James R. McKay

Evaluating the Effectiveness of Addiction Treatments: Reasonable Expectations, Appropriate Comparisons

Problems of alcohol and drug dependence are costly to society in terms of lost productivity, social disorder, and avoidable health care utilization. The dollar costs of alcohol and drug use run into billions of dollars, and from one-eighth to one-sixth of all deaths can be traced to this source. However, the efficacy of treatment for addiction is often questioned. A rationale for reasonable expectations of addiction treatments is offered, from which are derived three outcome criteria for judging the effectiveness of treatments: reduction in substance use; improvement in personal health and social function; and reduction in public health and safety risks. Based on these criteria, treatment was shown to be effective, especially when compared with alternatives like no treatment or incarceration. These evaluations, which were conducted in a scientific manner, support the continued value of public spending for carefully monitored treatment of addiction.

A Review of Temporal Effects and Outcome Predictors in Substance Abuse Treatment Studies With Long-Term Follow-Ups Preliminary Results and Methodological Issues

This article is an initial report from a review of alcohol and drug treatment studies with follow-ups of 2 years or more. The goals of the review are to examine the stability of substance use outcomes and the factors that moderate or mediate these outcomes. Results from 12 studies that generated multiple research reports are presented, and methodological problems encountered in the review are discussed. Substance use outcomes at the group level were generally stable, although moderate within-subject variation in substance use status over time was observed. Of factors assessed at baseline, psychiatric severity was a significant predictor of outcome in the highest percentage of reports, although the nature of the relationship varied. Stronger motivation and coping at baseline also consistently predicted better drinking outcomes. Better progress while in treatment, and the performance of pro-recovery behaviors and low problem severity in associated areas following treatment, consistently predicted better substance use outcomes.

Interviewer severity ratings and composite scores of the ASI: a further look

The psychometric characteristics of the Addiction Severity Index (ASI) interviewer severity ratings (ISRs) and composite scores (CSs) were examined for a newly trained group of interviewers. The interrater reliabilities of seven raters for 9 methadone maintenance (MM) pilot subjects were determined. These were found to be excellent for the CSs, but only moderate for the ISRs. Regression analyses were performed on the data of 407 methadone maintenance patients entering all of the variables in each area as the independent variables and the ISR as the dependent variable. These analyses indicated that, on average, 55-60% of the variance in ISRs was explained. However, while 63% of the variance was explained for the legal scale only 38% of the variance of the drug scale was explained. The subjects rating of either the need for treatment or the seriousness of the problem accounted for the most variance, with the exception of the drug and alcohol areas. The internal consistency of the composite scores was then examined for this sample using Cronbachs standardized alpha statistic. These were found to be generally satisfactory ranging from 0.62 for the drug scale to 0.87 for the alcohol and psychiatric scales. A mean interitem correlation of 0.11 for the drug scale was obtained suggesting relatively low item homogeneity. Finally, correlations between the CSs and ISRs were calculated for each scale. Moderate to high relationships were found (0.53-0.78) with the exception of the correlation for the employment area which was only 0.08. The findings are discussed in terms of the nature of and limitations of the ISRs and CSs.

Gender differences in the relapse experiences of cocaine patients

This study investigated potential gender differences in the onset, course, and termination of cocaine relapse episodes. The subjects were 98 cocaine dependent men and women who were participating in several treatment outcome studies. The Cocaine Relapse Interview was used to obtain data on specific relapse episodes that had occurred in a 6-month period before the interview. The analyses indicted that women reported more unpleasant affect and interpersonal problems and fewer positive experiences before relapse than men, and their relapses were more likely to have an impulsive quality. Women reported more help-seeking after initial use, whereas men reported stronger appetitive reactions and more self-justification. There were no gender differences in factors associated with terminating the relapse episodes. Clinical implications and limitations of the research are discussed.

Relationship of Perceived Competencies, Perceived Social Support, and Gender to Substance Use in Young Adolescents

OBJECTIVE This survey study explores the relationship between area-specific perceived self-competence, perceived social support, gender, and substance use in young adolescents. METHOD Questionnaires were administered to 140 male and 131 female adolescents attending middle school to assess self-perception of competencies, social support, and substance use. Correlations were performed between the predictor variables and the substance use measures. Hierarchical multiple regressions were also used to identify potential interactions between gender, perceived competencies, and perceived social support in the prediction of specific substances. RESULTS Higher perceived scholastic competence was associated with less substance use in both genders. In boys, more perceived support from teachers, and to a lesser degree parents, was associated with less substance use, particularly in those with low scholastic competence. In girls, social support was unrelated to substance use except for support from classmates, which was associated with more cigarette and marijuana use. However, in girls with low scholastic competence, more support from peers was consistently associated with more substance use. CONCLUSIONS The gender differences in risk factors for early substance use identified in this study deserve further investigation, in view of their potential relevance for adolescent substance abuse prevention and early intervention.

The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12-month outcomes.

This study of continuing care for substance dependent patients compared a telephone-based monitoring and brief counseling intervention (TEL) with 2 face-to-face interventions, relapse prevention (RP) and standard 12-step group counseling (STND). The participants were graduates of intensive outpatient programs who had current dependence on alcohol and/or cocaine. Self-report, collateral, and biological measures of alcohol and cocaine use were obtained over a 12-month follow-up. The treatment groups did not differ on abstinence-related outcomes in the complete sample (N = 359) or on cocaine use outcomes in participants with cocaine dependence (n = 268). However, in participants with alcohol dependence only (n = 91), TEL produced better alcohol use outcomes than STND on all measures examined and better outcomes than RP on some of the measures.

Effectiveness of Continuing Care Interventions for Substance Abusers: Implications for the Study of Long-Term Treatment Effects

Substance-abusing patients are frequently urged to participate in lower intensity continuing care interventions, also known as “stepdown care” or “aftercare,” following an initial phase of treatment. Since 1988, 15 controlled studies of continuing care for alcohol or drug abuse have been published, with follow-up data on substance use presented in 14 of these studies. In the studies that featured an active control condition, only 1 of 7 yielded positive findings. In the studies that featured a minimal- or no-treatment control, 3 of 7 studies yielded positive findings. The relative paucity of continuing care studies, coupled with the lack of stronger evidence of clinical effectiveness, provides a convincing rationale for conducting evaluations of continuing interventions, as well as evaluations of combinations of various primary and continuing interventions. Methodological issues in the evaluation of continuing care and potential research questions that could be addressed in long-term follow-up studies are outlined and discussed.

Personality disorders and treatment outcome in methadone maintenance patients.

This study examined the relationship between personality disorders (PDs) and 7− month treatment outcome in 197 men admitted to methadone maintenance. Subjects reported pervasive improvement, and the amount of improvement did not significantly differ for those subjects with and without PDs. PD subjects entered treatment with more severe self-reported drug, alcohol, psychiatric, and legal problems, and despite progress, remained ntore problematic in those areas relative to subjects without PDs. Subjects with antisocial PD had admission and 7-month problem status similar to subjects with other PDs. The 7-month urinalysis results for opiates and cocaine showed no significant differences between subjects with and without PDs. Fewer PD subjects stayed in treatment continuously for the 7-month period. Several cluster B PDs—borderline, antisocial, and histrionic—predicted poorest overall outcomes. Methadone-maintained patients with PDs may warrant additional treatment services if they are to approach the functional level of patients without PDs.

Prediction of attrition from day hospital treatment in lower socioeconomic cocaine-dependent men

This study attempted to identify predictors of completion of a 27 h/week 4-week day hospital program for cocaine dependence. The research subjects were 95 lower socioeconomic, primarily African American male veterans. Of a wide range of predictor variables available at baseline, including sociodemographic and historical information, Addiction Severity Index data, psychiatric diagnoses, SCL-90 measures, and measures of craving and familial alcoholism, only the cocaine urine toxicology result and self report of days of cocaine use in the past 30 days (log transformed) were significant predictors. The urine toxicology result was the more powerful predictor with 73 percent with a negative urine completing treatment, as contrasted with 36 percent with a positive urine. Three additional measures obtained at the end of treatment week 1 further increased ability to predict treatment completion/attrition. Two of these measures were based on counsellor ratings and one was based on the patients report of psychiatric treatment services received during the first treatment week. Thus, patients at high risk for dropout can be identified fairly early. Whether treatments can be adapted to retain such patients is an important question for the field.

An examination of the cocaine relapse process

Although empirical studies of the relapse process have been done with alcoholics, smokers, and opiate addicts, comparatively little information is available on the relapse process in cocaine abusers. This paper presents data from the Cocaine Relapse Interview (CRI), a structured interview that assesses factors associated with the onset, course, and termination of cocaine relapse episodes. In a sample of 95 cocaine dependent patients, the experiences that occurred with the greatest frequency immediately prior to relapse were wanting drugs, being alone, having money, and feeling extremely bored and lonely. Following the onset of the relapse, the most frequent experience was unpleasant affect, although positive reactions were also relatively common. The factors perceived as most important in terminating relapse were painful internal states, help-seeking behaviors, and other coping responses. Three types of relapse experiences, or pathways, were identified: (a) unpleasant affect--painful internal states prior to and throughout the relapse; (b) positive affect--positive affect and pleasant social experiences prior to relapse coupled with a relatively unproblematic course; and (c) sensation seeking--sensation seeking and interpersonal problems prior to relapse coupled with mixed emotional reactions and antisocial behavior during the relapse, and interpersonal problems at relapse termination.