Deni Carise

The Addiction Severity Index at 25: Origins, Contributions and Transitions

The Addiction Severity Index (ASI) is a multi-dimensional interview used to measure the substance use, health, and social problems of those with alcohol and other drug problems, both at admission to treatment and subsequently at follow-up contacts. This article first discusses the conceptual and practical importance of the ASIs multi-dimensional approach to measuring addiction severity, as illustrated by two case presentations. The second section of the paper reviews how this measurement approach has led to some important findings regarding the prediction and measurement of addiction treatment effectiveness. The third section describes the historical and practical considerations that have changed the instrument over time, details the problems with the instrument, and describes our efforts to correct those problems with the ASI-6. Finally, some recent ASI data collected from over 8,400 patients admitted to a nationally representative sample of U.S. addiction treatment programs are presented.

Developing a National Addiction Treatment Information System An Introduction to the Drug Evaluation Network System

The purpose of this article is to test the applicability and utility of the Drug Evaluation Network Study (DENS), a timely electronic information system that tracks trends in substance abuse treatment. This article examines existing large-scale data collection efforts, discusses the rationale and design of the DENS system, and presents results of the DENS pilot phase. Clinical staff from more than 40 service delivery units in five cities were trained to conduct intake assessments on laptop computers with the computerized Addiction Severity Index (ASI). The DENS computer system also included an automatic data transfer protocol to allow regular transmission of ASIs and other data to a central server at Treatment Research Institute. Descriptive information and discharge status were also collected. Several problems were encountered during the early stages of the pilot phase, including obtaining consecutive cases from treatment programs, computerization and software application, treatment staff turnover, and assuring quality of data. Data is presented on 4,300 adults entering drug and/or alcohol treatment at the nonrandomly selected DENS pilot programs between June 1996, and April 6, 1998. Various examples of how DENS data can be used are presented.

Telescoping of Drinking-Related Behaviors: Gender, Racial/Ethnic, and Age Comparisons

Objective. To examine demographic differences in alcohol telescoping—the rate of self-reported movement from regular alcohol consumption to the onset of regular heavy drinking—as well as differences in ages of initiation of regular alcohol use and alcohol use to intoxication. Method. The present study compared the retrospective reports of 2037 clients (1252 males, 785 females) enrolled in substance user treatment facilities around the country in 1998 and 1999. Results. Overall, the findings support previous research, indicating that women generally move more rapidly than men from initiation of regular alcohol use to problem use (telescoping). The findings also indicate that African-Americans generally begin regular alcohol use later than their Anglo counterparts and move more rapidly from initiation of regular alcohol use to problem use (telescoping). Examining the sample by older vs. younger age groups demonstrates that gender and racial/ethnic differences in the age of initiation of regular alcohol use and in telescoping may be limited by age group, as these patterns appear in the older but not the younger cohort. Conclusions. These findings suggest that self-reported regular alcohol use, alcohol abuse, and telescoping differences vary dramatically by gender, race/ethnicity, and age cohort. Furthermore, the pattern of findings suggests that these differences are more likely the result of sociocultural than biological differences between the groups under study.

Enhanced midbrain response at 6-month follow-up in cocaine addiction, association with reduced drug-related choice.

Drug addiction is characterized by dysregulated dopamine neurotransmission. Although dopamine functioning appears to partially recover with abstinence, the specific regions that recover and potential impact on drug seeking remain to be determined. Here we used functional magnetic resonance imaging (fMRI) to study an ecologically valid sample of 15 treatment‐seeking cocaine addicted individuals at baseline and 6‐month follow‐up. At both study sessions, we collected fMRI scans during performance of a drug Stroop task, clinical self‐report measures of addiction severity and behavioral measures of cocaine seeking (simulated cocaine choice); actual drug use in between the two study sessions was also monitored. At 6‐month follow‐up (compared with baseline), we predicted functional enhancement of dopaminergically innervated brain regions, relevant to the behavioral responsiveness toward salient stimuli. Consistent with predictions, whole‐brain analyses revealed responses in the midbrain (encompassing the ventral tegmental area/substantia nigra complex) and thalamus (encompassing the mediodorsal nucleus) that were higher (and more positively correlated) at follow‐up than baseline. Increased midbrain activity from baseline to follow‐up correlated with reduced simulated cocaine choice, indicating that heightened midbrain activations in this context may be marking lower approach motivation for cocaine. Normalization of midbrain function at follow‐up was also suggested by exploratory comparisons with active cocaine users and healthy controls (who were assessed only at baseline). Enhanced self‐control at follow‐up was suggested by a trend for the commonly hypoactive dorsal anterior cingulate cortex to increase response during a drug‐related context. Together, these results suggest that fMRI could be useful in sensitively tracking follow‐up outcomes in drug addiction.

Implementing Evidence-Based Practices in Community Treatment Programs: Initial Feasibility of a Counselor “Toolkit”

ABSTRACT Community substance abuse treatment programs face many barriers to adopting “evidence-based” therapies. Training budgets are inadequate to permit acquisition of complex skills, there is little clinical supervision available, and almost all counseling is done in group sessions. The authors adopted an approach widely used in the teaching field—developing a resource “toolkit” for a specific topic, in this case, a Decisional Balance exercise often used in the evidence-based treatment approach of Motivational Interviewing. This trial toolkit was comprised of a DVD (televised during group to illustrate the clinical concept), a laminated counselor guide (to provide guidance and talking points for the counselor during group), and some worksheets and wallet cards for patients to retain key points (see Table 1). A feasibility trial assessed the acceptability, and sustainability of the “Decisional Balance” concept toolkit among 26 counselors and 210 of their patients, from 6 community-based substance abuse treatment programs. The great majority of patients (97%) and all counselors (100%) reported they were satisfied with the toolkit session; 84% of patients said they would like more groups like the toolkit session. Almost all counselors (96%) were still using at least one component of the toolkit 3 months after their initial exposure with no prompting. The toolkit curriculum–based approach may be a viable and attractive way of translating core concepts from sophisticated evidence-based therapies into use by counselors within contemporary, community-based treatment programs with minimal training.

United Nations Office on Drugs and Crime International Network of Drug Dependence Treatment and Rehabilitation Resource Centres: Treatnet

Key to the dissemination of evidence-based addiction treatments is the exchange of experiences and mutual support among treatment practitioners, as well as the availability of accurate addiction training materials and effective trainers. To address the shortage of such resources, the United Nations Office on Drugs and Crime (UNODC) created Treatnet, a network of 20 drug dependence treatment resource centers around the world. Treatnets primary goal is to promote the use of effective addiction treatment practices. Phase I of this project included (1) selecting and establishing a network of geographically distributed centers; (2) conducting a capacity-building program consisting of a training needs assessment, development of training packages, and the training of 2 trainers per center in 1 content area each; and (3) creating good-practice documents. Data on the training activities conducted by the trainers during their first 6 months in the field are presented. Plans for Phase II of the Treatnet project are also discussed.

Results of a statewide evaluation of “paperwork burden” in addiction treatment

This article chronicles three steps taken by research, clinical, and state staff toward assessing, evaluating, and streamlining clinical and administrative paperwork at all public outpatient addiction treatment programs in one state. The first step was an accounting of all paperwork requirements at each program. The second step included the development of time estimates for the paperwork requirements; synthesis of information across sites; providing written evaluation of the need, utility, and redundancy of all forms (paperwork) collected; and suggestions for eliminating unused or unnecessary data collection and streamlining the remaining data collection. Thirdly, the state agency hosted a meeting with the state staff, researchers, and staff from all programs and agencies with state-funded contracts and took action. Paperwork reductions over the course of a 6-month outpatient treatment episode were estimated at 4 to 6 hours, with most of the time burden being eliminated from the intake process.

Identifying Need for Mental Health Services in Substance Abuse Clients

Objective: Counselor detection of co-occurring disorders is critical to ensuring that clients with mental disorders entering substance abuse treatment receive appropriate care. This study sought to (a) examine correspondence between client-reported psychiatric symptoms and client and counselor ratings of need for mental health treatment and (b) explore client- and program-level characteristics associated with client and counselor underrating. Methods: Psychiatric symptoms and client and counselor ratings of need for mental health services were collected using the Addiction Severity Index (ASI) among 3,972 clients entering outpatient substance abuse treatment at 30 treatment programs across the U.S. Kappa statistics were used to determine level of agreement between client-reported symptoms and client and counselor ratings of need for mental health treatment. Multilevel modeling was used to examine characteristics associated with underrating. Results: While agreement between symptoms and ratings of need for mental health treatment was fairly high (kappas = .62–.73), there was a substantial amount of underrating. Approximately 54% (n = 2,128) of clients had at least some psychiatric problems based on symptoms reported in the ASI, and 30% (n = 630) of these clients underrated their need for mental health services. Counselors also underrated need for mental health services in 32% (n = 691) of clients who reported psychiatric problems, even though 36% of them (250 of 691) indicated that obtaining treatment for mental health problems was important to them. Two factors emerged from the multivariate model for both client and counselor underrating of need for mental health services. Clients with psychiatric problems and a drug disorder were more likely than clients without a drug disorder (OR = 1.30, p < .05) to underrate their need for mental health services (as were counselors), and clients with psychiatric problems who were assessed at programs that were licensed by an outside agency were less likely (OR = 0.59, p < .01) to underrate their need for mental health services (as were counselors). Conclusions: Many clients entering substance abuse treatment also need mental health services, but this need may go unrecognized. It is imperative that counselors receive the training, supervision, and support necessary to appropriately identify mental disorders and help their clients access needed care.

Effects of Family Involvement on Length of Stay and Treatment Completion Rates with Cocaine and Alcohol Abusers

SUMMARY Substance abuse is a problem of national concern. This study sought to replicate and further develop findings from a previous study that found cocaine abusers continued in and completed treatment less frequently than alcohol abusers, and that family involvement may influence continuation in and completion of treatment for both cocaine and alcohol abusers. A sample of 99 primary cocaine abusers and 105 primary alcohol abusers in outpatient treatment were followed during the course of their treatment. Results indicated primary alcohol abusers were significantly more successful in completing treatment than primary cocaine abusers. Family involvement in treatment significantly increased the likelihood that cocaine and alcohol abusers would complete the full course of treatment. It is possible that treatment could be improved and completion rates increased by coordinating the involvement of the family.