Wouter Vanderplasschen

Impulsivity as a vulnerability factor for poor addiction treatment outcomes : a review of neurocognitive findings among individuals with substance use disorders

With the current review, we explore the hypothesis that individual differences in neurocognitive aspects of impulsivity (i.e., cognitive and motor disinhibition, delay discounting and impulsive decision-making) among individuals with a substance use disorder are linked to unfavorable addiction treatment outcomes, including high drop-out rates and difficulties in achieving and maintaining abstinence. A systematic review of the literature was carried out using PubMed, PsycINFO and Web of Knowledge searches. Twenty-five unique empirical papers were identified and findings were considered in relation to the different impulsivity dimensions. Although conceptual/methodological heterogeneity and lack of replication are key limitations of studies in this area, findings speak for a prominent role of cognitive disinhibition, delay discounting and impulsive decision-making in the ability to successfully achieve and maintain abstinence during and following addiction treatment. In contrast, indices of motor disinhibition appear to be unrelated to abstinence levels. Whereas the relationship between impulsivity and treatment retention needs to be examined more extensively, preliminary evidence suggests that impulsive/risky decision-making is unrelated to premature treatment drop-out among individuals with a substance use disorder. The reviewed findings are discussed in terms of their clinical implications.

Effectiveness of different models of case management for substance-abusing populations

Abstract Case management has been implemented in substance abuse treatment to improve (cost-) effectiveness, but controversy exists about its potential to realize this objective. A systematic and comprehensive review of peer-reviewed articles (n = 48) published between 1993 and 2003 is presented, focusing on the effects of different models of case management among various substance-abusing populations. Results show that several studies have reported positive effects, but only some randomized and controlled trials have demonstrated the effectiveness of case management compared with other interventions. Longitudinal effects of this intervention remain unclear. Although no compelling evidence was found for the effectiveness of case management, some evidence is available about the (differential) effectiveness of intensive case management and assertive community treatment for homeless and dually-diagnosed substance abusers. Strengths-based and generalist case management have proven to be relatively effective for substance abusers in general. Most positive effects concern reduced use of inpatient services and increased utilization of community-based services, prolonged treatment retention, improved quality of life, and high client satisfaction. Outcomes concerning drug use and psychosocial functioning are less consistent, but seem to be mediated by retention in treatment and case management. Further research is required to learn more about the extent of the effects of this intervention, how long these are sustained and what specific elements cause particular outcomes.

Therapeutic communities for addictions: a review of their effectiveness from a recovery-oriented perspective.

Therapeutic communities (TCs) for addictions are drug-free environments in which people with addictive problems live together in an organized and structured way to promote change toward recovery and reinsertion in society. Despite a long research tradition in TCs, the evidence base for the effectiveness of TCs is limited according to available reviews. Since most of these studies applied a selective focus, we made a comprehensive systematic review of all controlled studies that compared the effectiveness of TCs for addictions with that of a control condition. The focus of this paper is on recovery, including attention for various life domains and a longitudinal scope. We searched the following databases: ISI Web of Knowledge (WoS), PubMed, and DrugScope. Our search strategy revealed 997 hits. Eventually, 30 publications were selected for this paper, which were based on 16 original studies. Two out of three studies showed significantly better substance use and legal outcomes among TC participants, and five studies found superior employment and psychological functioning. Length of stay in treatment and participation in subsequent aftercare were consistent predictors of recovery status. We conclude that TCs can promote change regarding various outcome categories. Since recovering addicts often cycle between abstinence and relapse, a continuing care approach is advisable, including assessment of multiple and subjective outcome indicators.

Effectiveness of Case Management for Homeless Persons: A Systematic Review

We reviewed the literature on standard case management (SCM), intensive case management (ICM), assertive community treatment (ACT), and critical time intervention (CTI) for homeless adults. We searched databases for peer-reviewed English articles published from 1985 to 2011 and found 21 randomized controlled trials or quasi-experimental studies comparing case management to other services. We found little evidence for the effectiveness of ICM. SCM improved housing stability, reduced substance use, and removed employment barriers for substance users. ACT improved housing stability and was cost-effective for mentally ill and dually diagnosed persons. CTI showed promise for housing, psychopathology, and substance use and was cost-effective for mentally ill persons. More research is needed on how case management can most effectively support rapid-rehousing approaches to homelessness.

Co-Ordination and Continuity of Care in Substance Abuse Treatment An Evaluation Study in Belgium

Considering the complexity of drug dependence and the multiplicity of services for substance abusers, co-ordination and continuity of care are important prerequisites for the quality of substance abuse treatment. However, several shortcomings concerning co-operation, communication and co-ordination have been reported in most European countries. In this study, different aspects of co-ordination and continuity (e.g. first contact, intake, referral, follow-up) have been studied among all services (n = 27) that are addressed by substance abusers in a clear-cut region in Belgium. Structured interviews with key informants show a lack of systematic communication between services and a lack of follow-up of clients. A study of 57 client records in 12 of these 27 centers illustrates that relatively little information is registered concerning the course of the treatment process and that only 10% of all client files contain a treatment plan. Following the introduction of a formalized plan that was regarded as a precondition for systematizing and optimizing communication between services, key informants considered the implementation of a model of case management as an appropriate way of improving co-ordination and continuity of care in this region.

Substance use and misuse in persons with intellectual disabilities (ID): results of a survey in ID and addiction services in Flanders.

Little is known about the characteristics of substance users with intellectual disabilities (ID). Nevertheless, this group is assumed to be at greater risk of developing substance misuse problems. This study focuses on substance users and misusers with ID, and investigates whether the two groups differ significantly in terms of the nature and consequences of their substance (mis)use. Information regarding the characteristics of the substance (mis)users, the substances used, the negative consequences of substance (mis)use, and the service use was collected through a questionnaire forwarded to ID and addiction services in Flanders. Caregivers identified 104 substance users and misusers with ID. Overall, few differences were observed between users and misusers. This finding underscores that substance use in persons with ID can have important consequences. Substance misusers, however, were found to have more mood changes, more suicidal ideation/thoughts, and more negative long-term consequences on their health, daily activity, and relationships due to substance misuse. Substance use and misuse were associated with mental health problems and were suggested to be a risk factor for offending behavior. To provide appropriate support for this specific population, an individualized approach is suggested that supports better intersectoral collaboration between services.

‘The Human Prerogative’: A Critical Analysis of Evidence-Based and Other Paradigms of Care in Substance Abuse Treatment

Present-day substance abuse treatment is characterized by a compelling demand for applying evidence-based interventions. Vehement discussions between policymakers, practitioners and researchers illustrate this clash of differing paradigms. The aim of this article is to situate evidence-based practice among the leading paradigms of care and to elucidate its implicit assumptions and potential implications. Evidence-based practice is inherent in the empirical-analytical paradigm of care and science, founded upon randomized and controlled studies. This paradigm is compared with the phenomenological-existential and the critical post-structural paradigm, which focus on elaborating the human potential and exploring individuals’ subjective interpretations, and on criticizing social inequalities and striving for compliance with human rights, respectively. Evidence-based practice and the methodological rigidity in each paradigm are analyzed critically. We conclude that through the dialectical integration of these diverse approaches, evidence, existence/humanism and social emancipation can be combined for the benefit of the human prerogative of care.

Impact of addiction severity and psychiatric comorbidity on the quality of life of alcohol-, drug- and dual-dependent persons in residential treatment.

Background: Substance users’ quality of life (QoL) is influenced by several variables, including psychiatric comorbidity and addiction severity. Thus far, the impact of the type of dependence (alcohol, drug or dual dependence) remains unclear. Therefore, the objectives of the study were to evaluate QoL in a clinical sample of alcohol-, drug- and dual-dependent patients and to assess the independent impact of psychiatric comorbidity, addiction severity and type of dependence on QoL. Methods: Face-to-face interviews with 274 patients admitted to residential substance abuse treatment were conducted using the European Addiction Severity Index (EuropASI), the Mini-International Neuropsychiatric Interview and the Assessment of Personality Disorders self-report questionnaire. Results: Multivariate analyses showed that anxiety, mood or personality disorder, employment status and the severity rating on the EuropASI domain alcohol use were associated with overall QoL. Gender, anxiety disorder and the severity ratings on the EuropASI domains alcohol use, drug use, physical health and emotional and psychological health were associated with overall perception of health. Conclusion: Addiction severity and psychiatric comorbidity explained the greatest amount of QoL variance, whereas the type of dependence did not play a central role.

Disadvantageous Decision-Making as a Predictor of Drop-Out among Cocaine-Dependent Individuals in Long-Term Residential Treatment

Background: The treatment of cocaine-dependent individuals (CDI) is substantially challenged by high drop-out rates, raising questions regarding contributing factors. Recently, a number of studies have highlighted the potential of greater focus on the clinical significance of neurocognitive impairments in treatment-seeking cocaine users. In the present study, we hypothesized that disadvantageous decision-making would be one such factor placing CDI at greater risk for treatment drop-out. Methods: In order to explore this hypothesis, the present study contrasted baseline performance (at treatment onset) on two validated tasks of decision-making, the Iowa Gambling Task (IGT) and the Cambridge Gamble Task (CGT) in CDI who completed treatment in a residential Therapeutic Community (TC) (N = 66) and those who dropped out of TC prematurely (N = 84). Results: Compared to treatment completers, CDI who dropped out of TC prematurely did not establish a consistent and advantageous response pattern as the IGT progressed and exhibited a poorer ability to choose the most likely outcome on the CGT. There were no group differences in betting behavior. Conclusion: Our findings suggest that neurocognitive rehabilitation of disadvantageous decision-making may have clinical benefits in CDI admitted to long-term residential treatment programs.

Retrospective study of similarities and relations between American drug-free and European therapeutic communities for children and adults.

Abstract This article focuses on the similarities and relations between the European therapeutic community for children and adults on the one hand and the American drug-free “concept” therapeutic community on the other. Both approaches are reviewed in a historical and comparative perspective with special attention to several critical issues: democracy versus hierarchy, self-help versus professionalism, psychoanalysis versus behaviorism and concept versus social learning. These two different TC-approaches can be considered as subdivisions of one modality, namely an environment for social learning in which living together in a group can be regarded as the primary agent of growth and human development. In recent years there has been a tendency towards further integration of these two approaches.