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Introduction: Patient‐reported measures that assess satisfaction and experience are increasingly utilised in healthcare sectors, including the alcohol and other drug (AOD) sector. This scoping review identifies how and to what extent people accessing AOD services have been involved in the development of satisfaction and experience measures to date. Methods: PubMed, EMBASE, CINAHL, Scopus, ProQuest, Google and Google Scholar were searched. Included papers described the development and/or implementation of a multiple‐item measure of patient‐reported experience or satisfaction specifically for people accessing AOD treatment and/or harm reduction programmes. If there was more than one paper, key papers were chosen that described each measure. The method of development, including service user involvement, was assessed against a framework generated for this review. Two reviewers were involved at each stage. Results: Thirty measures—23 satisfaction and 7 experience—were identified. Sixteen measures reported some level of involvement by people accessing AOD services in their development, although, for most measures, at a relatively low level. This involvement increased over the time span of the review becoming more frequent in later years. Only four measures were developed for use in harm reduction‐specific settings, and fewer than half reported undertaking analysis of underlying scale structure and constructs. Conclusion: Several gaps could be addressed to enhance the measurement of patient‐centred care in the AOD sector, including: developing experience measures for use in harm reduction settings and across various AOD settings in a service system; improved reporting of psychometric properties of these measures and increasing commitment to the meaningful involvement of AOD service users in measure development. Patient or Public Contribution: This scoping review is part of a broader codesign project that involves a partnership between the peak organisation for AOD services and the peer‐based AOD consumer organisation in the Australian Capital Territory, Australia. These organisations are working closely together to engage with AOD service users, service providers and policy makers in this codesign project. As such, the Executive Director of the peer‐based AOD consumer organisation is involved as a co‐author of this scoping review. [ABSTRACT FROM AUTHOR]

Abstract: Background: There is increasing interest in individualized patient‐reported outcome measures (I‐PROMS), where patients themselves indicate the specific problems they want to address in therapy and these problems are used as items within the outcome measurement tool. Objective: This paper examined the extent to which 279 items reported in an I‐PROM (PSYCHLOPS) added qualitative information which was not captured by two well‐established outcome measures (CORE‐OM and PHQ‐9). Design: Comparison of items was only conducted for patients scoring above the “caseness” threshold on the standardized measures. Setting and patients: 107 patients were participating in therapy within addiction and general psychiatric clinical settings. Main results: Almost every patient (95%) reported at least one item whose content was not covered by PHQ‐9, and 71% reported at least one item not covered by CORE‐OM. Discussion: Results demonstrate the relevance of individualized outcome assessment for capturing data describing the issues of greatest concern to patients, as nomothetic measures do not always seem to capture the whole story. [ABSTRACT FROM AUTHOR]

Background: People who use drugs (PWUD) frequently delay or avoid obtaining medical care in traditional healthcare settings. Through a randomized controlled trial, we investigated facilitated telemedicine for hepatitis C virus (HCV) integrated into opioid treatment programmes. We sought to understand the experiences and meanings of facilitated telemedicine and an HCV cure among PWUD. Methods: We utilized purposive sampling to interview 25 participants, 6–40 months after achieving an HCV cure. We interpreted and explicated common meanings of participants' experiences of an HCV cure obtained through facilitated telemedicine. Results: Participants embraced facilitated telemedicine integrated into opioid treatment programmes as patient‐centred care delivered in 'safe spaces' (Theme 1). Participants elucidated their experiences of substance use and HCV while committing to treatment for both entities. Facilitated telemedicine integrated into opioid treatment programmes enabled participants to avoid stigma encountered in conventional healthcare settings (Theme 2). Participants conveyed facing negative perceptions of HCV and substance use disorder. Improved self‐awareness, acquired through HCV and substance use treatment, enabled participants to develop strategies to address shame and stigma (Theme 3). An HCV cure, considered by PWUD as a victory over a lethal infectious disease, promotes self‐confidence, enabling participants to improve their health and lives (Theme 4). Conclusions: Integrating facilitated telemedicine into opioid treatment programmes addresses several healthcare barriers for PWUD. Similarly, obtaining an HCV cure increases their self‐confidence, permissive to positive lifestyle changes and mitigating the negative consequences of substance use. Patient and Public Contribution: In this study of patient involvement, we interviewed patient‐participants to understand the meaning of an HCV cure through facilitated telemedicine. Participants from a facilitated telemedicine pilot study provided essential input on the design and outcomes of a randomized controlled trial. Pilot study participants endorsed facilitated telemedicine in a testimonial video. They attended site initiation meetings to guide trial implementation. A Patient Advisory Committee (PAC) ensured that patient participants were active members of the research team. The PAC represented patients' voices through feedback on study procedures. A Sustainability Committee supported public involvement in the research process, including educational opportunities, feedback on implementation, and future sustainability considerations. [ABSTRACT FROM AUTHOR]

Awareness of cannabis dependence as a clinically relevant issue has grown in recent years. Clinical and laboratory studies demonstrate that chronic marijuana smokers can experience withdrawal symptoms upon cessation of marijuana smoking and have difficulty abstaining from marijuana use. This paper will review data implicating the cannabinoid CB1 receptor in regulating the behavioral effects of Δ9-tetrahydrocannobinol (THC), the primary psychoactive component of cannabis, across a range of species. The behavioral effects that will be discussed include those that directly contribute to the maintenance of chronic marijuana smoking, such as reward, subjective effects, and the positive and negative reinforcing effects of marijuana, THC and synthetic cannabinoids. The role of the CB1 receptor in the development of marijuana dependence and expression of withdrawal will also be discussed. Lastly, treatment options that may alleviate withdrawal symptoms and promote marijuana abstinence will be considered. [ABSTRACT FROM AUTHOR]

Determining the proportion of avoidable disease burden attributable to substance use is important for both policy development and intervention implementation. Current epidemiological theory has in principle provided a method to estimate avoidable burden of disease and the available statistical tools can provide first rough estimates. The method described in this paper, and its statistical procedures, are exemplified to estimate avoidable burden of tobacco-related disease in Canada. However, further effort is needed to find solutions in the methodological details, namely exposure measurement, risk factor multidimensionality, estimation of changes in exposure distribution over time, and estimation of risk relationships from multiple exposures changing over time with multiple endpoints (causal webs). The impetus to begin refining methods to obtain better starting points for estimating avoidable burden of disease is obvious and should be carried through in order to see real changes through evidence-based policy and intervention. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Policy PointsOver the past century, the tax‐financed share of health care spending has risen from 9% in 1923 to 69% in 2020; a large part of this tax financing is now the subsidization of private health insurance.For‐profit ownership of health care facilities has also increased in recent decades and now predominates for many health subsectors. A rising share of physicians are now employees.US health care is, increasingly, publicly financed yet investor owned, a trend that has been accompanied by rising medical costs and, in recent years, stagnating or even worsening population health. A reconsideration of US health care financing and ownership appears warranted. Context: Who pays for health care—and who owns it—determine what care is delivered, who receives it, and who profits from it. We examined trends in health care ownership and financing over a century. Methods: We used multiple historical and current data sources (including data from the American Medical Association, the American Hospital Association, government publications and surveys, and analyses of Medicare Provider of Services files) to classify health care provider ownership as: public, private (for‐profit), and private (not‐for‐profit). We used US Census data to classify physicians' employers as public, not‐for‐profit, or for‐profit entities or "self‐employed." We combined estimates from the official National Health Expenditures Accounts with other data sources to determine the public vs. private share of health care spending since 1923; we calculated a "comprehensive" public share metric that accounted for public subsidization of private health expenditures, mostly via the tax exemption for employer‐sponsored insurance plans or government purchase of such plans for public employees. Findings: For‐profit ownership of most health care subsectors has risen in recent decades and now predominates in several (including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies). However, most community hospitals remain not‐for‐profit. Additionally, over the past century, a growing share of physicians identify as employees. Meanwhile, the comprehensive taxpayer‐financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer‐financed subsidies to private expenditures accounting for much of the recent growth. Conclusions: American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health. A reassessment of the US mode of health care financing and ownership appears warranted. [ABSTRACT FROM AUTHOR]

Policy PointsPeople are dying at record numbers from overdose in the United States.Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm‐reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm‐reduction services.Priorities for action include investing in evidence‐based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply. [ABSTRACT FROM AUTHOR]

Policy PointsAs a consequence of mass incarceration and related social inequities in the United States, jails annually incarcerate millions of people who have profound and expensive health care needs.Resources allocated for jail health care are scarce, likely resulting in treatment delays, limited access to care, lower‐quality care, unnecessary use of emergency medical services (EMS) and emergency departments (EDs), and limited services to support continuity of care upon release.Potential policy solutions include alternative models for jail health care oversight and financing, and providing alternatives to incarceration, particularly for those with mental illness and substance use disorders. Context: Millions of people are incarcerated in US jails annually. These individuals commonly have ongoing medical needs, and most are released back to their communities within days or weeks. Jails are required to provide health care but have substantial discretion in how they provide care, and a thorough overview of jail health care is lacking. In response, we sought to generate a comprehensive description of jails' health care structures, resources, and delivery across the entire incarceration experience from jail entry to release. Methods: We conducted in‐depth interviews with jail personnel in five southeastern states from August 2018 to February 2019. We purposefully targeted recruitment from 34 jails reflecting a diversity of sizes, rurality, and locations, and we interviewed personnel most knowledgeable about health care delivery within each facility. We coded transcripts for salient themes and summarized content by and across participants. Domains included staffing, prebooking clearance, intake screening and care initiation, withdrawal management, history and physicals, sick calls, urgent care, external health care resources, and transitional care at release. Findings: Ninety percent of jails contracted with private companies to provide health care. We identified two broad staffing models and four variations of the medical intake process. Detention officers often had medical duties, and jails routinely used community resources (e.g., emergency departments) to fill gaps in on‐site care. Reentry transitional services were uncommon. Conclusions: Jails' strategies for delivering health care were often influenced by a scarcity of on‐site resources, particularly in the smaller facilities. Some strategies (e.g., officers performing medical duties) have not been well documented previously and raise immediate questions about safety and effectiveness, and broader questions about the adequacy of jail funding and impact of contracting with private health care companies. Beyond these findings, our description of jail health care newly provides researchers and policymakers a common foundation from which to understand and study the delivery of jail health care. [ABSTRACT FROM AUTHOR]

Ethical frameworks can support professionals' decision‐making. Here, we identify two ethical frameworks to analyse the best support for families that struggle with parental substance or alcohol abuse. The first framework, which we call 'the framework of conflicting interests', is most prominent in the literature. Here, the interests of parents and children are weighed against each other using the medical ethical principles of respect for autonomy, justice, beneficence, and non‐maleficence. The second framework is most prominent in a series of interviews we conducted with alcohol‐dependent parents and professionals working in addiction care and youth care. This framework aligns more with an ethics of care, and starts with the assumption that the interests of people who are close to each other are often intertwined. This framework does not so much look at conflicting interests, but at relationships and vulnerability. We label this the ethics of care framework. In this article, we show the value of both frameworks and how they can support ethical decision‐making. [ABSTRACT FROM AUTHOR]

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Objective: Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence‐based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients' perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post–opioid overdose period. Methods: We administered a brief quantitative survey and conducted semistructured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across four levels of a modified social ecologic model (individual, interpersonal, organizational, and structural). Results: The mean (±SD) age of the sample was 33.5 (±9.33) years; 83% were White and 12% were Black; 67% were male; and 83% were diagnosed with OUD, with a mean (±SD) of 3.25 (±2.64) self‐reported lifetime opioid overdoses. Eight themes were identified as influencing participants' consideration of OUD treatment and other services: (1) perceptions about control of drug use, (2) personal experience with substance use treatment, (3) role of interpersonal relationships, (4) provider communication skills, (5) stigma, (6) availability of ED resources, (7) impact of treatment policies, and (8) support for unmet basic needs. Conclusions: Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED‐based research evaluating a patient‐oriented approach to engage patients after opioid overdose. [ABSTRACT FROM AUTHOR]

Objective: To examine the availability and facility‐level predictors of LGBT‐specific mental health and substance abuse treatment in the United States. Data Sources/Study Setting: 2016 National Survey of Substance Abuse Treatment Services, 2016 National Mental Health Service Survey, and 2015‐2016 Gallup Daily tracking survey. Study Design: Logistic regression models and average marginal effects were used to identify characteristics of facilities that offer LGBT‐specific programs. Linear regression models were used to estimate the association between the state‐level proportion of LGBT people and the proportion of facilities that offer LGBT‐specific programs. Data Collection/Extraction Methods: Secondary data analysis. Cases with missing values for any predictor were excluded. Principle Findings: 12.6 percent of mental health and 17.6 percent of substance abuse facilities reported LGBT‐specific programs. Several facility characteristics were statistically associated with the likelihood of mental health and substance abuse facilities providing LGBT‐specific programs, including offering outpatient or residential treatment, private ownership, religious affiliation, and payment type. The proportion of LGBT adults living within each state was statistically associated with state‐level density of LGBT‐specific mental health programs, but not substance abuse programs. Conclusions: Findings suggest limited availability of culturally competent mental health and substance abuse treatment, despite well‐documented need. [ABSTRACT FROM AUTHOR]

Objectives: The opioid crisis has risen dramatically in North America in the new millennium, due to both illegal and prescription opioid use. While emergency departments (EDs) represent a potentially strategic setting for interventions to reduce harm from opioid use disorder (OUD), the absence of a recent synthesis of literature limits implementation and scalability. To fill this gap, we conducted a systematic review of the literature on interventions targeting OUDs initiated in EDs. Methods: Using an explicit search strategy (PROSPERO), the MEDLINE, CINAHL Complete, EMBASE, and EBM reviews databases were searched from 1980 to October 4, 2019. The gray literature was explored using Google Scholar. Study characteristics were abstracted independently. The methodologic quality and risk of bias were assessed. Results: Twelve of 2,270 studies met the inclusion criteria (two of high quality). In addition to the heterogeneity of the outcome measures used (retention in treatment, opioid consumption, and overdose), brief intervention and buprenorphine initiation (six of 12 studies) were the most documented with mixed effects for the former and positive short‐term and confined to single ED sites effects for the latter. Conclusion: Emergency departments can be an appropriate setting for initiating opioid agonist treatment, but to be sustained, it likely needs to be coupled with community‐based follow‐up and support to ensure longer‐term retention. The scarcity of high‐quality evidence on OUD interventions initiated in emergency settings highlights the need for future research. [ABSTRACT FROM AUTHOR]

Drug addiction as a biological, psychological, and social issue affects all dimensions of one's life. The purpose of this study was to determine the role of attachment styles, dysfunctional attitudes, and spirituality in predicting membership in addicted and non‐addicted groups. This was a cross‐sectional study conducted on 60 addicted people and 60 non‐addicted people. The Adult Attachment Scale of Hazan and Shaver, Allport Religious Orientation Scale, and the 26‐item Dysfunctional Attitude Scale (DAS‐26) were used to measure the variables. Based on the results, which were analyzed by logistic regression analysis, the variables of attachment style and dysfunctional attitude can significantly predict drug addiction (p < .001). However, avoidant attachment style and spirituality cannot predict readiness for addiction. The results of this study indicate the importance of safe and ambivalent attachment styles and dysfunctional attitudes. Thus, attending to these factors in studies and interventions related to the treatment of substance abuse disorders is essential. [ABSTRACT FROM AUTHOR]

The α1 -adrenergic antagonist, doxazosin, has improved cocaine use disorder (CUD) presumably by blocking norepinephrine (NE) stimulation and reward from cocaine-induced NE increases. If the NE levels for release were lower, then doxazosin might more readily block this NE stimulation and be more effective. The NE available for release can be lower through a genetic polymorphism in dopamine β-hydroxylase (DBH) (C-1021T, rs1611115), which reduces DβH's conversion of dopamine to NE. We hypothesize that doxazosin would be more effective in CUD patients who have these genetically lower DβH levels. This 12-week, double-blind, randomized, placebo-controlled trial included 76 CUD patients: 49 with higher DβH levels from the DBH CC genotype and 27 with lower DβH levels from T-allele carriers (CT or TT). Patients were randomized to doxazosin (8 mg/day, N = 47) or placebo (N = 29) and followed with thrice weekly urine toxicology and once weekly cognitive behavioral psychotherapy. Cocaine use was reduced at a higher rate among patients in the doxazosin than in the placebo arm. We found significantly lower cocaine use rates among patients carrying the T-allele (CT/TT) than the CC genotype. The percentage of cocaine positive urines was reduced by 41 percent from baseline in the CT/TT group with low DβH and NE levels, as compared with no net reduction in the CC genotype group with normal DβH and NE levels. The DBH polymorphism appears play an important role in CUD patients' response to doxazosin treatment, supporting a pharmacogenetic association and potential application for personalized medicine. [ABSTRACT FROM AUTHOR]

High impulsivity and poor executive function are characteristic of methamphetamine use disorder. High arousal in the impulsive system has been proposed to compromise the executive system's regulating ability (i.e. the dual-systems model). While interaction between these variables may partly explain poor treatment outcomes associated with methamphetamine use disorder, previous research has tended to examine each factor separately. We investigated whether high impulsivity (measured with an impulsive choice task) and poor executive function (measured with a working memory task) predict methamphetamine use (determined by hair sample) in the 6 weeks following treatment commencement. We also investigated whether impulsive choice moderates the relationship between working memory and methamphetamine use. One hundred and eight individuals with methamphetamine use disorder (75 percent male) were tested within 3 weeks of commencing treatment; 80 (74 percent) were followed up 6 weeks following baseline testing. Cognitive measures significantly predicted drug use after controlling for nuisance variables. Working memory was a significant predictor, while impulsive choice was not. The interaction model included working memory as a predictor and impulsive choice as a moderator. This model was significant, as was the interaction term. Working memory significantly predicted levels of methamphetamine use in early treatment, and impulsive choice moderated this relationship. Those with working memory deficits are particularly vulnerable to using greater amounts of methamphetamine. As working memory increased methamphetamine use decreased among individuals with low/medium delay discounting. Pre-treatment cognitive testing may identify patients at high risk, while remediation of working memory function may be a treatment target for reducing methamphetamine use. [ABSTRACT FROM AUTHOR]

Objective: To assess frequency, type, and extent of behavioral health (BH) nonquantitative treatment limits (NQTLs) before and after implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).Data Sources: Secondary administrative data for Optum carve-out and carve-in plans.Study Design: Cross-tabulations and "two-part" regression models were estimated to assess associations of parity period with NQTLs.Data Collection/extraction Methods: Optum provided four proprietary BH databases, including 2008-2013 data for 40 carve-out and 385 carve-in employers from Optum's claims processing databases and 2010 data from interviews conducted by Optum's parity compliance team with 49 carve-out employers.Principal Findings: Preparity, carve-out plans required preauthorization for in-network inpatient/intermediate care; otherwise coverage was denied. Postparity, 73 percent would review later by request and half charged no penalty for late authorization. Outpatient visit authorization requirements virtually disappeared. For carve-out out-of-network inpatient/intermediate care, and for carve-ins, plans changed penalties to match medical service policies, but this did not necessarily lead to fewer requirements or lower penalties.Conclusion: After 2011, MHPAEA was associated with the transformation of BH care management, including much less restrictive preauthorization requirements, especially for in-network care provided by carve-out plans. [ABSTRACT FROM AUTHOR]

Objective: To examine the influence of Oregon's coordinated care organizations (CCOs) and pay-for-performance incentive model on completion of screening and brief intervention (SBI) and utilization of substance use disorder (SUD) treatment services.Data Sources/study Setting: Secondary analysis of Medicaid encounter data from 2012 to 2015 and semiannual qualitative interviews with stakeholders in CCOs.Study Design: Longitudinal mixed-methods design with simultaneous data collection with equal importance.Data Collection/extraction Methods: Qualitative interviews were recorded, transcribed, and coded in ATLAS.ti. Quantitative data included Medicaid encounters 30 months prior to CCO implementation, a 6-month transition period, and 30 months following CCO implementation. Data were aggregated by half-year with analyses restricted to Medicaid recipients 18-64 years of age enrolled in a CCO, not eligible for Medicare coverage or Medicaid expansion.Principal Findings: Quantitative analysis documented a significant increase in SBI rates coinciding with CCO implementation (0.1 to 4.6 percent). Completed SBI was not associated with increased initiation in treatment for SUD diagnoses. Qualitative analysis highlighted importance of aligning incentives, workflow redesign, and leadership to facilitate statewide SBI.Conclusions: Results provide modest support for use of a performance metric to expand SBI in primary care. Future research should examine health reform efforts that increase initiation and engagement in SUD treatment. [ABSTRACT FROM AUTHOR]

The aim of the current study was to determine genotype effects of four single nucleotide polymorphisms (SNPs) in the genes of the N-Methyl-d-aspartate receptor (GRIN1, GRIN2A, GRIN2C) and kainate receptor (GRIK1), which have been previously associated with alcoholism, on behavior, neural cue-reactivity and drinking outcome. Eighty-six abstinent alcohol dependent patients were recruited from an in-patient setting. Neuropsychological tests, genotyping and functional magnetic resonance imaging (fMRI) were used to study genotype effects. GRIN2C risk allele carriers displayed increased alcohol cue-induced activation in the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (dlPFC). Neural activation in the ACC positively correlated with craving for alcohol (r = 0.201, P = 0.032), whereas activation in the dlPFC showed a negative association (r = -0.215, P = 0.023). In addition, dlPFC activation predicted time to first relapse (HR = 2.701, 95%CI 1.244-5.864, P = 0.012). GRIK1 risk allele carriers showed increased cue-induced activation in the medial prefrontal (PFC) and orbitofrontal cortex (OFC) and in the lateral PFC and OFC. Activation in both clusters positively correlated with alcohol craving (rmedOFC, medPFC  = 0.403, P = 0.001, rlatOFC, latPFC  = 0.282, P = 0.008), and activation in the cluster that encompassed the medial OFC predicted time to first relapse (HR = 1.911, 95%CI 1.030-3.545, P = 0.040). Findings indicate that SNPs in the GRIN2C and GRIK1 genes are associated with altered cue-induced brain activation that is related to craving for alcohol and relapse risk. [ABSTRACT FROM AUTHOR]

Objective To examine the roles of facility- and state-level factors in treatment facilities' adoption and diffusion of pharmaceutical agents used in addiction treatment. Data Sources Secondary data from the National Survey of Substance Abuse Treatment Services (N- SSATS), Substance Abuse and Mental Health Services Administration ( SAMHSA), Centers for Medicare and Medicaid Services, Alcohol Policy Information System, and Kaiser Family Foundation. Study Design We estimate ordered logit and multinomial logit models to examine the relationship of state and treatment facility characteristics to the adoption and diffusion of three pharmaceutical agents over 4 years when each was at a different stage of adoption or diffusion. Data Collection N- SSATS data with facility codes, obtained directly from SAMHSA, were linked by state identifiers to the other publicly available, secondary data. Principal Findings The analysis confirms the importance of awareness and exposure to the adoption behavior of others, dissemination of information about the feasibility and effectiveness of innovations, geographical clustering, and licensing and accreditation in legitimizing facilities' adoption and continued use of pharmacotherapies in addiction treatment. Conclusions Policy and administrative levers exist to increase the availability of pharmaceutical technologies and their continued use by substance abuse treatment facilities. [ABSTRACT FROM AUTHOR]

Background Empirical research suggests that involving carers brings benefits to families and services. Consequently, drug-related policy and guidance has increasingly encouraged drug services to involve carers at all levels of service provision. Objective To explore the purpose and scope of carer involvement with adult drug services in North-east Scotland. Design, Setting and Participants A total of 82 participants (20 informal carers, 43 service providers and 19 policy makers) were purposively selected to take part in a qualitative study. Eight focus groups and 32 interviews were conducted between 2007 and 2008. Findings Three themes were identified through thematic coding: 'Current levels of involvement', 'Use of the term carer' and 'Opportunities for change?' Carer involvement was described as limited, unplanned and unstructured, and consisted largely of information and advice, practical and emotional support, and signposting of services. Although use of the term 'carer' was contested within and across the groups, caring in a drug context was considered the 'same but different' from caring in other contexts. Carers remained sceptical that services actually wanted to involve them in supporting their relative or to offer carers support in their own right. Many service providers and policy makers regarded carer involvement as an aspiration. Conclusion Encouraging carers, service providers and policy makers to reach a shared understanding of caring in a drug context may help translation of policy into practice. However, there is also a fundamental need for drug services to widen the level and type of involvement activities on offer to carers. [ABSTRACT FROM AUTHOR]

Objective To assess the costs of a housing and case management program in a novel sample-homeless adults with chronic medical illnesses. Data Source The study used data from multiple sources: (1) electronic medical records for hospital, emergency room, and ambulatory medical and mental health visits; (2) institutional and regional databases for days in respite centers, jails, or prisons; and (3) interviews for days in nursing homes, shelters, substance abuse treatment centers, and case manager visits. Total costs were estimated using unit costs for each service. Study Design Randomized controlled trial of 407 homeless adults with chronic medical illnesses enrolled at two hospitals in Chicago, Illinois, and followed for 18 months. Principal Findings Compared to usual care, the intervention group generated an average annual cost savings of (−)$6,307 per person (95 percent CI: −16,616, 4,002; p = .23). Subgroup analyses of chronically homeless and those with HIV showed higher per person, annual cost savings of (−)$9,809 and (−)$6,622, respectively. Results were robust to sensitivity analysis using unit costs. Conclusion The findings of this comprehensive, comparative cost analyses demonstrated an important average annual savings, though in this underpowered study these savings did not achieve statistical significance. [ABSTRACT FROM AUTHOR]

To examine the relationship of organizational characteristics of substance abuse treatment centers with their use of quality management practices (total quality management [TQM]) and the contribution of TQM use to a center's provision of comprehensive care and to use of evidence-based treatment practices. Data were collected from a national sample of over 700 private and public substance abuse treatment centers in the National Treatment Center Study. The design was a cross-sectional field study. The key variables were three TQM practices, the provision of comprehensive treatment services, and the implementation of evidence-based treatment practices. Numerous organizational characteristics were controlled. The data were obtained through interviews with administrative directors and clinical directors of the treatment centers in 2002-2004. In multivariate models, TQM practices were positively related to provision of comprehensive care and use of evidence-based practices. A limited set of organizational characteristics predicted the use of TQM practices. Substance abuse treatment centers' implementation of TQM processes may be positively related to the quality and cost-effectiveness of care provided. [ABSTRACT FROM AUTHOR]

Objective. To examine the extent to which U.S. methadone maintenance facilities meet established standards for minimum dosages, 1988–2005. Data Source. Data were collected from a nationally representative sample of outpatient treatment facilities in 1988 ( n=172), 1990 ( n=140), 1995 ( n=116), 2000 ( n=150), and 2005 ( n=146). Study Design. Random-effects multiple regression analysis was used to examine unit characteristics associated with below recommended doses. Data Collection. Data regarding the proportion of patients who received maintenance dosages of <40, 60, and 80 mg/day were collected from unit directors and clinical supervisors. Principal Findings. Forty-four percent of patients receive doses of at least 80 mg/day—the threshold identified as recommended practice in recent work. Thirty-four percent of patients receive doses below 60 mg/day, while 17 percent receive doses below 40 mg/day. Units that serve a high proportion of African American or Latino clients were more likely to report low-dose care. Units managed by individuals who strongly favor abstinence models (e.g., Narcotics Anonymous) were more likely to provide low-dose care. Conclusions. One-third of methadone facilities provide doses below recommended levels. Managerial attitudes about abstinence and their relationship to low doses underscore the contested role of methadone in treatment of opiate disorders. [ABSTRACT FROM AUTHOR]

Objective. To determine the extent to which the elimination of behavioral health benefits for selected beneficiaries of Oregon's Medicaid program affected general medical expenditures among enrollees using outpatient mental health and substance abuse treatment services. Data Source/Study Setting. Twelve months of claims before and 12 months following a 2003 policy change, which included the elimination of the behavioral health benefit for selected Oregon Medicaid enrollees. Study Design. We use a difference-in-differences approach to estimate the change in general medical expenditures following the 2003 policy change. We compare two methodological approaches: regression with propensity score weighting; and one-to-one covariate matching. Principal Findings. Enrollees who had accessed the substance abuse treatment benefit demonstrated substantial and statistically significant increases in expenditures. Individuals who accessed the outpatient mental health benefit demonstrated a decrease or no change in expenditures, depending on model specification. Conclusions. Elimination of the substance abuse benefit led to increased medical expenditures, although this offset was still smaller than the total cost of the benefit. In contrast, individuals who accessed the outpatient mental health benefit did not exhibit a similar increase, although these individuals did not include a portion of the Medicaid population with severe mental illnesses. [ABSTRACT FROM AUTHOR]

Objectives. To estimate a hybrid cost function of the relationship between total annual cost for outpatient methadone treatment and output (annual patient days and selected services), input prices (wages and building space costs), and selected program and patient case-mix characteristics. Data Sources. Data are from a multistate study of 159 methadone treatment programs that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project between 1998 and 2000. Study Design. Using least squares regression for weighted data, we estimate the relationship between total annual costs and selected output measures, wages, building space costs, and selected program and patient case-mix characteristics. Principal Findings. Findings indicate that total annual cost is positively associated with program's annual patient days, with a 10 percent increase in patient days associated with an 8.2 percent increase in total cost. Total annual cost also increases with counselor wages ( p<.01), but no significant association is found for nurse wages or monthly building costs. Surprisingly, program characteristics and patient case mix variables do not appear to explain variations in methadone treatment costs. Similar results are found for a model with services as outputs. Conclusions. This study provides important new insights into the determinants of methadone treatment costs. Our findings concur with economic theory in that total annual cost is positively related to counselor wages. However, among our factor inputs, counselor wages are the only significant driver of these costs. Furthermore, our findings suggest that methadone programs may realize economies of scale; however, other important factors, such as patient access, should be considered. [ABSTRACT FROM AUTHOR]

Objective. To examine state policies associated with adoption of a pharmaceutical agent—naltrexone—by substance abuse treatment facilities to treat alcohol-dependent clients. Data Sources. Facility-level data from the 2003 National Survey of Substance Abuse Treatment Services, and state-level data on policy and environmental factors from publicly available sources. Study Design. We use facility- and state-level data in a cross-sectional, multilevel model to analyze state-level policies that are associated with treatment facilities' naltrexone adoption. Data Collection/Extraction Methods. The analysis uses survey data. Principal Findings. State Medicaid policies supporting the use of generic drugs, reducing drug costs, and permitting managed care organizations to establish policies encouraging use of generics were associated with higher odds of naltrexone adoption (by up to 96 percent). State policies limiting access to pharmaceutical technologies through Medicaid preferred drug lists, restricting access to pharmacy networks, and imposing general limitations on use of Medicaid benefits for rehabilitation for substance abuse treatment were associated with reduced odds of naltrexone adoption. Conclusions. Policy levers that are available to state governments are associated with the adoption of pharmaceutical technologies such as naltrexone that could help meet widespread need for access to clinically proven and cost-effective treatments for substance abuse. [ABSTRACT FROM AUTHOR]

Objective. To extend our previous research by determining whether, and how, the impact of managed care (MC) on substance abuse treatment (SAT) services differs by facility ownership. Data Sources. The 2000 National Survey of Substance Abuse Treatment Services, which is designed to collect data on service offerings and other characteristics of SAT facilities in the U.S. These data are merged with data from the 2002 Area Resource File, a county-specific database containing information on population and MC activity. We use data on 10,513 facilities, virtually a census of all SAT facilities. Study Design. For each facility ownership type (for-profit [FP], not-for-profit [NFP], public), we estimate the impact of MC on the number and types of SAT services offered. We use instrumental variables techniques that account for possible endogeneity between facilities' involvement in MC and service offerings. Principal Findings. We find that the impact of MC on SAT service offerings differs in magnitude and direction by facility ownership. On average, MC causes FPs to offer approximately four additional services, causes publics to offer approximately four fewer services, and has no impact on the number of services offered by NFPs. The differential impact of MC on FPs and publics appears to be concentrated in therapy/counseling, medical testing, and transitional services. Conclusion. Our findings raise policy concerns that MC may reduce the quality of care provided by public SAT facilities by limiting the range of services offered. On the other hand, we find that FP clinics increase their range of services. One explanation is that MC results in standardization of service offerings across facilities of different ownership type. Further research is needed to better understand both the specific mechanisms of MC on SAT and the net impact on society. [ABSTRACT FROM AUTHOR]

This study focuses on (a) American 8th-, 10th-, and 12th-grade students' access to, and use of, substance abuse counseling services via schools and (b) associations between such access and student substance use prevalence. From 1999 through 2003, student data were obtained from the Monitoring the Future study; and school data were obtained through the Youth, Education, and Society study, resulting in nationally representative data from 113,008 students in 855 public and private schools. Results indicate that in contrast to relatively stable student heavy-drug use prevalence rates, internal counseling availability and participation decreased significantly over time, as did reported student referral to external counseling. Availability of internal counseling, as well as student participation in both internal and external referrals, differed significantly by school characteristics-school level, grade size, sector, population density, school socioeconomic status, majority student body race/ethnicity, and geographical region. Student use of counseling services did not show any relationships with school-level heavy drinking rates; however, student participation in external counseling referrals was positively associated with school-level prevalence rates for the use of illicit drugs other than marijuana and showed indications of a similar relationship with marijuana prevalence rates. The decreasing access to, and use of, counseling, the lower probability of counseling availability in middle schools, and the lack of association between heavy-alcohol use rates and counseling services, all suggest missed opportunities and a greater need for counseling services to reduce high-risk drug use. [ABSTRACT FROM AUTHOR]

To evaluate how a sample of outpatient substance abuse treatment units respond to organizational and environmental influences by adopting and implementing treatment services for women.The National Drug Abuse Treatment System Survey from 1995 and 2000, a national survey of outpatient substance abuse treatment units.Health services for women are the dependent variables. The predictors include organizational and environmental factors that represent resource dependence and institutional pressures for the treatment unit. Logistic regression and Heckman selection models were used to test hypotheses.Program directors and clinical supervisors at each treatment unit were interviewed by telephone in 1995 and 2000.Units that depended on specific funding for women's programs and that depended on government funds were more likely to adopt, but not necessarily implement, women's services. Methadone units and units that train more staff to work with women were more likely to adopt as well as implement women's services. Private not-for-profit units were more likely to adopt some services, while for-profit units were less so. However, in general, neither for-profit nor not-for-profit units significantly implemented services. There was evidence that the odds of adopting services were greater in 2000 than 1995 for two services, but were otherwise stable.There is considerable variation in the adoption and implementation of women's services. In addition, not all adopted services were significantly implemented, which could reflect limited organizational resources and/or conflicting expectations. This also suggests that referral mechanisms to these services, and therefore access, may not be adequate. Government funds and specific funds for women's programs are important resources for the provision of these services. Women's services appear more available in methadone units, suggesting that regulation has been influential and that the recent methadone accreditation system should be evaluated. Staff training may be one strategy to encourage implementation of these services. For the most part, the adoption of services for women did not change between 1995 and 2000. [ABSTRACT FROM AUTHOR]

Current clinical practice allows patients with low levels of physiological dependence on opioids (equivalent to methadone doses of 30 &ThickSpace; mg/d or less) to be transferred to buprenorphine. This study investigated the response of opioid – dependent patients receiving doses of methadone between 30 – 70 &ThickSpace; mg/d when transferred to buprenorphine at doses between 12 – 16 &ThickSpace; mg/d. Twenty-three patients receiving inpatient opioid detoxification agreed to take part in a trial of facilitated transfer to buprenorphine. Following the last morning dose of methadone, buprenorphine was substituted in doses increasing from 4 &ThickSpace; mg to a maximum of 16 &ThickSpace; mg, with adjunctive lofexidine (maximum of 2.4 &ThickSpace; mg/d). All except two patients successfully completed transfer to buprenorphine. To investigate the effect of initial methadone dose, the group was split into intermediate dose (ID; 30 – 49 &ThickSpace; mg/d; n = 10) and high dose (HD; 50 – 70 &ThickSpace; mg/d; n = 11) groups. Average stabilisation dose of buprenorphine for the sample who completed transfer was 14.0 &ThickSpace; mg/d (SD 2.3) and average daily lofexidine dose during transfer was 0.57 &ThickSpace; mg (SD 0.39). The HD group used significantly more lofexidine to complete transfer compared to the ID group. Increased opioid withdrawal symptoms, of mild severity as measured by the Short Opiate Withdrawal Scale (SOWS), were found in the HD group compared with the ID group during the first and last day of buprenorphine stabilisation. However, average SOWS scores for the whole of the period of transfer were not significantly different from those during the period of stabilisation on buprenorphine in either the ID or HD groups. This study suggests that transfer to buprenorphine is relatively uncomplicated from daily methadone doses of 30 – 70mg in an inpatient setting and may be facilitated by use of lofexidine. This procedure may allow a larger proportion of opioid-dependent patients access to buprenorphine treatment. [ABSTRACT FROM AUTHOR]

Objective. To investigate whether a performance-based contracting (PBC) system provides incentives for nonprofit providers of substance abuse treatment to select less severe clients into treatment. Data Sources. The Maine Addiction Treatment System (MATS) standardized admission and discharge data provided by the Maine Office of Substance Abuse (OSA) for fiscal years 1991–1995, provides demographic, substance abuse, and social functional information on clients of programs receiving public funding. Study Design. We focused on OSA clients (i.e., those patients whose treatment cost was covered by the funding from OSA) and Medicaid clients in outpatient programs. Clients were identified as being “most severe” or not. We compared the likelihood for OSA clients to be “most severe” before PBC and after PBC using Medicaid clients as the control. Multivariate regression analysis was employed to predict the marginal effect of PBC on the probability of OSA clients' being most severe after controlling for other factors. Principal Findings. The percentage of OSA outpatient clients classified as most severe users dropped by 7 percent (p<=0.001) after the innovation of performance-based contracting, compared to the increase of 2 percent for Medicaid clients. The regression results also showed that PBC had a significantly negative marginal effect on the probability of OSA clients being most severe. Conclusions. Performance-based contracting gave providers of substance abuse treatment financial incentives to treat less severe OSA clients in order to improve their performance outcomes. Fewer OSA clients with the greatest severity were treated in outpatient programs with the implementation of PBC. These results suggest that regulators, or payers, should evaluate programs comprehensively taking this type of selection behavior into consideration. [ABSTRACT FROM AUTHOR]

Objective. To assess the effectiveness and cost–effectiveness of four treatment modalities for substance abuse. Data Sources. The study used data from the Services Research Outcomes Study (SROS), a survey of 3,047 clients in a random sample of 99 drug treatment facilities across the United States. Detailed sociodemographic, substance use, and clinical data were abstracted from treatment records. Substance abuse outcome and treatment history following discharge from index facilities were assessed using a comprehensive interview with 1,799 of these individuals five years after discharge. Treatment success was defined in two ways: as abstinence and as any reduction in substance use. Study Design. Effectiveness and cost–effectiveness of four modalities were compared: inpatient, residential, outpatient detox/methadone, and outpatient drug–free. Clients were stratified based on propensity scores and analyses were conducted within these strata. Sensitivity analyses examined the impact of future substance abuse treatment on effectiveness and cost–effectiveness estimates. Principal Findings. Treatment of substance disorders appears to be cost–effective compared to other health interventions. The cost per successfully treated abstinent case in the least costly modality, the outpatient drug–free programs, was $6,300 (95 percent confidence intervals: $5,200–$7,900) in 1990 dollars. There were only minor differences between various modalities of treatment with regard to effectiveness. However, modalities varied considerably with regard to cost–effectiveness. Outpatient drug–free programs were the most cost–effective. There was little evidence that relative effectiveness or cost–effectiveness of programs varied according to factors that were associated with selection into different programs. Conclusions. Substance disorders can be treated most cost–effectively in outpatient drug–free settings. Savings from transitioning to the most cost–effective treatment modality may free resources that could be reinvested to improve access to substance abuse treatment for a larger number of individuals in need of such treatment. [ABSTRACT FROM AUTHOR]

Objective: To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems.Data Sources/study Setting: From a national telephone survey of 9,585 respondents.Design: Follow-up of adult participants in the Community Tracking Study.Data Collection: Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially managed private, or uninsured), ADM need, use of ADM services and treatments, and satisfaction with care in the last 12 months. PRINCIPAL METHODS: Logistic and linear regressions were used to compare persons by insurance type in ADM use.Principal Findings: The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured.Conclusions: The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM use, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice. [ABSTRACT FROM AUTHOR]

Objective. Local government officials closed the Central Methadone Clinic (CMT) in Miami, Florida on May 31, 1997. This study examined the economic consequences and related costs of closing this long-established substance abuse treatment program. Methods. Economic consequences were determined through a comparative analysis of patient status at baseline and one year following treatment cessation for Miami clients, relative to a comparison group in Jacksonville, Florida that had continued access to a publicly funded methadone treatment clinic. Outcome measures included health-care utilization, addiction treatment, employment income, and crime. Bivariate and multivariate analyses were conducted to estimate differences in consequences and related costs. Results. Total cost as well as the cost for each category (except for addiction treatment) were statistically similar for both groups. Conclusions. Clients at the CMT did not generate significant economic consequences/costs for taxpayers or society in general during the year following closure relative to clients at a comparison clinic. [ABSTRACT FROM AUTHOR]

Examines the effects of substance abuse treatment on employment outcomes among Aid to Families with Dependent Children recipients in Washington State. Patterns of earnings and welfare payments before and after treatment; Association of treatment exposure and employment outcomes; Effect of time on welfare prior to treatment on employment outcomes.

Research on adult substance abusers has revealed a number of social and psychological differences between males and females that have important implications for treatment. Thus far, little attention has been paid to such gender differences in etiology, referral, and treatment among adolescent substance abusers. Data from 930 adolescents in treatment for substance abuse were analyzed to help clarify differences between male and female adolescent substance abusers. Several implications for understanding adolescent substance abuse and treatment are advanced. [ABSTRACT FROM AUTHOR]