Sharon Reif

Use of Buprenorphine for Addiction Treatment: Perspectives of Addiction Specialists and General Psychiatrists

OBJECTIVE In 2002 buprenorphine (Suboxone or Subutex) was approved by the U.S. Food and Drug Administration for office-based treatment of opioid addiction. The goal of office-based pharmacotherapy is to bring more opiate-dependent people into treatment and to have more physicians address this problem. This study examined prescribing practices for buprenorphine, including facilitators and barriers, and the organizational settings that facilitate its being incorporated into treatment. METHODS Addiction specialists and other psychiatrists in four market areas were surveyed by mail and Internet in fall 2005 to examine prescribing practices for buprenorphine. Respondents included 271 addiction specialists (72% response rate) and 224 psychiatrists who were not listed as addiction specialists but who had patients with addictions in their practice (57% response rate). RESULTS Three years after approval of buprenorphine for office-based addiction treatment, nearly 90% of addiction specialists had been approved to prescribe it and two-thirds treated patients with buprenorphine. However, fewer than 10% of non-addiction specialist psychiatrists prescribed it. Regression-adjusted factors predicting prescribing of buprenorphine included support of training and use of buprenorphine by the physicians main affiliated organization, less time in general psychiatry compared with addictions treatment, more time in group practice rather than solo, ten or more opiate-dependent patients, belief that drugs play a large role in addiction treatment, and patient demand. CONCLUSIONS Office-based pharmacotherapy offers a promising path to improved access to addictions treatment, but prescribing has expanded little beyond the addiction specialist community.

Feasibility of multidimensional substance abuse treatment matching: automating the ASAM Patient Placement Criteria

UNLABELLED The Patient Placement Criteria published by the American Society of Addiction Medicine (ASAM Criteria) established a non-proprietary standard for matching substance use disorder patients to treatment settings. METHODS Data from 593 substance dependent adults who were assessed using the first computerized implementation of the ASAM Criteria were analyzed to determine whether the level of care assignments showed significant differences on a variety of clinical measures. RESULTS The algorithm showed acceptable discrimination between each of three ASAM Levels of Care across numerous clinical subscales. CONCLUSIONS It is feasible to implement complex, multidimensional criteria for substance abuse treatment that may improve reliability and facilitate validity studies.

The impact of employment counseling on substance user treatment participation and outcomes.

The nationally representative Alcohol and Drug Services Study (ADSS, 1996–1999) is used to examine employment counselings impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N = 988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.

The Value of Vocational Rehabilitation in Substance User Treatment: A Cost-Effectiveness Framework

Vocational rehabilitation (VR) programs within addiction treatment traditionally consider employment as the desired outcome. This singular focus ignores other benefits, such as reduced substance use. A framework for evaluating the cost-effectiveness of VR within addiction treatment is presented and illustrated with data from the Alcohol and Drug Services Study (ADSS, 1996–1999). VR was associated with a 2.5% increase in probability of abstinence at an

Residential Treatment for Individuals With Substance Use Disorders: Assessing the Evidence

883 increase in cost per admission. Thus, the estimated cost-effectiveness of VR in promoting abstinence is

Peer Recovery Support for Individuals With Substance Use Disorders: Assessing the Evidence

35,000 per additional abstinent client (

Substance Abuse Treatment Organizations as Mediators of Social Policy: Slowing the Adoption of a Congressionally Approved Medication

883/0.025), indicating that VR is a cost-effective contributor to other goals of addiction treatment.

Organizational and Financial Issues in the Delivery of Substance Abuse Treatment Services

OBJECTIVE Residential treatment is a commonly used direct intervention for individuals with substance use or co-occurring mental and substance use disorders who need structured care. Treatment occurs in nonhospital, licensed residential facilities. Models vary, but all provide safe housing and medical care in a 24-hour recovery environment. This article describes residential treatment and assesses the evidence base for this service. METHODS Authors evaluated research reviews and individual studies from 1995 through 2012. They searched major databases: PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, and Social Services Abstracts. They chose from three levels of evidence (high, moderate, and low) and described the evidence of service effectiveness. RESULTS On the basis of eight reviews and 21 individual studies not included in prior reviews, the level of evidence for residential treatment for substance use disorders was rated as moderate. A number of randomized controlled trials were identified, but various methodological weaknesses in study designs-primarily the appropriateness of the samples and equivalence of comparison groups-decreased the level of evidence. Results for the effectiveness of residential treatment compared with other types of treatment for substance use disorders were mixed. Findings suggested either an improvement or no difference in treatment outcomes. CONCLUSIONS Residential treatment for substance use disorders shows value and merits ongoing consideration by policy makers for inclusion as a covered benefit in public and commercially funded plans. However, research with greater specificity and consistency is needed.

No-Show for Treatment in Substance Abuse Patients with Comorbid Symptomatology: Validity Results from a Controlled Trial of the ASAM Patient Placement Criteria.

In recent years, peer recovery support services have become an accepted part of the treatment of substance use disorders, providing a more extensive array of services than typically associated with mutual support groups. Peer providers may help consumers set recovery goals, develop a plan, and work toward and maintain recovery. In this literature review, the last in the Assessing the Evidence Base (AEB) Series, the authors review the evidence supporting peer recovery support services, noting that more research is needed to distinguish the effects of peer recovery support from other recovery support activities.

Recovery Housing: Assessing the Evidence

Most substance abuse treatment occurs in outpatient treatment centers, necessitating an understanding of what motivates organizations to adopt new treatment modalities. Tichy’s framework of organizations as being comprised of three intertwined internal systems (technical, cultural, and political) was used to explain treatment organizations’ slow adoption of buprenorphine, a new medication for opiate dependence. Primary data were collected from substance abuse treatment organizations in four of the ten metropolitan areas with the largest number of heroin users. Only about one fifth offered buprenorphine. All three internal systems were important determinants of buprenorphine adoption in our multivariate model. However, the cultural system, measured by attitude toward medications, was a necessary condition for adoption. Health policies designed to encourage adoption of evidence-based performance measures typically focus on the technical system of organizations. These findings suggest that such policies would be more effective if they incorporate an understanding of all three internal systems.