Stanley Sacks

Mental disorders and drug abuse in persons living with HIV/AIDS

This article reviews the literature on the prevalence of mental and substance use disorders among persons living with HIV/AIDS. Drug use, both injection and non-injection, substantially increases the risk for HIV infection. While injection drug users have the highest prevalence rates for HIV, substantially elevated rates of HIV infection are also present among crack cocaine users and individuals with substance use disorders generally. Persons with HIV/AIDS and a mental and/or substance use disorder have highly variable patterns of accessing services. Persons with HIV/AIDS who have a serious mental illness are more highly involved with services than other groups. Most individuals with co-occurring disorders report some involvement with outpatient primary medical care, although ancillary services such as mental health and substance abuse treatment, transportation assistance, and case management improve involvement in medical care. Women with HIV/AIDS and co-occurring mental and substance use disorders experience unique vulnerabilities, particularly those related to exposure to traumatic events. Given the complexity of needs with which triply or multiply diagnosed individuals present, effective treatment programmes are likely to be those that provide some degree of integrated care.

Modified therapeutic community for homeless mentally ill chemical abusers: treatment outcomes.

This study compared homeless mentally ill chemical abuser (MICA) clients (n = 342), male and female, sequentially assigned to either of two modified therapeutic community programs (TC1 and TC2) and to a treatment-as-usual (TAU) control group. Follow-up interviews were obtained at 12 months postbaseline and at time F (on average more than 2 years postbaseline) on a retrieved sample of 232 (68%) clients and 281 (82%) clients, respectively. Outcome measures assessed five domains: drug use, crime, HIV risk behavior, psychological symptoms, and employment. Individuals in both modified TC groups showed significantly greater behavioral improvement than TAU at 12 months and time F, and the modified TC2, with lower demands and more staff guidance, was superior to modified TC1. Completers of both TC programs showed significantly greater improvement than dropouts and a subgroup of TAU clients with high exposure (i.e., more than 8 months) to other treatment protocols. The present findings support the effectiveness and longer term stability of effects of a modified TC program for treating homeless MICA clients.

Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions.

Medication-assisted treatment (MAT) is underutilized in the treatment of drug-dependent, criminal justice populations. This study surveyed criminal justice agencies affiliated with the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) to assess use of MAT and factors influencing use of MAT. A convenience sample (N = 50) of criminal justice agency respondents (e.g., jails, prisons, parole/probation, and drug courts) completed a survey on MAT practices and attitudes. Pregnant women and individuals experiencing withdrawal were most likely to receive MAT for opiate dependence in jail or prison, whereas those reentering the community from jail or prison were the least likely to receive MAT. Factors influencing use of MAT included criminal justice preferences for drug-free treatment, limited knowledge of the benefits of MAT, security concerns, regulations prohibiting use of MAT for certain agencies, and lack of qualified medical staff. Differences across agency type in the factors influencing use and perceptions of MAT were also examined. MAT use is largely limited to detoxification and maintenance of pregnant women in criminal justice settings. Use of MAT during the community reentry period is minimal. Addressing inadequate knowledge and negative attitudes about MAT may increase its adoption, but better linkages to community pharmacotherapy during the reentry period might overcome other issues, including security, liability, staffing, and regulatory concerns. The CJ-DATS collaborative MAT implementation study to address inadequate knowledge, attitudes, and linkage will be described.

Benefit-cost analysis of a modified therapeutic community for mentally ill chemical abusers

Abstract This paper estimates and compares the economic benefits and costs of modified therapeutic community (modified TC) treatment for homeless mentally ill chemical abusers (MICAs) relative to a ‘treatment-as-usual’ (TAU) comparison group. Data from the period 12 months pre-admission to the modified TC were compared to data from 12 months post-admission across three outcome categories: employment, criminal activity, and utilization of health care services. The economic cost of the average modified TC treatment episode was

Modified therapeutic community for mentally ill chemical abusers: outcomes and costs.

20,361. The economic benefit generated by the average modified TC client was

Modified Therapeutic Community Treatment for Offenders with MICA Disorders: Substance Use Outcomes

305,273. The incremental economic benefit per modified TC client (relative to TAU) was

Prison Therapeutic Community Treatment for Female Offenders: Profiles and Preliminary Findings for Mental Health and Other Variables (Crime, Substance Use and HIV Risk)

273,698, resulting in a net benefit per modified TC client of

Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: Crime outcomes

253,337 and a benefit–cost ratio of 13:1. Adjusting for extreme outlier observations, the incremental economic benefit estimate was

SEQUENTIAL ASSIGNMENT AND TREATMENT-AS-USUAL Alternatives to Standard Experimental Designs in Field Studies of Treatment Efficacy

105,618, net benefit was

Modified Therapeutic Community for Homeless Mentally Ill Chemical Abusers: Emerging Subtypes*

85,257, and the benefit–cost ratio was 5.2. These results quantify the potential economic and social advantages of the modified TC approach and highlight the policy implications of modified TC programs for homeless MICAs. This study is the first comprehensive economic evaluation of TC treatment for homeless MICAs; future research can draw from the economic analysis methods outlined here to apply to larger samples, longer follow-up periods, and other treatment settings.