013.01.009
View details for Web of Science ID 000318755400016
View details for PubMedID 23506781
- Extent and reporting of patient nonenrollment in influential randomized clinical trials, 2002 to 2010. JAMA internal medicine 2013; 173 (11): 1029-1031
- Commentary on Gustafson et?al. (2013): Can we know that addiction treatment has been improved without evidence of better patient outcomes? Addiction 2013; 108 (6): 1158-1159
Analysis of preoperative measures that predict interference with sleep recovery after surgery
CHURCHILL LIVINGSTONE. 2013: S19–S19
View details for Web of Science ID 000317639400076
Determinants of time to opioid cessation post-surgery
CHURCHILL LIVINGSTONE. 2013: S18–S18
View details for Web of Science ID 000317639400072
Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful?
2013; 108 (2): 275-293
Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (i) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (ii) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects.A systematic literature search identified 64 randomized, placebo-controlled, English-language clinical trials completed between 1970 and 2009 focused on acamprosate or naltrexone.Acamprosate had a significantly larger effect size than naltrexone on the maintenance of abstinence, and naltrexone had a larger effect size than acamprosate on the reduction of heavy drinking and craving. For naltrexone, requiring abstinence before the trial was associated with larger effect sizes for abstinence maintenance and reduced heavy drinking compared with placebo. For acamprosate, detoxification before medication administration was associated with better abstinence outcomes compared with placebo.In treatment for alcohol use disorders, acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving. Detoxification before treatment or a longer period of required abstinence before treatment is associated with larger medication effects for acamprosate and naltrexone respectively.
View details for DOI 10.1111/j.1360-0443.2012.04054.x
View details for Web of Science ID 000313746200011
View details for PubMedID 23075288
Ultra-Brief Intervention for Problem Drinkers: Results from a Randomized Controlled Trial
2012; 7 (10)
There are a number of evidence-based, in-person clinical inteventions for problem drinkers, but most problem drinkers will never seek such treatments. Reaching the population of non-treatment seeking problem drinkers will require a different approach. Accordingly, this randomized clinical trial evaluated an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as an indicated public health intervention (i.e., targeting the population of non-treatment seeking problem drinkers).Problem drinkers (N = 1767) completed a baseline population telephone survey and then were randomized to one of three conditions - a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions were sent their respective interventions by postal mail addressed to 'Check Your Drinking.' Changes in drinking were assessed post intervention at three-month and six-month follow-ups. The follow-up rate was 86% at three-months and 76% at six-months. There was a small effect (p = .04) in one of three outcome variables (reduction in AUDIT-C, a composite measure of quantity and frequency of drinking) observed for the personalized feedback pamphlet compared to the no intervention control. No significant differences (p>.05) between groups were observed for the other two outcome variables - number of drinks consumed in the past seven days and highest number of drinks on one occasion.Based on the results of this study, we tentatively conclude that a brief intervention, modified to an ultra-brief, public health format can have a meaningful impact.ClinicalTrials.gov NCT00688584.
View details for DOI 10.1371/journal.pone.0048003
View details for Web of Science ID 000310310200133
View details for PubMedID 23110157
A Pilot Cohort Study of the Determinants of Longitudinal Opioid Use After Surgery
ANESTHESIA AND ANALGESIA
2012; 115 (3): 694-702
Determinants of the duration of opioid use after surgery have not been reported. We hypothesized that both preoperative psychological distress and substance abuse would predict more prolonged opioid use after surgery.Between January 2007 and April 2009, a prospective, longitudinal inception cohort study enrolled 109 of 134 consecutively approached patients undergoing mastectomy, lumpectomy, thoracotomy, total knee replacement, or total hip replacement. We measured preoperative psychological distress and substance use, and then measured the daily use of opioids until patients reported the cessation of both opioid consumption and pain. The primary end point was time to opioid cessation. All analyses were controlled for the type of surgery done.Overall, 6% of patients continued on new opioids 150 days after surgery. Preoperative prescribed opioid use, depressive symptoms, and increased self-perceived risk of addiction were each independently associated with more prolonged opioid use. Preoperative prescribed opioid use was associated with a 73% (95% confidence interval [CI] 0.51%-87%) reduction in the rate of opioid cessation after surgery (P = 0.0009). Additionally, each 1-point increase (on a 4-point scale) of self-perceived risk of addiction was associated with a 53% (95% CI 23%-71%) reduction in the rate of opioid cessation (P = 0.003). Independent of preoperative opioid use and self-perceived risk of addiction, each 10-point increase on a preoperative Beck Depression Inventory II was associated with a 42% (95% CI 18%-58%) reduction in the rate of opioid cessation (P = 0.002). The variance in the duration of postoperative opioid use was better predicted by preoperative prescribed opioid use, self-perceived risk of addiction, and depressive symptoms than postoperative pain duration or severity.Preoperative factors, including legitimate prescribed opioid use, self-perceived risk of addiction, and depressive symptoms each independently predicted more prolonged opioid use after surgery. Each of these factors was a better predictor of prolonged opioid use than postoperative pain duration or severity.
View details for DOI 10.1213/ANE.0b013e31825c049f
View details for Web of Science ID 000307942900028
View details for PubMedID 22729963
Pharmacotherapy of Alcohol Use Disorders by the Veterans Health Administration: Patterns of Receipt and Persistence
2012; 63 (7): 679-685
This study assessed changes since 2007 at Veterans Health Administration (VHA) facilities (N=129) in use of the medications approved by the U.S. Food and Drug Administration for treatment of alcohol use disorders.VHA data from fiscal years (FYs) 2008 and 2009 were used to identify patients with a diagnosis of an alcohol use disorder who received oral or extended-release naltrexone, disulfiram, or acamprosate as well as the proportion of days covered (PDC) in the 180 days after initiation and the time to first ten-day gap in possession (persistence) for each medication. Multilevel, mixed-effects logistic regression models examined the association between patient and facility characteristics and use of medications.Nationally, 3.4% of VHA patients with an alcohol use disorder received medications in FY 2009 (11,165 of 331,635 patients), up from 3.0% in FY 2007. Use of medications by patients at the facilities ranged from 0% to 12%. In fully adjusted analyses, facilities offering evening and weekend services had higher rates of medication receipt, but other facility characteristics, such as having prescribers on the addiction program's staff or using medication to treat opioid or tobacco dependence, were unrelated to medication receipt. The mean PDC of acamprosate was significantly lower than mean PDCs of the other medications (p<.05), and persistence in use of naltrexone was significantly greater than use of acamprosate and significantly less than use of disulfiram (p<.05).Use of these medications is increasing but remains variable across the VHA system. Interventions are needed to optimize initiation of and persistence in use of these medications.
View details for DOI 10.1176/appi.ps.201000553
View details for Web of Science ID 000305931900011
View details for PubMedID 22549276
- Scientific evidence alone is not sufficient basis for health policy BRITISH MEDICAL JOURNAL 2012; 344
- What can we learn from the failure of yet another miracle cure' for addiction? ADDICTION 2012; 107 (2): 237-239
Drug policy and the public good: evidence for effective interventions
2012; 379 (9810): 71-83
Debates about which policy initiatives can prevent or reduce the damage that illicit drugs cause to the public good are rarely informed by scientific evidence. Fortunately, evidence-based interventions are increasingly being identified that are capable of making drugs less available, reducing violence in drug markets, lessening misuse of legal pharmaceuticals, preventing drug use initiation in young people, and reducing drug use and its consequences in established drug users. We review relevant evidence and outline the likely effects of fuller implementation of existing interventions. The reasoning behind the final decisions for action might be of a non-scientific nature, focused more on what the public and policy-makers deem of value. Nevertheless, important opportunities exist for science to inform these deliberations and guide the selection of policies that maximise the public good.
View details for Web of Science ID 000298913000039
View details for PubMedID 22225672
Federal Policy on Criminal Offenders Who Have Substance Use Disorders: How Can We Maximize Public Health and Public Safety?
2012; 33 (1): 5-8
The Obama Administration is striving to promote both public health and public safety by improving the public policy response to criminal offenders who have substance use disorders. This includes supporting drug courts, evidence-based probation and parole programs, addiction treatment and re-entry programs. Scientists and clinicians in the addiction field have a critical role to play in this much-needed effort to break the cycle of addiction, crime and incarceration.
View details for DOI 10.1080/08897077.2011.616805
View details for Web of Science ID 000302609500002
View details for PubMedID 22263708
Normative Misperceptions about Alcohol Use in a General Population Sample of Problem Drinkers from a Large Metropolitan City
ALCOHOL AND ALCOHOLISM
2012; 47 (1): 63-66
Heavy drinkers tend to overestimate how much others drink (normative fallacy), at least in college samples. Little research has been conducted to evaluate whether normative misperceptions about drinking extend beyond the college population. The present study explored normative misperceptions in an adult general population sample of drinkers.As part of a larger study, in Toronto, Canada, a random digit dialling telephone survey was conducted with 14,009 participants who drank alcohol at least once per month. Respondents with Alcohol Use Disorders Identification Test of eight or more (n = 2757) were asked to estimate what percent of Canadians of their same sex: (a) drank more than they do; (b) were abstinent and (c) drank seven or more drinks per week. Respondents' estimates of these population drinking norms were then compared with the actual levels of alcohol consumption in the Canadian population.A substantial level of normative misperception was observed for estimates of levels of drinking in the general population. Estimates of the proportion of Canadians who were abstinent were fairly accurate. There was some evidence of a positive relationship between the respondents' own drinking severity and the extent of normative misperceptions. Little evidence was found of a relationship between degree of normative misperceptions and age.Normative misperceptions have been successfully targeted in social norms media campaigns as well as in personalized feedback interventions for problem drinkers. The present research solidifies the empirical bases for extending these interventions more widely into the general population.
View details for DOI 10.1093/alcalc/agr125
View details for Web of Science ID 000298384600010
View details for PubMedID 22028458
A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients
2011; 106 (12): 2058-2066
To inform policy makers on available options for improving the effectiveness of treatments for substance use disorders and to stimulate debate about treatment improvement strategies among public officials, clinical providers, care managers, service users, families and researchers. We draw on the scientific literature and our public policy experiences in two countries (the United Kingdom and the United States) to give an overview of policies which may improve care for individuals with substance use disorders. We divide such policies into 'process-focused quality improvement strategies' that attempt to change some aspect of treatment (e.g. increased retention, greater use of evidence-based practices) and 'patient-focused strategies' that attempt to reward outcomes directly (e.g. contingency management for patients, payment by results for providers). Many policies of both types are poorly developed, have shown poor results, or both. The evidence is clear that process-focused quality improvement strategies can change what providers do and how treatment programs work, but such changes have thus far demonstrated only minimal impact on patient outcomes. Patient-focused strategies face challenges including treatment providers avoiding hard-to-treat patients or spending inordinate time relocating patients after treatment to assess outcome. However, policies that reward in-treatment outcomes and policies that allow the patient to purchase desired recovery support services show more promise. As policy makers go forward in this endeavor, they can do an enormous service to their countries and the field by embedding careful evaluation studies alongside new treatment outcome improvement initiatives.
View details for DOI 10.1111/j.1360-0443.2011.03464.x
View details for Web of Science ID 000296534200002
View details for PubMedID 21631620
- Cross-Level Bias and Variations in Care JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2011; 306 (19): 2096-2097
If substance use disorder treatment more than offsets its costs, why don't more medical centers want to provide it? A budget impact analysis in the Veterans Health Administration
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2011; 41 (3): 243-251
Given that many studies have reported that the costs of substance use disorder (SUD) treatment are more than offset by other savings (e.g., in health care, in criminal justice, in foster care), why haven't health care system managers rushed to expand treatment? This article attempts to explain this puzzling discrepancy by analyzing 1998-2006 data from the national Veterans Affairs (VA) health care system. The main outcome measures were annual cost and utilization for VA SUD-diagnosed patients. The key independent variable was the medical centers' annual spending for SUD treatment. There was no evidence that SUD spending was associated with lower medical center costs over time within the medical center that paid for the treatment. Health care system managers may not be influenced by research suggesting that the costs of SUD treatment are more than fully offset because they bear the cost of providing treatment while the savings largely accrue to other systems.
View details for DOI 10.1016/j.jsat.2011.04.006
View details for Web of Science ID 000294982100004
View details for PubMedID 21664790
Who uses online interventions for problem drinkers?
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2011; 41 (3): 261-264
The goal of this research was to understand why some people use online interventions for drinking problems, whereas others with comparable access to the interventions do not. As part of a randomized controlled trial, 92 participants in the experimental condition were provided access to a password-protected version of a Web-based personalized feedback intervention (the Check Your Drinking [CYD] screener, www.CheckYourDrinking.net). Information collected at baseline was compared between those who accessed the Web site and those who did not. Those who accessed the Web site tended to be more frequent users of the Internet, to drink less, and to perceive that others of the same age and gender drank less as compared with those who did not access the intervention. Some of these results are troubling as the preferred target of this type of intervention would be those who drink more and perceive that others are also heavy alcohol consumers.
View details for DOI 10.1016/j.jsat.2011.03.003
View details for Web of Science ID 000294982100006
View details for PubMedID 21632197
Why Health Care Process Performance Measures Can Have Different Relationships to Outcomes for Patients and Hospitals: Understanding the Ecological Fallacy
AMERICAN JOURNAL OF PUBLIC HEALTH
2011; 101 (9): 1635-1642
Relationships between health care process performance measures (PPMs) and outcomes can differ in magnitude and even direction for patients versus higher level units (e.g., health care facilities). Such discrepancies can arise because facility-level relationships ignore PPM-outcome relationships for patients within facilities, may have different confounders than patient-level PPM-outcome relationships, and may reflect facility effect modification of patient PPM-outcome relationships. If a patient-level PPM is related to better patient outcomes, that care process should be encouraged. However, the finding in a multilevel analysis that the proportion of patients receiving PPM care across facilities nevertheless is linked to poor hospital outcomes would suggest that interventions targeting the health care facility also are needed.
View details for DOI 10.2105/AJPH.2011.300153
View details for Web of Science ID 000294090500017
View details for PubMedID 21778493
- OUR MAP SHOULD CORRESPOND WITH THE TERRITORY ADDICTION 2010; 105 (12): 2054-2056
- Brief Intervention, Treatment, and Recovery Support Services for Americans Who Have Substance Use Disorders: An Overview of Policy in the Obama Administration PSYCHOLOGICAL SERVICES 2010; 7 (4): 275-284
- Something Must Be Done!: But Is Moore Correct that Something Can Be Worse than Nothing in Alcohol Control Policy? ALCOHOL AND ALCOHOLISM 2010; 45 (5): 409-411
The cost of concordance with opiate substitution treatment guidelines
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2010; 39 (2): 141-149
The Multisite Opiate Substitution Treatment study compared four opioid substitution programs that were highly concordant with clinical practice guidelines to four programs that were less concordant. Program staff were surveyed, and consenting new patients from highly concordant (n = 164) and less-concordant programs (n = 91) were assessed. After 12 months, treatment of new clients of highly staffed, guideline concordant sites cost $10,252, which is significantly more than the $6,476 cost at less-concordant programs (p < .01). Clients at highly concordant sites received significantly more group visits (M = 37.0 vs. 13.1, p < .01) but fewer dosing visits. There were no significant differences in medical care costs. Opioid substitution therapy was effective at reducing heroin use, especially at sites that were highly concordant with treatment guidelines. Annual mortality was 3.0% and did not differ by type of care. Preference-based quality of life significantly improved only at highly concordant sites.
View details for DOI 10.1016/j.jsat.2010.05.012
View details for Web of Science ID 000280623600007
View details for PubMedID 20598830
Twelve-Month Follow-up Results from a Randomized Controlled Trial of a Brief Personalized Feedback Intervention for Problem Drinkers
ALCOHOL AND ALCOHOLISM
2010; 45 (3): 258-262
To examine the impact of a web-based personalized feedback intervention, the Check Your Drinking (CYD; www.CheckYourDrinking.net) screener at 12-month follow-up.Respondents (N = 185) were recruited from a general population telephone survey of Ontario, Canadian adults (> or =18 years) by asking risky drinkers if they were willing to help develop and evaluate Internet-based interventions for drinkers. Those randomly assigned to the intervention condition were provided with the web address and a unique password to a study-specific copy of the CYD. Respondents assigned to the control condition were sent a written description of the different components of the CYD and asked how useful they thought each of the components might be. Respondents were followed up at 3, 6 and 12 months.By the 12-month follow-up, the impact of the intervention previously reported at 3 and 6 months of CYD on problem drinkers' alcohol consumption was no longer apparent (P > 0.05).Recognizing that many people with alcohol concerns will never seek treatment, recent years have seen an increase in efforts to find ways to take treatment to problem drinkers. The CYD is one such intervention that has a demonstrated effect on reducing alcohol consumption in the short term (i.e. 6 months). Other more intensive Internet-based interventions or interventions via other modalities may enhance this positive outcome over the short and long term among problem drinkers who would be otherwise unlikely to access treatment for their alcohol concerns.
View details for DOI 10.1093/alcalc/agq009
View details for Web of Science ID 000276995500008
View details for PubMedID 20150170
Pharmacotherapy of Alcohol Use Disorders in the Veterans Health Administration
2010; 61 (4): 392-398
Acamprosate, oral and long-acting injectable naltrexone, and disulfiram are approved for treatment of alcohol dependence. Their availability and consideration of their use in treatment are now standards of high-quality care. This study determined rates of medication initiation among Veterans Health Administration (VHA) patients.VHA pharmacy and administrative data were used to identify patients with alcohol use disorder diagnoses in fiscal years (FY) 2006 and 2007 and the proportion (nationally and by facility) who received each medication. Patient characteristics associated with receipt were also examined.Among more than a quarter-million patients with alcohol use disorder diagnoses, the percentage receiving any of the medications increased from 2.8% in FY 2006 to 3.0% in FY 2007. Receipt of these medications was more likely among patients who received specialty addiction care, those with alcohol dependence (compared with abuse), those younger than 55 years, and females. In the patient subgroups examined, the largest proportion to receive any of the medications was 11.6%. Across 128 VHA facilities, rates of use among patients in the sample who had received past-year specialty addiction treatment ranged from 0% to 20.5%; rates ranged from 0% to 4.3% among those with no specialty treatment. Patient preferences and medical contraindications could not be determined from the data.Findings suggest the need to better understand systemwide variation in use of these medications and their use as a rough proxy for availability and consideration of pharmacotherapy--a standard of care with strong organizational support.
View details for Web of Science ID 000276254200011
View details for PubMedID 20360279
Does Meeting the HEDIS Substance Abuse Treatment Engagement Criterion Predict Patient Outcomes?
JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH
2010; 37 (1): 25-39
This study examines the patient-level associations between the Health Plan Employer Data and Information Set (HEDIS) substance use disorder (SUD) treatment engagement quality indicator and improvements in clinical outcomes. Administrative and survey data from 2,789 US Department of Veterans Affairs SUD patients were used to estimate the effects of meeting the HEDIS engagement criterion on improvements in Addiction Severity Index Alcohol, Drug, and Legal composite scores. Patients meeting the engagement indicator improved significantly more in all domains than patients who did not engage, and the relationship was stronger for alcohol and legal outcomes for patients seen in outpatient settings. The benefit accrued by those who engaged was statistically significant but clinically modest. These results add to the literature documenting the clinical benefits of treatment entry and engagement. Although these findings only indirectly support the use of the HEDIS engagement measure for its intended purpose-discriminating quality at the facility or system level-they confirm that the processes of care captured by the measure are associated with important patient outcomes.
View details for DOI 10.1007/s11414-008-9142-2
View details for Web of Science ID 000273686300003
View details for PubMedID 18770044
Developing and Validating Process Measures of Health Care Quality An Application to Alcohol Use Disorder Treatment
Academy Health Annual Research Meeting
LIPPINCOTT WILLIAMS & WILKINS. 2009: 1244–50
Health care process quality measures usually are designed by expert panels attempting to synthesize nuanced clinical evidence and subsequently operationalized using administrative data. Many quality measures are then adopted without directly validating their presumed links with outcomes. Later efforts to validate process measures often yield negative results, leaving policy makers without a defensible means of measuring quality. This article presents an alternative strategy for developing and validating process quality measures. The development of an alcohol use disorder (AUD) treatment quality measure is used as an example.An expert panel generated a range of candidate process quality measures of AUD treatment derivable from administrative data that were then tested to determine which had the strongest associations with facility- and patient-level outcomes. Outcome and process data were from 2701 US Veterans Health Administration patients starting a new episode of care at 54 VA facilities.Several of the candidate process-of-care quality measures predicted facility- and patient-level outcomes. Having at least 3 visits during the first month of specialty AUD treatment was correlated with improvement on the Addiction Severity Index Alcohol composite at the facility level, r = 0.41 (95% Confidence Interval 0.16-0.61), and at the patient level, r = 0.07 (CI: 0.03-0.11).These "prevalidated" quality measures can now be judged for the extent they map onto the extant clinical literature and other design requirements. The development and validation strategy we describe should aid in efficiently producing quality measures in other areas of health care.
View details for Web of Science ID 000272488100008
View details for PubMedID 19786908
A randomized controlled trial of an internet-based intervention for alcohol abusers
2009; 104 (12): 2023-2032
Misuse of alcohol imposes a major public health cost, yet few problem drinkers are willing to access in-person services for alcohol abuse. The development of brief, easily accessible ways to help problem drinkers who are unwilling or unable to seek traditional treatment services could therefore have significant public health benefit. The objective of this project is to conduct a randomized controlled evaluation of the internet-based Check Your Drinking (CYD) screener ( http://www.CheckYourDrinking.net).Participants (n = 185) recruited through a general telephone population survey were assigned randomly to receive access to the CYD, or to a no-intervention control group.Follow-up rates were excellent (92%). Problem drinkers provided access to the CYD displayed a six to seven drinks reduction in their weekly alcohol consumption (a 30% reduction in typical weekly drinking) at both the 3- and 6-month follow-ups compared to a one drink per week reduction among control group respondents.The CYD is one of a growing number of internet-based interventions with research evidence supporting its efficacy to reduce alcohol consumption. The internet could increase the range of help-seeking options available because it takes treatment to the problem drinker rather than making the problem drinker come to treatment.
View details for DOI 10.1111/j.1360-0443.2009.02726.x
View details for Web of Science ID 000271625500011
View details for PubMedID 19922569
Responding to the Psychological Impact of War on the Iraqi People and US Veterans: Mixing Icing, Praying for Cake
2009; 64 (8): 712-723
The psychological impact of the war in Iraq stimulated major initiatives to build a modern mental health care system for the Iraqi people and to improve mental health services for U.S. veterans of the Iraq war. Although these two initiatives differ in important respects, they are both informed by general principles of psychology concerning the nature of social problem definition, the process of human adaptation to extreme stress and its aftermath, and the role and limits of mental health services. Building on these common themes and my own experiences, I describe how two nations are trying to address the colossal psychological damage wrought by the war in Iraq.
View details for Web of Science ID 000271875300016
View details for PubMedID 19899875
How Internet technology can improve the quality of care for substance use disorders.
Current drug abuse reviews
2009; 2 (3): 256-262
By allowing for the efficient delivery of instructional content and the secure collection of self-report data regarding substance use and related problems, the Internet has tremendous potential to improve the effectiveness and accessibility of addiction treatment services. This article discusses some of the ways in which Internet technology can facilitate, complement and support the process of traditional clinician-delivered treatment for individuals with substance use disorders. Internet applications are being used to support a range of activities including (a) the assessment and feedback process that constitutes a central feature of brief motivational interventions, (b) the concurrent monitoring of individual level outcomes among patients who are currently enrolled in addiction treatment programs, (c) the continuing care and ongoing recovery of patients who have completed treatment, and (d) the delivery of clinical training in evidence based practices for addiction treatment providers. This emerging body of literature suggests that addiction counselors and program administrators can enhance the quality of clinician-delivered treatment by incorporating internet applications into existing processes of care. Internet applications provide an unparalleled opportunity to engage patients in the treatment process, incorporate real-time data into treatment planning, prevent relapse, and promote evidence-based treatment approaches.
View details for PubMedID 20443772
HEDIS Initiation and Engagement Quality Measures of Substance Use Disorder Care: Impact of Setting and Health Care Specialty
POPULATION HEALTH MANAGEMENT
2009; 12 (4): 191-196
Many health care systems track the HEDIS measures of initiation and engagement in substance use disorder (SUD) care. However, the impact of setting of care (inpatient vs. outpatient) and health care specialty (SUD, psychiatric, other) on the likelihood of patients meeting the initiation and engagement criteria are unknown. If the vast majority of initiation and engagement occurs within SUD specialty clinics, then these quality measures could be used to discriminate among and incentivize SUD clinic managers. However, if these criteria are satisfied in different settings and specialties, then they should be considered characteristics of the entire facility, rather than just specialty SUD units. Using a Markov model, the probabilities of advancing to treatment initiation and engagement given initial setting and specialty of care were estimated for 320,238 SUD-diagnosed Veterans Health Affairs (VA) patients. Patients in SUD specialty units progressed more often (diagnosis to initiation, initiation to engagement) than patients in other specialties. Progression through the criteria differed for inpatients vs. outpatients. Approximately 25% of initiation and over 40% of engagement occurred outside of SUD specialty care. VA patients who have contact with SUD specialty treatment have higher rates of advancing to initiation, and from initiation to engagement, compared to SUD-diagnosed patients in psychiatric or other medical locations. Even so, a substantial portion of initiation and engagement occurs outside of SUD specialty units. Therefore, these quality measures should be considered measures of facility performance rather than measures of the quality of SUD specialty care. The usual combining of inpatient and outpatient performance on these measures into overall facility scores clouds measurement and interpretation.
View details for DOI 10.1089/pop.2008.0028
View details for Web of Science ID 000268811100004
View details for PubMedID 19663621
- Datapoints: Iraqi psychiatrists' perceptions of substance use disorders among patients. Psychiatric services 2009; 60 (6): 728-?
Measuring the quality of substance use disorder treatment: Evaluating the validity of the Department of Veterans Affairs continuity of care performance measure
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2009; 36 (3): 294-305
This study examined the patient- and facility-level associations between the continuity of care performance measure adopted by the Department of Veterans Affairs (VA) and improvements in self-administered Addiction Severity Index (ASI) composites and other indicators of problematic substance use. Up to 50 patients from each of a nationally representative sample of 109 VA substance use disorder (SUD) treatment programs at 73 VA facilities were assessed at intake and posttreatment. The continuity of care performance measure specifies that patients should receive at least two SUD outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. In analyses adjusting for baseline characteristics, meeting the continuity of care performance measure was not associated with patient-level improvements in the ASI alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Facility-level rates of continuity of care were negatively associated with improvements in ASI alcohol and drug composites. The continuity of care performance measure derived from prior patient-level evidence did not discriminate facility-level performance as predicted. Translating research into process-of-care quality measures requires postconstruction validation.
View details for DOI 10.1016/j.jsat.2008.05.011
View details for Web of Science ID 000264510000006
View details for PubMedID 18835678
- Searching Where the Light Is Worse: Overemphasizing Genes and Underplaying Environment in the Quest to Reduce Substance Misuse CLINICAL PHARMACOLOGY & THERAPEUTICS 2009; 85 (4): 357-358
Performance Monitoring of Substance Use Disorder Interventions in the Veterans Health Administration
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2009; 35 (3): 123-127
Measuring and improving the quality of treatment for patients with substance use disorders are enduring challenges.This article describes how the Veterans Affairs health care system is using incentivized performance measures to promote more effective delivery of interventions for nicotine, illegal drug, and alcohol disorders.The monitoring and incentive system has increased the delivery of evidence-based services, including screening for alcohol use disorders.Further work remains to be done to strengthen the connection between process-based measures and longer-term patient outcomes.
View details for DOI 10.1080/00952990802707042
View details for Web of Science ID 000266277700002
View details for PubMedID 19462294
Responding to Rising Substance Misuse in Iraq
SUBSTANCE USE & MISUSE
2009; 44 (12): 1744-1748
We present an overview of the current substance misuse situation in Iraq. Numerous indicators as well as first-hand observations of the authors, suggest that substance misuse is increasing in Iraq. Violence, economic uncertainty, poorly monitored borders, and a porous pharmacy system, all appear to be contributing to the problem. Yet, Iraq also has significant features that put some restraints on the size of the problem, most notably highly cohesive families and prevalent religiosity. The Iraqi Ministry of Health is leading an international effort to respond to rising substance misuse and associated mental and physical health conditions.
View details for DOI 10.3109/10826080902963415
View details for Web of Science ID 000272093000007
View details for PubMedID 19895304
Assessing spirituality/religiosity in the treatment environment: The Treatment Spirituality/Religiosity Scale
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2008; 35 (4): 427-433
There has been much interest in measuring and evaluating the role of spirituality/religiosity (S/R) in substance use disorder (SUD) treatment. This study presents the initial evaluation of a new measure of S/R in the treatment environment: the Treatment Spirituality/Religiosity Scale (TSRS). The TSRS has 10 items and can be completed by both patient and staff to measure the emphasis on S/R in a given treatment program, which may have important implications for patient-program fit. Data on the TSRS were gathered from 3,018 patients and 329 staff members from 15 residential SUD treatment programs within the Department of Veterans Affairs Health Care System. The TSRS showed good internal consistency (alpha = .77), a single-factor structure, close agreement between patients and staff members (r = .93), and good discriminant validity. The TSRS appears to be a brief, easily administered, and potentially useful measure of the emphasis on S/R in residential SUD treatment programs.
View details for DOI 10.1016/j.jsat.2008.02.002
View details for Web of Science ID 000260800700009
View details for PubMedID 18424049
Subject eligibility criteria can substantially influence the results of alcohol-treatment outcome research
JOURNAL OF STUDIES ON ALCOHOL AND DRUGS
2008; 69 (5): 757-764
Most alcohol-treatment studies exclude some patients from participation based on particular criteria (e.g., comorbid illegal drug abuse, homelessness). The current study evaluated whether such eligibility criteria can change the outcome results a study obtains.Five widely used treatment research eligibility criteria--(1) psychiatric problems, (2) medical problems, (3) social-residential instability, (4) low motivation/noncompliance, and (5) drug problems--were applied to two samples of real-world alcohol patients whose outcomes were known. Comparing outcomes of the samples with and without the application of eligibility criteria produced estimates of bias in outcome results, as well as an assessment of change in statistical power.Medical and psychiatric eligibility criteria produced a moderate bias in outcome estimates (e.g., a 10% or less change in outcome results). In contrast, social-residential instability, low motivation/noncompliance, and drug use produced a large (e.g., up to an 18% change) to a very large (e.g., up to a 51% change) bias in outcome estimates. Sensitivity analyses showed that these biases are even larger if eligibility criteria are operationalized in a broad rather than a narrow fashion. Contrary to expectation, eligibility criteria did not produce their theoretically expected benefit of increased statistical power.Researchers who use eligibility criteria should do so judiciously and interpret outcome results in light of potential bias introduced by the ineligibility of some patients for study enrollment. Efforts to integrate findings across treatment outcome studies should also consider how conclusions might be affected by the eligibility criteria used in different research areas.
View details for Web of Science ID 000259205200015
View details for PubMedID 18781251
Mutual help groups for mental health problems: A review of effectiveness studies
AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY
2008; 42 (1-2): 110-121
This paper reviews empirical studies on whether participating in mutual help groups for people with mental health problems leads to improved psychological and social functioning. To be included, studies had to satisfy four sets of criteria, covering: (1) characteristics of the group, (2) target problems, (3) outcome measures, and (4) research design. The 12 studies meeting these criteria provide limited but promising evidence that mutual help groups benefit people with three types of problems: chronic mental illness, depression/anxiety, and bereavement. Seven studies reported positive changes for those attending support groups. The strongest findings come from two randomized trials showing that the outcomes of mutual help groups were equivalent to those of substantially more costly professional interventions. Five of the 12 studies found no differences in mental health outcomes between mutual help group members and non-members; no studies showed evidence of negative effects. There was no indication that mutual help groups were differentially effective for certain types of problems. The studies varied in terms of design quality and reporting of results. More high-quality outcome research is needed to evaluate the effectiveness of mutual help groups across the spectrum of mental health problems.
View details for DOI 10.1007/s10464-008-9181-0
View details for Web of Science ID 000258653100010
View details for PubMedID 18679792
A randomized trial of a mental health consumer-managed alternative to civil commitment for acute psychiatric crisis
AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY
2008; 42 (1-2): 135-144
This experiment compared the effectiveness of an unlocked, mental health consumer-managed, crisis residential program (CRP) to a locked, inpatient psychiatric facility (LIPF) for adults civilly committed for severe psychiatric problems. Following screening and informed consent, participants (n = 393) were randomized to the CRP or the LIPF and interviewed at baseline and at 30-day, 6-month, and 1-year post admission. Outcomes were costs, level of functioning, psychiatric symptoms, self-esteem, enrichment, and service satisfaction. Treatment outcomes were compared using hierarchical linear models. Participants in the CRP experienced significantly greater improvement on interviewer-rated and self-reported psychopathology than did participants in the LIPF condition; service satisfaction was dramatically higher in the CRP condition. CRP-style facilities are a viable alternative to psychiatric hospitalization for many individuals facing civil commitment.
View details for DOI 10.1007/s10464-008-9180-1
View details for Web of Science ID 000258653100012
View details for PubMedID 18626766
Ultra-brief intervention for problem drinkers: research protocol
BMC PUBLIC HEALTH
Helping the large number of problem drinkers who will never seek treatment is a challenging issue. Public health initiatives employing educational materials or mass media campaigns have met with mixed success. However, clinical research has developed effective brief interventions to help problem drinkers. This project will employ an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as a public health intervention. The major objective of this study is to conduct a randomized controlled trial to establish the effectiveness of an ultra-brief, personalized feedback intervention for problem drinkers.Problem drinkers recruited on a baseline population telephone survey conducted in a major metropolitan city in Canada will be randomized to one of three conditions - a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions will be sent their respective pamphlets. Changes in drinking will be assessed post intervention at three-month and six-month follow-ups. Drinking outcomes will be compared between experimental conditions using Structural Equation Modeling. The primary hypothesis is that problem drinkers from households who receive the personalized feedback pamphlet intervention will display significantly improved drinking outcomes at three and six-month follow-ups as compared to problem drinkers from households in the no intervention control condition. Secondary hypotheses will test the impact of the intervention on help seeking, and explore the mediating or moderating role of perceived drinking norms, perceived alcohol risks and the problem drinker's social reasons for drinking.This trial will provide information on the effectiveness of a pamphlet-based personalized feedback intervention for problem drinkers in a community setting.ClinicalTrials.gov registration #NCT00688584.
View details for DOI 10.1186/1471-2458-8-298
View details for Web of Science ID 000258797400001
View details for PubMedID 18727823
The underrepresentation of African Americans in online cancer support groups
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
2008; 100 (6): 705-712
The Internet is increasingly important for many cancer survivors because it provides access to the latest information on cancer treatments and also allows them to receive support by participating in online cancer support groups. Unfortunately, little is known about why African-American cancer survivors are underrepresented in online cancer support groups. This article reviews the relevant literature and discusses three possible explanations for why African Americans are underrepresented in online cancer support groups: the digital divide/digital inequality, preferences for face-to-face support or culture-specific online support, and trust concerns. We conclude that a health inequity exists with regard to the utilization of information that can be obtained from online cancer support groups. However, with regard to the potential benefits of the psychosocial and emotional support aspect of online cancer support groups, a health inequity may not exist, as African Americans have other preferred avenues for obtaining needed support, and there is no evidence that this is detrimental to their health.
View details for Web of Science ID 000256771200007
View details for PubMedID 18595573
Does following research-derived practice guidelines improve opiate-dependent patients' outcomes under everyday practice conditions? Results of the Multisite Opiate Substitution Treatment study
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2008; 34 (2): 173-179
The Multisite Opiate Substitution Treatment study evaluated whether adhering to clinical-trial-derived practice guidelines improves treatment outcomes of unselected opiate-dependent patients seen in everyday practice. Clinics that were relatively concordant (n = 4) or nonconcordant (n = 4) with guidelines concerning medication dose levels and psychosocial service provision were identified. Staff interviewed 256 patients at intake and 6-month follow-up regarding past month heroin use, criminal activities, and mental health. To represent real-world practice conditions, clinics provided care in accordance with their usual approach, and no patient exclusion criteria were employed. Patients in each type of clinic were similar at baseline, but by follow-up, heroin use and mental health outcomes were significantly better in guideline-concordant clinics than in guideline-discordant clinics. Notably, 60.6% of patients in concordant clinics had urinalysis-confirmed heroin abstinence versus only 40.0% in nonconcordant clinics. Following research-derived practice guidelines seems to increase opiate substitution treatment effectiveness for opiate-dependent patients in the real world.
View details for DOI 10.1016/j.jsat.2007.03.001
View details for Web of Science ID 000253222900004
View details for PubMedID 17499955
Veterans affairs facility performance on Washington circle indicators and casemix-adjusted effectiveness
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2007; 33 (4): 333-339
Self-administered Addiction Severity Index (ASI) data were collected on 5,723 patients who received substance abuse treatment in 1 of 110 programs located at 73 Veterans Affairs facilities. The associations between each of three Washington Circle (WC) performance indicator scores (identification, initiation, and engagement) and their casemix-adjusted facility-level improvement in ASI drug and alcohol composites 7 months after intake were estimated. Higher initiation rates were not associated with facility-level improvement in ASI alcohol composite scores but were modestly associated with greater improvements in ASI drug composite scores. Identification and engagement rates were unrelated to 7-month outcomes. WC indicators focused on the early stages of treatment may tap necessary but insufficient processes for patients with substance use disorder to achieve good posttreatment outcomes. Ideally, the WC indicators would be supplemented with other measures of treatment quality.
View details for DOI 10.1016/j.jsat.2006.12.015
View details for Web of Science ID 000251110700001
View details for PubMedID 17400416
Improving medicare coverage of psychological services for older Americans
2007; 62 (7): 637-649
Professional psychology's ability to meet older Americans' psychological needs and to simultaneously thrive as a profession will be closely tied to the federal Medicare program over the coming decades. Despite legislative changes in the 1980s providing professional autonomy to psychologists and expanding coverage for mental health services, Medicare coverage policies, reimbursement mechanisms, and organizational traditions continue to limit older Americans' access to psychological services. This article describes how psychologists can influence Medicare coverage policy. Specifically, the authors examine widely unrecognized policy processes and recent political developments and analyze the recent creation of a new Medicare counseling benefit, applying J. W. Kingdon's (1995) well-known model of policy change. These recent developments offer new opportunities for expanding Medicare coverage of psychological services, particularly in the areas of prevention, screening, and early intervention. The article provides an analysis to guide psychologists in engaging in strategic advocacy and incorporating psychological prevention and early intervention services into Medicare. As Medicare policy entrepreneurs, psychologists can improve the well-being of millions of Americans who rely on the national health insurance program and, in so doing, can help shape the future practice of psychology.
View details for DOI 10.1037/0003-066X.62.7.637
View details for Web of Science ID 000250131700002
View details for PubMedID 17924748
Consistent adherence to guidelines improves opioid dependent patients' first year outcomes
JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH
2007; 34 (3): 260-271
Clinical practice guidelines for opioid substitution treatment (OST) for opioid dependence recommend that patients receive at least 60 mg daily methadone and have access to a broad array of psychosocial services. However, there is still wide variation in clinical practice in OST clinics. In real-world settings, patients could receive lower methadone doses and less psychosocial care because they require less intensive care for recovery; alternatively, barriers to delivery of guideline concordant care could limit treatment received and impair recovery. The Multisite Opioid Substitution Treatment (MOST) study examines the impact of more consistent adherence to guideline recommendations in eight Veterans Affairs OST clinics. While patients at all clinics demonstrated improvements in substance use over the first year in treatment, patients at clinics that more consistently adhered to guidelines had greater reductions in heroin and cocaine use and greater improvement in mental health. These results suggest that efforts to increase guideline adherence in OST will improve patient outcomes.
View details for DOI 10.1007/s11414-007-9074-2
View details for Web of Science ID 000249225600003
View details for PubMedID 17610159
Influence of subject eligibility criteria on compliance with national institutes of health guidelines for inclusion of women, minorities, and children in treatment research
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH
2007; 31 (6): 988-995
Many alcohol treatment outcome studies exclude some patients with particular problems, such as psychiatric disorders, noncompliance, and homelessness. Such criteria may increase the likelihood of a study being successfully conducted, but may also have the unintended consequence of reducing a study's ability to comply with National Institutes of Health guidelines for inclusion of racial minorities, women, and children in treatment research.This paper examined this issue empirically using 5 prior studies of treatment systems enrolling over 100,000 alcohol patients. Widely used eligibility criteria in the alcohol treatment field typically exclude between one-fifth to one-third of patients from enrolling in research. Under several eligibility criteria, most notably those for drug use and social/residential instability, women and African-American patients are substantially more likely to be excluded than are men and non-African-American patients, respectively.In designing treatment studies with many eligibility criteria, researchers may therefore inadvertently be thwarting their own good faith efforts to ensure that a range of vulnerable populations are able to participate in research. We analyze the implications of this dilemma for the generalizability of treatment results and for research design, and provide data that may help researchers working in different treatment systems estimate the impact of various eligibility criteria.
View details for DOI 10.1111/j.1530-0277/2007.00391.x
View details for Web of Science ID 000246576500009
View details for PubMedID 17428295
Different components of opioid-substitution treatment predict outcomes of patients with and without a parent with substance-use problems
JOURNAL OF STUDIES ON ALCOHOL AND DRUGS
2007; 68 (2): 165-172
The aim of this study was to determine how the treatment needs and outcomes of polysubstance-using patients entering opioid-substitution treatment (OST) may be affected if the patient had a parent with substance-use problems.This prospective observational study examined outcomes of 255 patients (97% male) entering OST at eight clinics in the Veterans Health Administration. Self-reported substance-use outcomes in the first year of treatment were compared between patients with (n = 121) and without (n = 134) a parent with substance-use problems. The association between receipt of practice guideline-recommended elements of care and treatment outcome was examined.Parent history-positive patients had greater drug use at 6 months, but by 12 months they had reduced their drug use to the same extent as parent history-negative patients. Ongoing methadone (Dolophine, Methadose) maintenance was associated with improved outcomes of drug use in parent history-negative patients; however, parent history-positive patients who ended methadone maintenance reduced drug use as much as those who continued treatment. The association between treatment received and outcome differed in these populations. In parent history-negative patients, reduced severity of substance use at 1 year was predicted solely by receiving methadone for a greater number of days. In parent history-positive patients, reduced severity of substance use was predicted by receiving methadone for fewer days, by greater satisfaction with and receipt of counseling services, and by lesser tendency for providers to encourage a reduction in methadone use.The importance of counseling and medication components of OST may differ depending on family history. For parent history-negative patients, medication maintenance may be more therapeutically necessary.
View details for Web of Science ID 000248712700001
View details for PubMedID 17286334
The psychological science of addiction
2007; 102 (3): 352-361
To discuss the contributions and future course of the psychological science of addiction.The psychology of addiction includes a tremendous range of scientific activity, from the basic experimental laboratory through increasingly broad relational contexts, including patient-practitioner interactions, families, social networks, institutional settings, economics and culture. Some of the contributions discussed here include applications of behavioral principles, cognitive and behavioral neuroscience and the development and evaluation of addiction treatment. Psychology has at times been guilty of proliferating theories with relatively little pruning, and of overemphasizing intrapersonal explanations for human behavior. However, at its best, defined as the science of the individual in context, psychology is an integrated discipline using diverse methods well-suited to capture the multi-dimensional nature of addictive behavior.Psychology has a unique ability to integrate basic experimental and applied clinical science and to apply the knowledge gained from multiple levels of analysis to the pragmatic goal of reducing the prevalence of addiction.
View details for DOI 10.1111/j.1360-0443.2006.01706.x
View details for Web of Science ID 000244098000005
View details for PubMedID 17298641
How are substance use disorders addressed in VA psychiatric and primary care settings? Results of a national survey
2007; 58 (2): 266-269
This study examined interventions for substance use disorders within the Department of Veterans Affairs (VA) psychiatric and primary care settings.National random samples of 83 VA psychiatry program directors and 102 primary care practitioners were surveyed by telephone. The survey assessed screening practices to detect substance use disorders, protocols for treating patients with substance use disorders, and available treatments for substance use disorders.Respondents reported extensive contact with patients with substance use problems. However, a majority reported being ill equipped to treat substance use disorders themselves; they usually referred such patients to specialty substance use disorder treatment programs.Offering fewer specialty substance use disorder services within the VA may be problematic: providers can refer patients to specialty programs only if such programs exist. Caring for veterans with substance use disorders may require increasing the capacity of and establishing new specialty programs or expanding the ability of psychiatric programs and primary care practitioners to provide such care.
View details for Web of Science ID 000244070800018
View details for PubMedID 17287386
Encouraging posttreatment self-help group involvement to reduce demand for continuing care services: Two-year clinical and utilization outcomes
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH
2007; 31 (1): 64-68
Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n=887 patients) or cognitive-behavioral (CB, n=887 patients) treatment programs. The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p=0.01).Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.
View details for DOI 10.1111/j.1530-0277.2006.00273.x
View details for Web of Science ID 000243022200009
View details for PubMedID 17207103
- Inquirers, triers, and buyers of an alcohol harm reduction self-help organization ADDICTION RESEARCH & THEORY 2006; 14 (5): 527-535
- Closing remarks: Swimming to the horizon-reflections on a special series ADDICTION 2006; 101 (9): 1238-1240
Predictors of retention in methadone programs: A signal detection analysis
DRUG AND ALCOHOL DEPENDENCE
2006; 83 (3): 218-224
Retention in Opioid Agonist Therapy (OAT) is associated with reductions in substance use, HIV risk behavior, and criminal activities in opioid dependent patients. To improve the effectiveness of treatment for opioid dependence, it is important to identify predisposing characteristics and provider-related variables that predict retention in OAT. Participants include 258 veterans enrolled in 8 outpatient methadone/l-alpha-acetylmethadol (LAAM) treatment programs. Signal detection analysis was utilized to identify variables predictive of 1-year retention and to identify the optimal cut-offs for significant predictors. Provider-related variables play a vital role in predicting retention in OAT programs, as higher methadone dose (> or =59 mg/day) and greater treatment satisfaction were among the strongest predictors of retention at 1-year follow-up.
View details for DOI 10.1016/j.drugalcdep.2005.11.020
View details for Web of Science ID 000239081300005
View details for PubMedID 16384657
Rebuilding Iraq's mental health system.
2006; 26 (7): 34-35
View details for PubMedID 16915888
Response to methadone maintenance treatment of opiate dependent patients with and without significant pain
DRUG AND ALCOHOL DEPENDENCE
2006; 82 (3): 187-193
Both clinicians and researchers have expressed doubt that opiate dependent patients with significant pain can be effectively treated in methadone maintenance treatment (MMT) programs; however, little research exists on this topic. Patients who report significant pain in the month preceding entry to MMT present with a distinct and more severe pattern of polysubstance use, medical and psychosocial problems than do those without pain. The present study investigated the 1-year treatment outcomes of MMT patients with opiate dependence and pain.Analyses were based on a national sample of 200 patients presenting in MMT programs for treatment of opiate dependence. Substance use and related problems were measured at treatment entry and 12 months later. Patients reported pain severity over the month preceding treatment entry.Compared to patients without significant pain, patients who reported significant pain at baseline (n = 103) showed similar substance-related functioning, but poorer psychosocial functioning at 1 year.Patients with and without significant pain experience comparable reductions in substance use when provided with standard care in MMT programs. However, additional medical and/or mental health treatment is needed for their pain and other problems.
View details for DOI 10.1016/j.drugalcdep.2005.09.005
View details for Web of Science ID 000237317000002
View details for PubMedID 16219429
Determining effective methadone doses for individual opioid-dependent patients
2006; 3 (3): 380-387
Randomized clinical trials of methadone maintenance have found that on average high daily doses are more effective for reducing heroin use, and clinical practice guidelines recommend 60 mg/d as a minimum dosage. Nevertheless, many clinicians report that some patients can be stably maintained on lower methadone dosages to optimal effect, and clinic dosing practices vary substantially. Studies of individual responses to methadone treatment may be more easily translated into clinical practice.A volunteer sample of 222 opioid-dependent US veterans initiating methadone treatment was prospectively observed over the year after treatment entry. In the 168 who achieved at least 1 mo of heroin abstinence, methadone dosages on which patients maintained heroin-free urine samples ranged from 1.5 mg to 191.2 mg (median = 69 mg). Among patients who achieved heroin abstinence, higher methadone dosages were predicted by having a diagnosis of posttraumatic stress disorder or depression, having a greater number of previous opioid detoxifications, living in a region with lower average heroin purity, attending a clinic where counselors discourage dosage reductions, and staying in treatment longer. These factors predicted 42% of the variance in dosage associated with heroin abstinence.Effective and ineffective methadone dosages overlap substantially. Dosing guidelines should focus more heavily on appropriate processes of dosage determination rather than solely specifying recommended dosages. To optimize therapy, methadone dosages must be titrated until heroin abstinence is achieved.
View details for DOI 10.1371/journal.pmed.0030080
View details for Web of Science ID 000236897500018
View details for PubMedID 16448216
Access to the Internet among drinkers, smokers and illicit drug users: Is it a barrier to the provision of interventions on the World Wide Web?
MEDICAL INFORMATICS AND THE INTERNET IN MEDICINE
2006; 31 (1): 53-58
Expanding Internet-based interventions for substance use will have little benefit if heavy substance users are unlikely to have Internet access. This paper explored whether access to the Internet was a potential barrier to the provision of services for smokers, drinkers and illicit drug users.As part of a general population telephone survey of adults in Ontario, Canada, respondents were asked about their use of different drugs and also about their use of the Internet.Pack-a-day smokers were less likely (48%) to have home Internet access than non-smokers (69%), and current drinkers (73%) were more likely to have home access than abstainers (50%). These relationships remained true even after controlling for demographic characteristics. Internet access was less clearly associated with cannabis or cocaine use.Even though there is variation in access among smokers, drinkers and illicit drug users, the World Wide Web remains an excellent opportunity to potentially provide services for substance abusers who might never access treatment in person because, in absolute terms, the majority of substance abusers do use the Internet.
View details for DOI 10.1080/14639230600562816
View details for Web of Science ID 000238135000005
View details for PubMedID 16754367
Opioid substitution treatment reduces substance use equivalently in patients with and without posttraumatic stress disorder
JOURNAL OF STUDIES ON ALCOHOL
2006; 67 (2): 228-235
The purpose of this study was to determine whether opioid-dependent patients with diagnosed posttraumatic stress disorder (PTSD) have poorer long-term outcomes in opioid substitution treatment than do patients without PTSD.This prospective observational study examined outcomes of 255 opioid-dependent patients (men = 248) entering opioid substitution treatment at eight clinics in the Veterans Health Administration (VHA). Subjects were interviewed at treatment entry, 6 months, and 1 year about substance use and related problems, health status, treatment satisfaction, and non-VHA health care utilization. Medical records were reviewed to obtain toxicology results, health care utilization data, and diagnoses. Medical record review identified a diagnosis of PTSD in 71 (28%) patients. Substance-use and mental-health outcomes and health care utilization in the first year following treatment entry were compared between patients with and without a diagnosis of PTSD.Patients with and without PTSD had similar treatment responses. Although patients with PTSD had longer histories of drug use at intake, at 1-year follow-up they showed reductions in heroin, cocaine, and alcohol use, comparable to patients without the disorder. PTSD patients received higher doses of opiate medication, attended more psychosocial treatment sessions for substance-use disorder, and had better treatment retention. Psychiatric symptoms for patients with PTSD were more severe at intake and showed little improvement throughout treatment.Opioid substitution therapy is as effective at reducing substance use in PTSD patients as it is in patients without the disorder, but additional services are needed for treatment of psychological problems that are largely unchanged by treatment for addiction.
View details for Web of Science ID 000235318900005
View details for PubMedID 16562404
Formative evaluation and three-month follow-up of an online personalized assessment feedback intervention for problem drinkers
JOURNAL OF MEDICAL INTERNET RESEARCH
2006; 8 (2)
In recent years, online services for problem drinkers have been developed. This paper describes ongoing efforts to improve one of these services, the Alcohol Help Center.This report summarizes new modules added to the Check Your Drinking (CYD) screener, a component of the Alcohol Help Center, to make the CYD screener more useful to periodic heavy drinkers, as well as to regular alcohol consumers. Participants' initial reactions to the CYD screener and the changes in their drinking habits at a three-month follow-up are presented.The CYD screener provides a free personalized Final Report that compares the user's drinking to that of others in the general population of the same age, gender, and country of origin. Current alcohol consumption and demographic characteristics are collected as part of the CYD screening process. After users were presented with a customized Final Report, they were hot-linked to a volunteer feedback survey. The voluntary feedback survey asked about impressions of the CYD Final Report. Respondents agreeing to participate were sent a follow-up survey after three months.We recruited 388 volunteers (69% female) who were registered users of another free-to-consumer online eHealth service. Of the 343 respondents agreeing to participate in the three-month follow-up, 138 accessed the survey, and 97 provided complete data (participation rate = 40%; completion rate = 70%). Compared to moderate drinkers, current problem drinkers judged the Final Report to be more useful (34% vs. 69%, chi2 (1) = 41.5, P < .001) and accurate (43% vs. 76%, chi2 (1) = 36.0, P < .001). Respondents who participated in the three-month follow-up displayed reductions in drinking compared to baseline (F(4,76) = 12.2, P = .001).Improvements can still be made to make the CYD screener more relevant to specific populations, particularly periodic heavy drinkers. There is a need to further tailor algorithms that can present questions only relevant to specific populations. There also appears to be a need to further customize the Final Report for respondents who identify themselves as infrequent heavy drinkers. These improvements will be made, and a randomized controlled trial is planned to conduct a rigorous evaluation of the CYD screener as an intervention to help problem drinkers.
View details for DOI 10.2196/jmir.8.2.e5
View details for Web of Science ID 000239759200002
View details for PubMedID 16867968
Prevalence and predictors of research participant eligibility criteria in alcohol treatment outcome studies, 1970-98
2005; 100 (9): 1249-1257
To describe the eligibility criteria (i.e. study participant inclusion and exclusion rules) employed in alcohol treatment outcome research and to identify predictors of their use.The eligibility criteria of 683 alcohol treatment outcome studies conducted between 1970 and 1998 were coded reliably into 14 general categories. Predictors of the use of eligibility criteria were then examined.Patients were most often ruled ineligible for research studies because of their level of alcohol problems (39.1% of studies), comorbid psychiatric problems (37.8%), past or concurrent utilization of alcohol treatment (31.8%), co-occurring medical conditions (31.6%), and because they were deemed non-compliant and unmotivated (31.5%). The number of eligibility criteria employed in studies increased from the 1970s through the 1990s, and was positively associated with funding from the US National Institute of Alcohol Abuse and Alcoholism (NIAAA) and from the private sector, lack of an inpatient/residential treatment condition, presence of a pharmacotherapy, and use of a randomized, multiple-condition design. Principal investigators with doctoral degrees used more eligibility criteria than those with lower degrees.Participant eligibility criteria are extensively employed in alcohol treatment outcome research, and vary significantly across historical periods, funders and research designs. Researchers should report the details of subject eligibility criteria and excluded patients more fully, and, evaluate how eligibility criteria affect the cost, feasibility, and generalizability of treatment outcome research.
View details for DOI 10.1111/j.1360-0443.2005.01175.x
View details for Web of Science ID 000231505700014
View details for PubMedID 16128714
Internet and paper self-help materials for problem drinking: Is there an additive effect?
2005; 30 (8): 1517-1523
The objective of this study was to conduct a preliminary evaluation of an Internet-based intervention for problem drinkers, comparing changes in drinking between respondents who only received the intervention to those who also received a self-help book. After receiving a personalized feedback summary on the Internet, 83 respondents provided complete baseline information and volunteered to participate in a 3-month follow-up survey. Half of the respondents were randomized to receive an additional self-help book. The follow-up was returned by 48 respondents (69% female). Repeated measures ANOVAs were conducted to compare drinking levels at baseline and 3-month follow-up among respondents who only received the Internet-based intervention. There was minimal support for an impact of the Internet intervention alone. In addition, hierarchical regression analyses were conducted to compare respondents in the two intervention conditions on their drinking at follow-up, controlling for baseline consumption. Respondents who received the additional self-help book reported drinking less and experiencing fewer consequences at follow-up as compared to respondents who received only the Internet-based intervention. While the results are promising, they cannot be taken as evidence of the efficacy of Internet-based personalized feedback as a stand-alone intervention because of the absence of a control group that did not receive the intervention. Further research on this topic should be a priority because of the potential for Internet-based interventions to reach problem drinkers underserved by traditional treatment.
View details for DOI 10.1016/j.addbeh.2005.03.003
View details for Web of Science ID 000232088200003
View details for PubMedID 15893433
Does writing affect asthma? - A randomized trial
2005; 67 (1): 130-136
Nonpharmacologic treatments for asthma may act as useful adjuncts to pharmacotherapy but should be recommended to patients only after several well-controlled studies provide evidence of efficacy. Research demonstrating that written emotional expression can improve pulmonary function in patients with asthma consists of one impressive yet unreplicated study. Our main objective was to test and extend previous research finding that written emotional expression improves pulmonary function in patients with asthma compared with writing on neutral topics.We conducted a randomized, controlled trial of outpatient asthmatics recruited from hospitals and the community. Of the 137 adult patients with asthma who were randomized, 117 began and 114 completed the study. Patients were randomly assigned to write for 20 minutes, once per week, for 3 weeks about stressful experiences (n = 41), positive experiences (n = 37), or neutral experiences (n = 36; control group). At baseline, postintervention, and 2-month follow up, patients were assessed by spirometry.The mean change from baseline to 2-month follow up in percentage of predicted forced expiratory volume in 1 second (FEV1) was 4.2% in the stress-writing group, 1.3% in the positive-writing group, and 3.0% in the control group. In forced vital capacity (FVC), there was 3.1% improvement in the stress-writing group, 3.6% in the positive-writing group, and 2.4% in the control group. These changes were not statistically or clinically significant.The present study reduces confidence in the ability of written emotional expression to benefit the disease status of asthma patients.
View details for DOI 10.1097/01.psy.0000146345.73510.d5
View details for Web of Science ID 000226673700019
View details for PubMedID 15673635
- Expanding self-help group participation in culturally diverse urban areas: Media approaches to leveraging referent power JOURNAL OF COMMUNITY PSYCHOLOGY 2004; 32 (4): 413-424
Depression increases diabetes symptoms by complicating patients' self-care adherence
2004; 30 (3): 485-492
This study evaluated whether diabetes patients with depressive symptoms are more likely than other diabetes patients to report symptoms of glucose dysregulation, and whether this relationship is mediated by the impact of depressive symptoms on patients' adherence to their diabetes self-care regimen.Participants were English- and Spanish-speaking adults with type 2 diabetes. Interviewers assessed participants' depressive symptoms and diabetes-related symptoms at baseline. Self-care behaviors and diabetes symptoms were measured at a 1-year follow-up. Structural equation models were used to determine whether depression affected diabetes symptoms by limiting patients' ability to adhere to self-care recommendations.An initial model identified direct effects of baseline depressive symptoms on self-care and diabetes symptoms at follow-up. The relationship between self-care behaviors and physical symptoms of poor glycemic control were assessed using a second model. Results explained the relationship between depressive symptoms at baseline and diabetes symptoms at 1 year.Depressive symptoms impact subsequent physical symptoms of poor glucose control by influencing patients' ability to adhere to their self-care regimen. More aggressive management of depression among patients with diabetes may improve their physical health as well as their mental health.
View details for Web of Science ID 000223738100012
View details for PubMedID 15208846
Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2004; 26 (3): 151-158
This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to client's needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse.
View details for DOI 10.1016/S0740-5472(03)00212-5
View details for Web of Science ID 000220939400002
View details for PubMedID 15063905
- A few apologies, but no regrets ADDICTION 2004; 99 (2): 155-156
Treatment needs associated with pain in substance use disorder patients: implications for concurrent treatment
DRUG AND ALCOHOL DEPENDENCE
2004; 73 (1): 23-31
Although pain problems are prevalent in substance use disorder (SUD) patients, the special treatment needs of SUD patients with pain have not been investigated. This study examines the problems and behaviors associated with reported pain among veterans treated at eight opioid substitution treatment clinics. Patients reporting pain had more severe medical and psychiatric problems and greater health care utilization. Pain was associated with an increased propensity for misuse of substances with analgesic effects, suggesting that ongoing pain contributes to an altered and more severe pattern of drug-seeking behavior. Patients without pain rarely abused sedatives or opioid medication, indicating that misuse of these substances is unique to co-morbid pain and SUD patients. Patients reporting pain did not differ from patients without pain in use of heroin, alcohol, cocaine or in injection practices, demonstrating that they are truly SUD patients in need of SUD treatment. Pain complicates the treatment of SUD and should be addressed as an important co-morbidity during treatment.
View details for DOI 10.1016/j.drugalcdep.2003.08.007
View details for Web of Science ID 000188121900003
View details for PubMedID 14687956
- Circles of Recovery: Self-help organizations for addictions. Cambridge, UK: Cambridge University Press 2004
Datapoints: do participants in alcoholism treatment outcome studies resemble patients seen in everyday practice?
2003; 54 (12): 1576-?
View details for PubMedID 14645790
Characteristics and motives of problem drinkers seeking help from moderation management self-help groups
COGNITIVE AND BEHAVIORAL PRACTICE
2003; 10 (4): 384-389
View details for Web of Science ID 000228551000012
Response: the marriage of drug abuse treatment and 12-step strategies.
Science & practice perspectives / a publication of the National Institute on Drug Abuse, National Institutes of Health
2003; 2 (1): 52-54
View details for PubMedID 18552723
- The cost of institutional review board procedures in Multicenter Observational Research ANNALS OF INTERNAL MEDICINE 2003; 139 (1): 77-77
Alcohol & drug abuse: A research-based analysis of the Moderation Management controversy.
2003; 54 (5): 621-622
View details for PubMedID 12719491
Alcoholics anonymous involvement and positive alcohol-related outcomes: Cause, consequence, or just a correlate? A prospective 2-year study of 2,319 alcohol-dependent men
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2003; 71 (2): 302-308
A positive corelation between Alcoholics Anonymous (AA) involvement and better alcohol-related outcomes has been identified in research studies, but whether this correlation reflects a causal relationship remains a subject of meaningful debate. The present study evaluated the question of whether AA affiliation appears causally related to positive alcohol-related outcomes in a sample of 2,319 male alcohol-dependent patients. An initial structural equation model indicated that 1-year posttreatment levels of AA affiliation predicted lower alcohol-related problems at 2-year follow-up, whereas level of alcohol-related problems at 1-year did not predict AA affiliation at 2-year follow-up. Additional models found that these effects were not attributable to motivation or psychopathology. The findings are consistent with the hypothesis that AA participation has a positive effect on alcohol-related outcomes.
View details for DOI 10.1037/0022-006X.71.2.302
View details for Web of Science ID 000181602000009
View details for PubMedID 12699024
Participation in alcoholics anonymous: Intended and unintended change mechanisms
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH
2003; 27 (3): 524-532
This article is a compilation of the information presented at a symposium at the 2001 RSA Meeting in Montreal, Canada. The presentations were: (1) Maintaining change after conjoint behavioral alcohol treatment for men: the role of involvement with Alcoholics Anonymous, by Barbara S. McCrady and Elizabeth E. Epstein; (2) Changing AA practices and outcomes: Project MATCH 3-year follow-up, by J. Scott Tonigan; (3) Life events and patterns of recovery of AA-exposed adults and adolescents, by Patricia L. Owen and Valerie Slaymaker; (4) Social networks and AA involvement as mediators of change, by Lee Ann Kaskutas and Keith Humphreys; and (5) What do we know about Alcoholics Anonymous? by William R. Miller, discussant.
View details for DOI 10.1097/01.ALC.0000057941.57330.39
View details for Web of Science ID 000181843000018
View details for PubMedID 12658120
Alcoholics Anonymous and 12-step alcoholism treatment programs.
Recent developments in alcoholism : an official publication of the American Medical Society on Alcoholism, the Research Society on Alcoholism, and the National Council on Alcoholism
2003; 16: 149-164
Alcoholics Anonymous (AA) self-help groups are the most commonly accessed component of the de facto system of care for alcohol problems in the United States. Further, AA's concepts and approach have strongly influenced a significant number of professional treatment programs. Nevertheless, only a modest number of longitudinal, comparative outcome studies on AA and on professional 12-step treatment programs have been conducted, which has limited both the certainty and scope of conclusions that can be drawn about these interventions. Research indicates that participation in Alcoholics Anonymous and in 12-step treatment are associated with significant reductions in substance abuse and psychiatric problems. Further, such interventions, it has been found, reduce health care costs over time in naturalistic, quasi-experimental, and experimental studies. Evaluation studies have also begun to illuminate the processes through which self-help groups and 12-step treatment programs exert their effects. To build on this knowledge base, future research should (1) be methodologically flexible and well-matched to its phenomenon of interest, (2) include evaluation of the unique features of self-help organizations, (3) increase representation of African-Americans and women in research samples, and (4) increase statistical power through larger sample sizes and more reliable measurement. Key content areas for future enquiry include further longitudinal evaluation of the outcomes of participation in AA and 12-step treatment (particularly in outpatient samples); better specification of the aspects of AA that influence outcome; and individual-, community-, and health organization-level controlled studies of the health care cost consequences of 12-step interventions.
View details for PubMedID 12638636
Datapoints: moving from inpatient to residential substance abuse treatment in the VA.
2002; 53 (8): 927-?
View details for PubMedID 12161662
Social networks as mediators of the effect of Alcoholics Anonymous
2002; 97 (7): 891-900
This study tested the hypothesis that the relationship between Alcoholics Anonymous (AA) involvement and reduced substance use is partially explained (or 'mediated') by changes in social networks.This is a naturalistic longitudinal study of the course of alcohol problems.Study sites were the 10 largest public and private alcohol treatment programs in a northern California county.Three hundred and seventy-seven men and 277 women were recruited upon seeking treatment at study sites.At baseline and 1-year follow-up, we assessed alcohol consequences and dependence symptoms, consumption, social support for abstinence, pro-drinking social influences and AA involvement.In the structural equation model, AA involvement was a significant predictor of lower alcohol consumption and fewer related problems. The size of this effect decreased by 36% when network size and support for drinking were included as mediators. In logistic regression models predicting abstinence at follow-up, AA remained highly significant after including social network variables but was again reduced in magnitude. Thirty-day abstinence was predicted by AA involvement (OR=2.9), not having pro-drinking influences in one's network (OR=0.7) and having support for reducing consumption from people met in AA (versus no support; OR=3.4). In contrast, having support from non-AA members was not a significant predictor of abstinence. For alcohol-related outcomes other than abstinence, significant relationships were found for both AA-based and non-AA-based support.The type of social support specifically given by AA members, such as 24-hour availability, role modeling and experientially based advice for staying sober, may help to explain AA's mechanism of action. Results highlight the value of focusing on outcomes reflective of AA's goals (such as abstinence) when studying how AA works.
View details for Web of Science ID 000176684600018
View details for PubMedID 12133128
Pilot study of racial and geographic HIV risk among methadone patients
14th International AIDS Conference
MEDIMOND S R L. 2002: 279–282
View details for Web of Science ID 000180241900057
Individual and contextual predictors of involvement in twelve-step self-help groups after substance abuse treatment
AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY
2001; 29 (4): 537-563
Drawing on ecological and narrative theories of self-help groups, this study tests a multilevel model predicting self-help group involvement among male veterans who received inpatient substance abuse treatment. Following K. Maton (1993), the study moves beyond the individual-level of analysis to encompass variables in the treatment and post-treatment social ecology. Surveys administered to patients (N = 3,018) and treatment staff (N = 329) assessed these predictor domains and self-help group involvement 1 year after discharge. A hierarchical linear model fit to the data indicates that greater involvement in 12-step groups after discharge is predicted by the compatibility between personal and treatment belief systems. The implications of these findings for efforts to facilitate transitions between inpatient professional treatment and community-based self-help groups are discussed.
View details for Web of Science ID 000170756300002
View details for PubMedID 11554152
Can targeting nondependent problem drinkers and providing Internet-based services expand access to assistance for alcohol problems? A study of the moderation management self-help/mutual aid organization
JOURNAL OF STUDIES ON ALCOHOL
2001; 62 (4): 528-532
Moderation Management (MM) is the only alcohol self-help organization to target nondependent problem drinkers and to allow moderate drinking goals. This study evaluated whether MM drew into assistance an untapped segment of the population with nondependent alcohol problems. It also examined how access to the organization was influenced by the provision of Internet-based resources.A survey was distributed to participants in MM face-to-face and Internet-based self-help groups. MM participants (N = 177, 50.9% male) reported on their demographic characteristics, alcohol consumption, alcohol problems and utilization of professional and peer-run helping resources.MM appears to attract women and young people, especially those who are nondependent problem drinkers. It was also found that a significant minority of members experienced multiple alcohol dependence symptoms and therefore may have been poorly suited to a moderate drinking program.Tailoring services to nondependent drinkers and offering assistance over the Internet are two valuable methods of broadening the base of treatment for alcohol problems. Although interventions like MM are unlikely to benefit all individuals who access them, they do attract problem drinkers who are otherwise unlikely to use existing alcohol-related services.
View details for Web of Science ID 000170348900014
View details for PubMedID 11513231
Can encouraging substance abuse patients to participate in self-help groups reduce demand for health care? A quasi-experimental study
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH
2001; 25 (5): 711-716
Twelve-step-oriented inpatient treatment programs emphasize 12-step treatment approaches and the importance of ongoing attendance at 12-step self-help groups more than do cognitive-behavioral (CB) inpatient treatment programs. This study evaluated whether this difference in therapeutic approach leads patients who are treated in 12-step programs to rely less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term health care costs.A prospective, quasi-experimental comparison of 12-step-based (N = 5) and cognitive-behavioral (n = 5) inpatient treatment programs was conducted. These treatments were compared on the degree to which their patients participated in self-help groups, used outpatient and inpatient mental health services, and experienced positive outcomes (e.g., abstinence) in the year following discharge. Using a larger sample from an ongoing research project, 887 male substance-dependent patients from each type of treatment program were matched on pre-intake health care costs (N = 1774). At baseline and 1-year follow-up, patients' involvement in self-help groups (e.g., Alcoholics Anonymous), utilization and costs of mental health services, and clinical outcomes were assessed.Compared with patients treated in CB programs, patients treated in 12-step programs had significantly greater involvement in self-help groups at follow-up. In contrast, patients treated in CB programs averaged almost twice as many outpatient continuing care visits after discharge (22.5 visits) as patients treated in 12-step treatment programs (13.1 visits), and also received significantly more days of inpatient care (17.0 days in CB versus 10.5 in 12-step), resulting in 64% higher annual costs in CB programs ($4729/patient, p < 0.001). Psychiatric and substance abuse outcomes were comparable across treatments, except that 12-step patients had higher rates of abstinence at follow-up (45.7% versus 36.2% for patients from CB programs, p < 0.001).Professional treatment programs that emphasize self-help approaches increase their patients' reliance on cost-free self-help groups and thereby lower subsequent health care costs. Such programs therefore represent a cost-effective approach to promoting recovery from substance abuse.
View details for Web of Science ID 000168773500012
View details for PubMedID 11371720
Self-help group participation among substance use disorder patients with posttraumatic stress disorder
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2001; 20 (1): 25-32
Debate has ensued about whether substance use disorder (SUD) patients with comorbid posttraumatic stress disorder (PTSD) participate in and benefit from 12-step groups. One hundred fifty-nine SUD-PTSD and 1,429 SUD-only male patients were compared on participation in 12-step activities following an index episode of treatment. Twelve-step participation was similar for SUD patients with and without PTSD. PTSD patients with worldviews (e.g., holding disease model beliefs) that more closely matched 12-step philosophy participated more in 12-step activities. Although greater participation was associated with better concurrent functioning, participation did not prospectively predict outcomes after case mix adjustment. An exception was that greater participation predicted decreased distress among PTSD patients whose identity was more consistent with 12-step philosophy. In summary, PTSD patients participate in and benefit from 12-step participation; continuing involvement may be necessary to maintain positive benefits.
View details for Web of Science ID 000167491300005
View details for PubMedID 11239725
A comparative, process-effectiveness evaluation of VA substance abuse treatment.
Recent developments in alcoholism : an official publication of the American Medical Society on Alcoholism, the Research Society on Alcoholism, and the National Council on Alcoholism
2001; 15: 373-391
Over 3,000 patients from 15 VA inpatient, substance abuse treatment programs showed considerable improvement from intake to a one-year follow-up. Patients in 12-step programs, as opposed to cognitive-behavioral (CB) or eclectic programs, and those with more extended continuing outpatient mental health care and 12-step self-help group involvement, were more likely to be abstinent and free of substance use problems at follow-up. Consistent with their better one-year outcomes, patients in 12-step programs improved more between intake and discharge than CB patients on proximal outcomes assumed to be specific to 12-step treatment (e.g., disease model beliefs) and as much or more on CB proximal outcomes. Proximal outcomes assessed at treatment discharge and follow-up were, at best, modestly related to one-year substance use and other outcomes. No evidence was found that CB or 12-step treatment is more beneficial for certain types of patients.
View details for PubMedID 11449754
Assessing readmission to substance abuse treatment as an indicator of outcome and program performance
2000; 51 (12): 1568-1569
Managed health care systems often use treatment readmission data as an indicator of psychiatric patient outcome and program performance. This study of 3,018 inpatients being treated for substance abuse in Department of Veterans Affairs medical centers found that across a range of measures and patient subpopulations, patient outcomes and program performance were virtually independent of treatment readmission. These findings suggest that even though readmission for substance abuse treatment may have value as an easily obtainable measure of health care utilization and cost, it cannot serve as a valid substitute for direct assessment of patient outcome or program performance.
View details for Web of Science ID 000165681400017
View details for PubMedID 11097655
Providing personalized assessment feedback for problem drinking on the Internet: A pilot project
JOURNAL OF STUDIES ON ALCOHOL
2000; 61 (6): 794-798
This project developed an Internet program that conducts a brief assessment of an individual's drinking habits and then provides normative feedback comparing the user's drinking to that of others of the same gender and age group. The Internet program, "Try Our Free Drinking Evaluation," was based at the Addiction Research Foundation Internet web site (now at http://notes.camh.net/efeed.nsf/ newform).A voluntary survey linked to the participant's feedback summary collected respondents' impressions of the program.During the trial period, the site received approximately 500 hits per month. While the feedback was generally well received, the weekly summary format was less credible to those individuals who drink less than once per week or whose consumption varies a great deal over time.Given these pilot results indicating that there is an audience for Internet-based interventions, the next step is to evaluate whether receiving such personalized feedback materials on the Internet leads to any change in drinking behavior by participants
View details for Web of Science ID 000165874700004
View details for PubMedID 11188484
Psychologists' ethical responsibilities in Internet-based groups: Issues, strategies, and a call for dialogue
PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE
2000; 31 (5): 493-496
How can psychologists participate ethically as facilitators, advisers, and peer members in Internet-based groups? The astonishing growth of Internet technology and on-line groups has outpaced the development of formal ethical guidelines for psychologists involved in on-line groups. This article provides an initial appraisal of psychologists' ethical responsibilities in discussion, support, and self-help groups that operate on the Internet and offers practical strategies for avoiding ethical problems. By presenting initial strategies and guidelines for ethical behavior in Internet-based groups, the authors hope to stimulate the field to further discuss and analyze these issues.
View details for Web of Science ID 000089750800008
View details for PubMedID 14621714
Communication patterns in an on-line mutual help group for problem drinkers
JOURNAL OF COMMUNITY PSYCHOLOGY
2000; 28 (5): 535-546
View details for Web of Science ID 000088819000007
- Beyond the mental health clinic: New settings and activities for clinical psychology internships PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2000; 31 (3): 300-304
Use of exclusion criteria in selecting research subjects and its effect on the generalizability of alcohol treatment outcome studies
AMERICAN JOURNAL OF PSYCHIATRY
2000; 157 (4): 588-594
Researchers have not systematically examined how exclusion criteria used in selection of research subjects affect the generalizability of treatment outcome research. This study evaluated the use of exclusion criteria in alcohol treatment outcome research and its effects on the comparability of research subjects with real-world individuals seeking alcohol treatment.Eight of the most common exclusion criteria described in the alcohol treatment research literature were operationalized and applied to large, representative clinical patient samples from the public and private sectors to determine whether the hypothetical research samples differed substantially from real-world samples. Five hundred ninety-three consecutive individuals seeking alcohol treatment at one of eight treatment programs participated. A trained research technician gathered information from participants on demographic variables and on alcohol, drug, and psychiatric problems as measured by the Addiction Severity Index.Large proportions of potential research subjects were excluded under most of the criteria tested. The overall pattern of results showed that African Americans, low-income individuals, and individuals who had more severe alcohol, drug, and psychiatric problems were disproportionately excluded under most criteria.Exclusion criteria can result in alcohol treatment outcome research samples that are more heavily composed of white, economically stable, and higher-functioning individuals than are real-world samples of substance abuse patients seen in clinical practice, potentially compromising the generalizability of results. For both scientific and ethical reasons, in addition to studies that use exclusion criteria, outcome research that uses no or minimal exclusion criteria should be conducted so that alcohol treatment outcome research can be better generalized to vulnerable populations.
View details for Web of Science ID 000086232300014
View details for PubMedID 10739418
Alcohol & drug abuse: the transformation of the Veterans Affairs substance abuse treatment system.
1999; 50 (11): 1399-1401
View details for PubMedID 10543846
Alcoholics anonymous affiliation at treatment intake among white and black Americans
JOURNAL OF STUDIES ON ALCOHOL
1999; 60 (6): 810-816
Black Americans are overrepresented in the public alcohol treatment system, but may be less likely to use informal services such as Alcoholics Anonymous (AA). Some commentators perceive AA as a white, middle-class organization that is unlikely to appeal to blacks. This epidemiological study considers prior attendance and engagement in AA among 791 black and white men and women entering treatment in public, private and HMO substance abuse programs.Clients were interviewed in-person within the first 3 days of inpatient treatment or the first 3 weeks of outpatient treatment.Black clients dominate public detoxification programs and report more drug and employment problems than whites (who report more family problems). Those with prior treatment experiences and those reporting they had gone to AA as part of treatment reported overall higher rates of AA affiliation, with blacks more likely to say they felt like a member of AA (64% vs 54% of whites), had a spiritual awakening as a result of AA (38% vs 27%) and had done service at AA meetings in the last year (48% vs 37%); whites were more likely to have had a sponsor (23% vs 14%) and to have read program literature (77% vs 67%).Controlling for other effects such as prior inpatient or outpatient treatment, blacks are about twice as likely as whites to report having attended AA as part of treatment (OR = 1.70). More research is needed to understand referral pathways to AA among blacks, and the differential effect this may have on sustained participation in AA and on long-term sobriety.
View details for Web of Science ID 000083530700012
View details for PubMedID 10606493
Should patients' religiosity influence clinicians' referral to 12-step self-help groups? Evidence from a study of 3,018 male substance abuse patients
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1999; 67 (5): 790-794
Twelve-step self-help organizations maintain that anyone, regardless of his or her religious beliefs, can benefit from participation in their groups. Yet many addiction professionals have reservations about referring nonreligious patients to 12-step groups. The present study examined the influence of patients' religiosity on whether they were referred to and benefited from 12-step groups. Participants were 3,018 male substance abuse inpatients. Individuals who engaged in fewer religious behaviors in the past year were referred to 12-step groups less frequently by clinicians. However, referrals to 12-step groups were effective at increasing meeting attendance, irrespective of patients' religious background, and all experienced significantly better substance abuse outcomes when they participated in 12-step groups. The viewpoint that less religious patients are unlikely to attend or benefit from 12-step groups may therefore be overstated.
View details for Web of Science ID 000083117200018
View details for PubMedID 10535246
- The case for a partnership with self-help groups PUBLIC HEALTH REPORTS 1999; 114 (4): 322-?
A comparative evaluation of substance abuse treatment: V. Substance abuse treatment can enhance the effectiveness of self-help groups
151st Annual Meeting of the American-Psychiatric-Association
WILEY-BLACKWELL PUBLISHING, INC. 1999: 558–63
Affiliation with Alcoholics Anonymous (AA) and other 12-Step self-help groups is becoming more common at the same time as professional substance abuse treatment services are becoming less available and of shorter duration. As a result of these two trends, patients' outcomes may be increasingly influenced by the degree to which professional treatment programs help patients take maximum advantage of self-help groups. The present study of 3018 treated veterans examined how the theoretical orientation of a substance abuse treatment program affects (1) the proportion of its patients that participate in self-help groups, and, (2) the degree of benefit patients derive from participation in self-help groups. Patients treated in 12-Step and eclectic treatment programs had higher rates of subsequent participation in 12-Step self-help groups than did patients treated in cognitive behavioral programs. Furthermore, the theoretical orientation of treatment moderated the outcome of self-help group participation: As the degree of programs' emphasis on 12-Step approaches increased, the positive relationships of 12-Step group participation to better substance use and psychological outcomes became stronger. Hence, it appears that 12-Step oriented treatment programs enhance the effectiveness of 12-Step self-help groups. Findings are discussed in terms of implications for clinical practice and for future evaluations of the combined effects of treatment and self-help groups.
View details for Web of Science ID 000079269900028
View details for PubMedID 10195833
A comparative evaluation of substance abuse treatment: II. Linking proximal outcomes of 12-Step and cognitive-behavioral treatment to substance use outcomes
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH
1999; 23 (3): 537-544
This study examines the linkages in the treatment process chains that are thought to underlie two prevalent approaches to substance abuse treatment, traditional 12-Step treatment and cognitive-behavioral treatment. The focus is on the "proximal outcomes" specified by the two treatment approaches and their relation to "ultimate" substance use outcomes assessed at a 1-year follow-up. A total of 2687 men who received treatment in 15 Department of Veterans Affairs substance abuse treatment programs were assessed at treatment entry, at or near discharge, and at a 1-year follow-up. Based on the results of factor analyses, composite proximal outcomes variables were constructed to assess 12-Step cognitions, 12-Step behaviors, cognitive-behavioral beliefs, substance-specific coping, and general coping. Correlation analyses indicated that some of the proximal outcome composites assessed at treatment discharge were linked to 1-year outcomes, but the relationships were weak (r = .09 to .15). At follow-up, the cross-sectional relationships between the proximal outcome composites and two substance use outcomes were stronger, but still modest in magnitude (r = .16 to .39). The weak predictive findings suggest some mechanism is needed to sustain treatment-induced change on proximal outcomes so that positive ultimate outcomes can be achieved more frequently. In this regard, participation in continuing care was associated with enhanced maintenance of treatment gains on proximal outcomes. However, the modest cross-sectional relationships between proximal and substance use outcomes at follow-up suggest that the theories on which 12-Step and cognitive-behavioral substance abuse treatments are based are not sufficiently comprehensive.
View details for Web of Science ID 000079269900025
View details for PubMedID 10195830
Do enhanced friendship networks and active coping mediate the effect of self-help groups on substance abuse?
20th Annual Meeting of the Research-Society-on-Alcoholism
SPRINGER. 1999: 54–60
Self-help groups are the most commonly sought source of help for substance abuse problems, but few studies have evaluated the mechanisms through which they exert their effects on members. The present project evaluates mediators of the effects of self-help groups in a sample of 2,337 male veterans who were treated for substance abuse. The majority of participants became involved in self-help groups after inpatient treatment, and this involvement predicted reduced substance use at 1-year follow-up. Both enhanced friendship networks and increased active coping responses appeared to mediate these effects. Implications for self-help groups and professional treatments are discussed.
View details for Web of Science ID 000085538800009
View details for PubMedID 18425655
Evaluating and improving VA substance abuse patients ' care
AMERICAN JOURNAL OF MEDICAL QUALITY
1999; 14 (1): 45-54
The VA has implemented a nationwide evaluation program to monitor process and outcome of care for substance abuse patients. This program focuses on the changing characteristics of VA substance abuse patients and treatment services and involves outcome-based evaluations of major VA substance abuse treatment modalities. Initial findings show that VA substance abuse patients, including patients with concomitant psychiatric disorders, improve substantially from treatment intake to a 1-year follow-up and that community residential facilities are an important part of the continuum of substance abuse care. Moreover, within broad limits, there is a dose-response relationship between the continuity of outpatient mental health care and better 1-year substance use and psychosocial outcomes. These findings are placed into context as part of an evidence-based initiative to improve the quality of VA mental health care.
View details for Web of Science ID 000083697400007
View details for PubMedID 10446663
The Alcoholics Anonymous affiliation scale: Development, reliability, and norms for diverse treated and untreated populations
ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH
1998; 22 (5): 974-978
Affiliation with Alcoholics Anonymous (AA) is an important variable to measure in many clinical and research activities. This paper reports on the development of an AA affiliation scale, and demonstrates its utility in a sample of 927 alcohol treatment seekers and 674 untreated problem drinkers. The scale is short (9 items), covers a range of AA experiences, and is internally consistent across diverse demographic groups, multiple health services settings, and treated and untreated populations. The validity of the scale is supported by the findings that treatment seekers report significantly higher AA affiliation than do untreated problem drinkers, and inpatients report higher affiliation than outpatients. Potential clinical and research applications of the scale are proposed.
View details for Web of Science ID 000075475100002
View details for PubMedID 9726265
Treatment involvement and outcomes for four subtypes of homeless veterans
AMERICAN JOURNAL OF ORTHOPSYCHIATRY
1998; 68 (2): 285-294
A longitudinal study examined treatment services and outcomes in a nationwide sample of 565 homeless veterans who were classified as alcoholic, psychiatrically impaired, multiproblem, or best-functioning. All four groups experienced some improvement in their primary problem area, in employment status, and in residential quality at eight-month follow-up, but there were significant differences in degree of improvement across groups. Implications for the design of homeless programs and policies are discussed.
View details for Web of Science ID 000073293200013
View details for PubMedID 9589766
The relationship of pre-treatment Alcoholics Anonymous affiliation with problem severity, social resources and treatment history
20th Annual Meeting of the Research-Society-on-Alcoholism
ELSEVIER IRELAND LTD. 1998: 123–31
Little research has examined the relationship of substance abuse patients' prior Alcoholics Anonymous (AA) affiliation to important treatment-related variables. This study of 927 individuals seeking treatment in public, health maintenance organization (HMO) and private-for-profit medical programs, found that 82.8% of patients presented at treatment with a history of AA affiliation. Degree of prior AA affiliation was significantly associated with more extensive prior utilization of formal and informal helping resources, current seeking of treatment in the public sector, having low income, being divorced/separated and having more severe alcohol, employment/support and psychiatric problems. Implications for service delivery and future research are discussed.
View details for Web of Science ID 000072544800006
View details for PubMedID 9543649
Policy-relevant program evaluation in a national substance abuse treatment system
JOURNAL OF MENTAL HEALTH ADMINISTRATION
1997; 24 (4): 373-385
This article discusses recent trends in public and private substance abuse services and offers suggestions on how the evaluation of such services can inform clinical practice and policy making. This analysis focuses particularly on the Department of Veterans Affairs (VA), which operates the largest substance abuse treatment system in the United States. In recent years, there has been an erosion of services for substance abuse outside the VA. In contrast, due to increased funding from the U.S. Congress, the VA significantly expanded substance abuse treatment from 1990 to 1994. However, efforts to "reinvent" and downsize government initiated a reversal of this growth trend in 1994, and VA services may shrink further as the system becomes more decentralized and adopts managed care strategies from the private sector. Drawing from the VA Program Evaluation and Resource Center's (PERC) experience of evaluating the VA system and working with federal policy makers, this article presents examples and suggestions for making evaluations of substance abuse treatment systems more useful in policy discussions and in day-to-day clinical practice.
View details for Web of Science ID 000070961800001
View details for PubMedID 9364108
Social and community resources and long-term recovery from treated and untreated alcoholism
1996 Kettil-Bruun-Society Annual Meeting
ALCOHOL RES DOCUMENTATION INC CENT ALCOHOL STUD RUTGERS UNIV. 1997: 231–38
Long-term studies of the course of alcoholism suggest that a variety of factors other than professional treatment influence the process of recovery. This study evaluated the role of demographic factors, baseline alcohol-related problems and depression, professional treatment, Alcoholics Anonymous (AA) and other social and community resources in predicting remission and psychosocial outcome over 8 years.A sample of 628 previously untreated alcoholic individuals was recruited at detoxification units and alcoholism information and referral services. Of these participants, 395 (68.2%) were followed 3 and 8 years later. Most (83.3%) were white (n = 329) and 50.1% (n = 198) were men. At each contact point, participants completed a self-administered inventory that assessed their current problems, treatment utilization, AA participation and quality of relationships.Number of inpatient treatment days received in the 3 years after baseline were not independently related to 8-year remission or psychosocial outcomes. More outpatient treatment in the first 3 years increased the likelihood of 8-year remission, but was not related to psychosocial outcomes. The number of AA meetings attended in the first 3 years predicted remission, lower depression, and higher quality relationships with friends and spouse/partner at 8 years. Extended family quality at baseline also predicted remission and higher quality friendships and family relationships at 8 years.Given that alcoholism is a chronic, context-dependent disorder, it is not surprising that short-term interventions have little long-term impact. Social and community resources that are readily available for long periods are more likely to have a lasting influence on the course of alcoholism.
View details for Web of Science ID A1997WU28900002
View details for PubMedID 9130214
- Treatment of VA inpatients with diagnoses of substance abuse PSYCHIATRIC SERVICES 1997; 48 (2): 171-171
The influence of posttreatment mutual help group participation on the friendship networks of substance abuse patients
Meeting of the Society-for-Community-Research-and-Action
SPRINGER/PLENUM PUBLISHERS. 1997: 1–16
The effect of 12-step mutual help groups (e.g., Narcotics Anonymous) on members' friendship networks has received little attention. This 1-year longitudinal study examined such effects in a sample of 2,337 male substance abuse inpatients, 57.7% of whom became significantly involved in 12-step activities (e.g., reading program literature, attending meetings) after treatment. An a priori model of the interplay of 12-step involvement) and friendship networks was tested using structural equation modeling, and found to have excellent fit to the data. Twelve-step group involvement after treatment predicted better general friendship characteristics (e.g., number of close friends) and substance abuse-specific friendship characteristics (e.g., proportion of friends who abstain from drugs and alcohol) at follow-up. Results are discussed in terms of how mutual help group involvement benefits patients and how the self-help group evaluation paradigm should be broadened.
View details for Web of Science ID A1997XK42700001
View details for PubMedID 9231993
Addressing self-selection effects in evaluations of mutual help groups and professional mental health services: An introduction to two-stage sample selection models
EVALUATION AND PROGRAM PLANNING
1996; 19 (4): 301-308
View details for Web of Science ID A1996VZ90400003
Datapoints. Psychiatric services in VA substance abuse treatment programs.
1996; 47 (11): 1203-?
View details for PubMedID 8916236
Psychiatric services in VA substance abuse treatment programs
1996; 47 (11): 1203-1203
View details for Web of Science ID A1996VP79400007
Life domains, alcoholics anonymous, and role incumbency in the 3-year course of problem drinking
JOURNAL OF NERVOUS AND MENTAL DISEASE
1996; 184 (8): 475-481
This study examined the course of problem drinking among 439 individuals over 3 years, using a life domains perspective that distinguishes life stressors and social resources in different contexts. More severe chronic financial stressors both predicted and were predicted by more alcohol consumption and drinking-related problems. Among social resources, Alcoholics Anonymous was the most robust predictor of better functioning on multiple outcome criteria. Support from friends and extended family also predicted better outcomes; this effect was stronger for individuals who were low on primary role incumbency (i.e., who were unemployed and/or did not have a spouse/partner).
View details for Web of Science ID A1996VD33100004
View details for PubMedID 8752076
Reduced substance-abuse-related health care costs among voluntary participants in alcoholics anonymous
International Congress on Alcohol and Drug Dependence
AMER PSYCHIATRIC ASSOCIATION. 1996: 709–13
This study examined differences in outcomes, alcoholism treatment utilization, and costs between alcoholic individuals with no previous treatment history who chose to attend Alcoholics Anonymous (AA) or to seek help from a professional outpatient alcoholism treatment provider.Participants in this three-year prospective study were recruited at alcoholism information and referral services and at detoxification units in the San Francisco Bay Area. Chi square and t tests and repeated-measures analyses of variance were used to examine data gathered from interviews with 201 participants at baseline and at one and three years.At baseline, participants who chose to attend AA meetings (N = 135) were not significantly different from those who chose professional outpatient treatment (N = 66) in sex, marital status, employment, race, and symptoms of alcohol dependence and depression. However, AA attendees had lower incomes and less education and experienced more adverse consequences of drinking at baseline than did those who sought outpatient care, suggesting somewhat worse prognoses for the AA group. Over the three-year study, per-person treatment costs for the AA group were 45 percent (or $1,826) lower than costs for the outpatient treatment group. Despite the lower costs, outcomes for the AA group at both one and three years were similar to those of the outpatient treatment group.Voluntary AA participation may significantly reduce professional treatment costs. Clinicians, researchers, and policymakers should recognize the potential health care cost offsets offered by AA and other self-help organizations.
View details for Web of Science ID A1996UV45800006
View details for PubMedID 8807683
World view change in Adult Children of Alcoholics Al-Anon self-help groups: Reconstruction the alcoholic family
INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY
1996; 46 (2): 255-263
Although 12-step self-help groups have become extremely popular in U.S. society, clinicians and researchers have devoted little attention to how these groups affect members. This project used naturalistic and qualitative methods to examine the processes through which committed members of self-help groups for adult children of alcoholics experience alterations in their perceptions of family of origin. Results suggest that world view transformation in the family of origin domain involves learning to define the family as pathological, assigning responsibility for this pathology to a disease, forgiving oneself, accepting that one was adversely affected by the family's problem, and ultimately learning to accept one's parents' shortcomings.
View details for Web of Science ID A1996UE73900007
View details for PubMedID 8935765
Clinical psychologists as psychotherapists - History, future, and alternatives
1996; 51 (3): 190-197
As managed care and other cost-containment strategies become central features of the American health care system, doctoral-level clinical psychologists will be increasingly supplanted in the role of psychotherapist by lower cost providers such as social workers, marriage and family counselors, and masters-level psychologists. To provide one basis for clinical psychologists to make judgments about their role in psychotherapy; this article describes what the field was like before psychotherapy became a core activity and then compares the present transition with its historical counterpart: the opening up of the psychotherapy profession to doctoral-level clinical psychologists after World War II. History suggests that efforts to resist the current changes will be unsuccessful and that the most adaptive coping strategy for clinical psychologists is to take advantage of the transition by reenvisioning training and practice of clinical psychologists.
View details for Web of Science ID A1996UB19800002
View details for PubMedID 8881525
Reliability, validity, and normative data for a short version of the understanding of alcoholism scale
PSYCHOLOGY OF ADDICTIVE BEHAVIORS
1996; 10 (1): 38-44
View details for Web of Science ID A1996UA16700005
Recovering substance abuse staff members' beliefs about addiction
JOURNAL OF SUBSTANCE ABUSE TREATMENT
1996; 13 (1): 75-78
This study of 329 substance abuse treatment staff assessed how recovery status, in combination with other variables, influences beliefs about the causes and treatment of substance abuse. About 15% (n = 47) of participants were "in recovery" from substance abuse problems; these staff members were not significantly different than nonrecovering staff members on education, age, race/ethnicity, years of clinical experience, or amount of client contact. When examined in a multiple regression equation that also included age, education, and treatment program goals and activities, staff members' recovery status was not associated with endorsement of disease and psychosocial models of substance abuse. However, being in recovery was associated with endorsing an eclectic approach to substance abuse treatment. The importance of recognizing the diversity of beliefs about substance abuse among recovering staff and of acknowledging that multiple influences affect all staff members viewpoints on treatment is discussed.
View details for Web of Science ID A1996UD52700009
View details for PubMedID 8699546
2 PATHWAYS OUT OF DRINKING PROBLEMS WITHOUT PROFESSIONAL TREATMENT
1995; 20 (4): 427-441
This 3-year longitudinal study examined two recovery pathways among 135 problem drinking individuals who never received professional treatment. Almost half (48.3%) of those individuals for whom outcome could be clearly determined became moderate drinkers or stably abstinent. At baseline, individuals who subsequently became abstinent (n = 28) were of low socioeconomic status, had severe drinking problems, and believed their drinking was a very serious problem. Once they began their recovery, they relied heavily on Alcoholics Anonymous as a maintenance factor. In contrast, individuals who became moderate drinkers (n = 29) had higher socioeconomic status and more social support at baseline than did individuals who became abstinent or continued to have drinking problems. A logistic regression on baseline data showed that it was possible to predict which natural recovery pathway an individual drinker would follow. The implications of these findings for alcoholism treatment and policy are discussed.
View details for Web of Science ID A1995RH48600002
View details for PubMedID 7484324
SEQUENTIAL VALIDATION OF CLUSTER ANALYTIC SUBTYPES OF HOMELESS VETERANS
AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY
1995; 23 (1): 75-98
View details for Web of Science ID A1995RT87700005
World views of Alcoholics Anonymous, Women for Sobriety, and Adult Children of Alcoholics/Al-Anon mutual help groups
1995; 3 (3): 231-243
View details for Web of Science ID A1995UU78500006
APPLYING A STRESS AND COPING FRAMEWORK TO RESEARCH ON MUTUAL HELP ORGANIZATIONS
JOURNAL OF COMMUNITY PSYCHOLOGY
1994; 22 (4): 312-327
View details for Web of Science ID A1994PQ01700003