Treatment‐as‐usual in effectiveness studies: What is it and does it matter?

Andrée Löfholm C, Brännström L, Olsson M, Hansson K. Treatment‐as‐usual in effectiveness studies: What is it and does it matter? A hallmark of an evidence‐based practice (EBP) is the systematic appraisal of research related to the effectiveness of interventions. This study addressed the issue of interpreting results from effectiveness studies that use treatment‐as‐usual (TAU) as a comparator. Using randomised controlled studies that evaluate the effectiveness of multisystemic therapy as an illustrative example, we show that TAU includes a wide variety of treatment alternatives. Estimated treatment effects on recidivism suggest that TAU seems to contain a greater variation in underlying risk than experimental conditions, supporting the hypothesis that the content of TAU could affect outcomes. Implications for the realisation of an EBP are discussed.     

Predicting Retention in Three Substance Abuse Treatment Modalities Among Anglo,African American,and Mexican American Juvenile Offenders

Abstract

Many of the same factors that predict delinquent behavior also predict adolescent drug use. This study examined factors that predict, and interventions that maximize, substance abuse treatment retention in three modalities among high-risk Anglo, Mexican American, and African American juvenile offenders. The study sample includes youth (N = 211) who were discharged from probation supervision and who received substance abuse services through a CSAT-funded federal demonstration project. The key predictors examined included the stage-of-change (i.e., precontemplation, contemplation, preparation) in which a juvenile fell, various dimensions captured by the Comprehensive Addiction Severity Index for Adolescents, and other intervention status (probation, case management, and mental health treatment). The research questions were addressed using statistical models known as survival analysis that treated time from entry into substance abuse treatment to exit from substance abuse treatment as the outcomes. Among key findings were that females were 73% more likely to leave day treatment relative to males; for each additional family problem ever experienced, Mexican American adolescents were 15% more likely to leave residential treatment compared with African American adolescents; and African American and Mexican American adolescents in the contemplation stage-of-change were 50% less likely to leave day treatment compared with Anglo adolescents. Applications for practice and research with this population are discussed.     

Substance use and other factors associated with child welfare case duration: Looking beyond out of home care

Little is known about factors associated with child welfare case duration. Understanding factors associated with case duration may help stakeholders make more informed decisions about funding and service allocation and improve compliance with federal law. This study had two research questions: (1) What factors are associated with child welfare case duration? And (2) Do factors differ depending on whether children were placed exclusively with parents or with others (e.g. relatives and foster care) during the case? The study sample consisted of families (N = 874) with co-occurring child maltreatment and substance use in one midwestern state in the United States between 2007 and 2016. Linear regression models were used to identify correlates of case duration while controlling for child placement status. Overall, having a child under 1 year of age, benzodiazepine use, methamphetamine use and injection drug use were all associated with longer case duration, whereas marijuana use with no other substance use was associated with shorter case duration. Additionally, factors associated with case duration differed based on child placement status during the case. These findings suggest important heterogeneity in families involved with child welfare services and may allow for proactive mitigation of cases at greater risk.     

Further Evidence of Racial Disparities in Drug Court Outcomes: Enhancing Service-Delivery to Reduce Criminal Recidivism Rates for Non-White Participants

Abstract

The first drug court began in 1989, and since their inception, they have expanded to over 3,000 in the United States and United States territories. The long-term goal of drug courts is to reduce criminal recidivism rates for nonviolent offenders who have substance use disorders. This study adds to the literature by using secondary data to compare criminal recidivism rates between drug court participants (n?=?163) and probationers who had diagnosed substance use disorders and arrests that were eligible for drug court but they did probation instead (n?=?185). Criminal recidivism was measured up to 36?months post drug court/probation discharge, which provides a more accurate assessment of the long-term effectiveness of drug court. Furthermore, this study identified which drug court participants were most likely to recidivate. Drug court participants were less likely to recidivate than the probation group. However, differences between the two groups may have contributed to the difference in criminal recidivism rates and also suggest that screening criteria may exclude some non-White participants from drug court. Non-white participants were more likely to recidivate than their White counterparts. Implications for future research and drug court practice are discussed, focusing on enhancing the service-delivery of education and employment opportunities to non-White drug court participants.     

吸毒人群社会支持网研究对重庆市南岸区戒毒所的调查

本文通过对重庆市南岸区戒毒所的调查,采用社会支持网分析方法,发现吸毒人员的社会支持网规模很小,吸毒网络具有秘密性和牢固性。其相识关系提供毒品支持,朋友关系和亲戚关系提供情感和经济支持。吸毒人员的吸毒年限、有抢劫和偷盗行为对注射吸毒行为和共用针头注射吸毒行为有明显的影响等一系列特征。     

Intervening in youth problem behavior in Sweden: a pragmatic cost analysis of MST from a randomized trial with conduct disordered youth

Olsson TM. Intervening in youth problem behavior in Sweden: a pragmatic cost analysis of MST from a randomized trial with conduct disordered youth Int J Soc Welfare 2010: 19: 194–205 © 2009 The Author(s), Journal compilation © 2009 Blackwell Publishing Ltd and the International Journal of Social Welfare. Within the context of a randomized trial, this study assessed the costs of treating conduct disorder with multisystemic therapy (MST) or treatment as usual (TAU) for 156 youth in Sweden. From the perspective of the municipal Social Welfare Administration, all intervention costs were collected for the 6‐month period starting at randomization. MST was found to cost, on average, US$8,847 per youth. A course of intervention including MST was found to cost significantly more (US$5,038 per youth) than TAU. Although MST was found to reduce the use of and costs associated with non‐placement interventions, MST was not found to reduce the use of or costs associated with placement interventions. This is contrary to findings reported from studies undertaken in the USA. Intent‐to‐treat (ITT) and treatment‐of‐treated (TOT) analyses are presented.     

Improving Graduation Rates in Drug Court Through Employment and Schooling Opportunities and Medication-Assisted Treatment (MAT)

ABSTRACT

Drug courts have been a key part of the criminal justice system since 1989, and this study contributes to the existing body of research by identifying which participants (n = 248) were most likely to graduate from a drug court in Indiana (United States). Three variables emerged as significant predictors of graduation. First, participants who were employed or were students at the time of admission were nearly 2.5 times more likely to graduate than participants who were not. Second, participants who were using opiates as their primary drug of choice were over 80% less likely to graduate than participants who were using non-opiates as their primary drug of choice. Third, participants who had violations in the first 30 days of the program were nearly 50% less likely to graduate than participants who did not violate in the first 30 days. Offering medication-assisted treatment (MAT), such as methadone, Suboxone, or Vivitrol, to participants who have an opiate use disorder may improve graduation rates for this population. Additionally, graduation rates may also improve by offering more resources to assist participants in gaining and maintaining employment or schooling, and this seems to be especially important within the first month of the program.     

Baby Boomer’s Substance Abuse and Researcher Indifference

The current older adult population is more likely to need and seek treatment for alcohol and drug abuse than previous cohorts of older adults, which necessitates the need for age-appropriate substance use treatment. Building on previous research that examined the lack of attention on substance use among older adults, this study examines articles addressing substance use disorders among older adults in leading gerontological and substance abuse journals and federal funding between 2011 and 2017. Publications were identified from ten leading gerontological and ten leading substance abuse journals using Medical Subject Heading (MeSH) terms. During this time-period, there were 68 and 44 articles published in gerontology and substance abuse journals respectively related to substance use disorders in older adults. Most (59.8%) addressed alcohol abuse and 7% involved intervention studies. In the 7-year period, there were 13 federal grants. A paucity of published or funded work exists in this area despite growing misuse and treatment seeking among older adults with substance use disorders. Effectively addressing substance abuse in older adults will require a coordinated effort between researchers and practitioners to establish and implement best practices for practitioners to rely on when working with substance abusing older adults.     

Can Case Management Contribute to Effective Use of Small Self‐Directed Support Packages for People with Disabilities?

While self‐directed support for people with disabilities and their families represents a welcome shift toward self‐determination and increasing control, the risk of managing with insufficient funds remains. This article examines whether different types of case management can mitigate that risk by providing support when people have only a small direct funding package. It applies the question to an evaluated program of self‐directed support in Queensland, Australia that allocated A$4000 with one of two approaches to case management: program‐focused or organizationally oriented. Case management contributed to the effective use of limited budgets and addressing goals when it promoted choice and control, built relationships, and enabled flexible fund use. Program‐focused case management seemed to be less constrained in enhancing social participation than organizationally oriented case management, which tended to restrict some participatory opportunities. These findings are consistent with earlier research, which indicated that case management can interfere with participation. Even in the context of a small funding allocation, a case management approach that promotes flexibility and person‐centered planning, control over funding, and capacity building can improve the effectiveness of self‐directed support; however it does not overcome the inherent limitations of insufficient funds for adequate support, or the cost of case management itself.     

Risk and resilience factors for substance use among street adolescents: Assessment and development of an integrative model

In this study, risk and protective factors for substance use were explored to develop an intervention program and test its efficacy among male street‐based adolescents. Twenty expert interviews and key informant interviews were conducted. In addition, 30 street adolescents (15 substance‐users and 15 non‐users) participated in four focus group discussions for needs assessment, wherein risk and protective factors were discussed. Based on the identified needs, an intervention package was developed and validated by experts. The package was implemented in a natural environment of 50 street adolescents. After the intervention, about 60% of the respondents quit or cut down on their substance use substantially, and approximately 40% of the respondents agreed to reunite with their respective families, while 20% did not change their substance use habits. The results showed that if several protective factors were present, there was a lower risk of substance use. Many factors contribute to substance use and protective factors need to be strengthened in order to make interventions effective.     

Fostering educational prosperity: A randomized controlled trial of home tutoring in foster care

The educational gap between children in out-of-home care and their non-placed peers is well-documented. However, tutoring stands out as a promising intervention to raise children's educational attainment in out-of-home care. This study randomized 105 children in foster care (62% girls, aged 7–15 years [M = 10.3, SD = 2.0]) to the home tutoring program Foster Caregivers as Tutors (FCT) or regular public school services (treatment as usual [TAU]). In the FCT group, the foster caregivers tutored the children for 2.5 h/week for 40 weeks. The program effect is measured in learning and developmental outcomes, including reading and math ability, learning skills, IQ, executive function, and psychosocial function. Follow-up was 17.5 months after baseline. The results show a significant effect over time in both groups on IQ (effect size [ES] = 0.40, P < 0.001), verbal comprehension (ES = 0.29 P = 0.02) and perceptual reasoning (ES = 0.60, P < 0.001) measured by WISC IV. Neither the FCT nor TAU provided any significant academic recovery in reading and math nor progression in executive function, learning skills or psychosocial function. These findings, implications for practice and future efforts to support the schooling of children in out-of-home care are discussed.     

Parental substance misuse and child care social work: findings from the first stage of a study of 100 families

Parental misuse of drugs or alcohol is known to be a common issue for child care social workers, yet there has been surprisingly little British research on the topic. The study reported here attempts to address this gap. All files going for long‐term allocation in four London boroughs over on average 1 year were examined (290 files). Parental substance misuse (PSM) emerged as a major feature of social work caseloads. Of the 290 cases, 100 (34%) involved concerns about parental substance misuse. The families involving substance misuse were more vulnerable on a variety of measures: the children were younger, the parents had more individual problems and the families lived in more difficult social situations. PSM cases tended to be ‘heavy end’ at the point of allocation: they accounted for 62% of all children subject to care proceedings and 40% of those placed on the child protection register. There was a fairly even spread between alcohol and drug misuse, and a number of cases involved both. Substance misuse specialists were rarely involved in working with families, primarily because parents said that they did not think that they had a problem. Suggestions for ways in which policy and practice with PSM might be improved are made in light of these findings.     

Treatment Utilization Among Metropolitan and Nonmetropolitan Participants of Corrections-Based Substance Abuse Programs Reentering the Community

ABSTRACT

This study examines differences in drug use and recidivism outcomes at 12 months postrelease from jail or prison as a function of geographic location and treatment utilization. Participants (N= 700) were previously enrolled in drug treatment during the last 6 to 9 months of their incarceration and were released to the community on either parole or serve-out. Findings from this study indicated that offenders returning to metropolitan areas reported more use of community treatment services following release than offenders in nonmetropolitan areas. Although offenders in both metropolitan and nonmetropolitan areas who reported community treatment following release were less likely to be reincarcerated, community treatment utilization was not a significant correlate of relapse. Findings are discussed, and future directions include favorable outcomes when community treatment is utilized.     

Effects of a Therapeutic Community on Korean Substance Abusers in Prison

ABSTRACT. This study tested the effectiveness of a therapeutic community (TC) intervention on imprisoned Korean substance abusers. Volunteer participants from 2 Korean prisons were randomly assigned to either the experimental group (n = 24) with the TC intervention or a control group (n = 24) with optional supportive sessions. Pretest and posttest data were collected on measures of abstinence self-efficacy and problem-solving skills. Participants in the TC intervention showed significant increases in abstinence self-efficacy and problem-solving skills, whereas those in the control group did not. The differences in abstinence self-efficacy for the TC were found for 2 of 3 subscales: Problem-Solving Confidence and Approach-Avoidance Style but not Self-Control. Further study is needed to replicate these findings with larger Korean prison populations and to establish the relationship between these skill dimensions and subsequent drug use and criminal recidivism for this population. Nevertheless, the findings suggest potential benefits of using a TC intervention with imprisoned Korean substance abusers.     

Rising to the Challenge of Treating OEF/OIF Veterans with Co‐occurring PTSD and Substance Abuse

This article reviews data on the relatively high incidence of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans reporting mental health and substance abuse problems, and some perceived barriers that may account for low rates of their engaging in treatment. Treatment outcomes for veterans with co‐occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) are generally poorer than for those with PTSD or substance abuse alone. Several evidence‐based individual therapy approaches offered by VA Medical Centers are described along with how they conceptualize the relationship of substance abuse to PTSD. Problems with sequential treatment for persons with PTSD and substance abuse in specialized programs are discussed, including notably the practice of requiring veterans to be completely drug and alcohol free for a month or longer prior to entering PTSD treatment. Several integrated treatment programs are described along with a brief summary of evidence supporting their effectiveness. Some recent policy changes from the Department of Veterans Affairs that bode well for the future of PTSD/SUD treatment are described. Differences between younger and older veterans were cited along with their implications for treatment. Recommendations regarding how to better engage and retain OEF/OIF veterans with PTSD/SUD in treatment are presented together with examples of their implementation. The author concludes that to rise to the challenge of treating this difficult population it is necessary to adapt treatment to meet their needs rather than requiring them to adapt to therapies that may not be a good fit.     

Use of Professional and Informal Support by Black Men with Mental Disorders

This study utilized data from the National Survey of American Life to investigate the use of professional services and informal support among African American and Caribbean black men with a lifetime mood, anxiety, or substance use disorder. Thirty-three percent used both professional services and informal support, 14% relied on professional services only, 24% used informal support only, and 29% did not seek help. African American men were more likely than to rely on informal support alone. Having co-occurring mental and substance disorders, experiencing an episode in the past 12 months, and having more people in the informal network increased the likelihood of using professional services and informal supports. Marital status, age, and socioeconomic status were also significantly related to help-seeking. The results suggests potential unmet need. However, the reliance on informal support also suggests a strong protective role that informal networks play in the lives of black men.     

Service user experience of participation in child welfare case management

Child welfare case management systems were designed, in part, to standardize participatory practices for both young people and their parents. This paper reports the findings of a qualitative study of Australian service users' experiences of participation when using the case management systems, Looking After Children and Supporting Children and Responding to Families. Findings indicate that the majority of service users reported positive experiences of participating in the use of these systems. However, participatory relations were often slow to develop and frequently involved conflict. Some service users used their power to control the flow and accuracy of information, or resisted workers in other ways. Some children and young people were excluded from the opportunity to participate because the systems did not have a ‘text‐based’ format to ‘ensure’ that this process occurred. These findings indicate that case management systems did not result in relationships which consistently informed the intervention in a way that the systems' authors had envisaged. Service users did not necessarily take up the openings offered to them and workers did not necessarily comply with the systems' obligations. The findings cause us to question the assumptions that power can be bestowed or withdrawn, in the way suggested by these case management systems.     

Easy target and moral panic: the Law on Drug Addiction No. 162 of 1990

In industrialized societies the war against drugs tends to develop into a war that concretely strengthens control by the state over potentially dangerous classes. This is also true for Italy. In 1988, Bettino Craxi, now under investigation for a series of serious crimes, but at the time the powerful leader of the Socialist Party, launched a crusade against drugs. After about 18 months of moral panic campaigns, Law No. 162 was passed. Its ideological keystone is the section forbidding the personal use of narcotic or psychotropic drugs. Its officially declared objectives are to reduce the drug trade, to increase access by drug addicts to the services and, of course, to reduce the number of deaths by overdose. The available evidence, however, does not prove that these objectives have been reached. Rather, the true motivations must be sought elsewhere: in the attempt by the political class to regain legitimacy and thus consensus.     

Dilemmas when working with substance abusers with multiple and complex problems: the case manager's perspective

Since the 1990s, case management has been implemented in the USA and Canada – and recently also in various European countries – to support substance abusers with multiple and complex needs. Although this intervention is often presented as a set of standardised functions, its application is often a subjective task involving various dilemmas, which may influence case management outcomes significantly. Based on a comparison of case managers' experiences in Denmark and Belgium, we focus on several core dilemmas in case management for substance abusers with complex problems. Case management practices vary from one project to the next and even within the same project. Such differences are apparently related to the way in which case managers approach dilemmas such as those existing between control versus self-determination, or between systematic versus ad-hoc planning. The conclusion is that it is vital to discuss these dilemmas during training courses and supervision meetings in order to ensure that the intended form of intervention is actually delivered on the ground.     

Childhood maltreatment among Norwegian drug abusers in treatment

This article reports on the investigation of the correlation between the European Addiction Severity Index (EuropASI) and the Childhood Trauma Questionnaire (CTQ) among 102 Norwegian drug abusers admitted to treatment. The aim of the study is to explore how different types and levels of childhood trauma and social and psychiatric factors, medical situation and experienced family history are interrelated. The study addresses three main questions: 1) What is the prevalence of different kinds of childhood trauma among drug abusers in treatment? 2) Does type or level of maltreatment in childhood predict specific substance abuse problems as adults and/or specific social, psychiatric and medical problems as adults? 3) Do substance abuse problems and mental health problems in the primary family predict different types and levels of childhood maltreatment? Twenty‐five per cent of the total sample was included in the high‐level trauma group and 54% in the intermediate‐level group. Females had significantly higher scores than males in all types of childhood trauma. The strongest correlations were found between childhood trauma and lifetime psychiatric problems and psychiatric status during the last 30 days before admission for treatment. More research, and especially prospective studies, is needed to clarify the importance of parents' substance abuse and psychiatric problems in childhood/adolescent compared with trauma in the client's childhood and the client's current psychiatric status.