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APPENDIX B
Pages 271-311

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From page 271...
... 1. Many of the traditional forms of substance abuse treatment (e.g., methadone maintenance, therapeutic communities, outpatient drug-free treatment)
From page 272...
... and that have been associated with favorable outcomes following treatment. These early indicators of subsequent favorable outcomes have been called "quality indicators." Until now, these indicators have typically been developed by groups of clinicians and administrators who have simply selected indicators that have a clear, "face-valid" or intuitive link with longer-term outcomes.
From page 273...
... First, the definition in' eludes both treatment process factors and patient changes during treatment. Al' though the majority of current quality indicators focus on treatment practices, policies, and processes, it is potentially more practical and more informative to focus upon interim patient changes brought about during the course of treatment.
From page 274...
... Each section will include a description of processes and therapeutic goals for the treatment stage, define outcomes on the basis of these therapeutic goals, discuss a strategy for reviewing the literature based on the outcomes definitions, and finally, present research findings pertinent to the identification of quality indicators within that stage of treatment. The review includes only data from clinical trials, treatment matching program studies, or health services studies where the patients were adults who were clearly alcohol or drug (excluding tobacco)
From page 275...
... In cases of severe withdrawal potential or extreme physiological or emotional instability, detoxification-stabilization helps to prevent serious medical consequences of abrupt withdrawal, to reduce the physiological and emotional signs of instability, and to motivate necessary behavioral change strategies that will be the focus of rehabilitation. This stage of treatment may take place in inpatient settings, either a hospital or a nonhospital, residential setting, or in outpatient settings, such as in a hospital-based clinic or a residential or social setting.
From page 276...
... Setting of Care: Medical or Nonmedical and Inpatient or Outpatient Debate regarding the appropriate setting of care in which to detoxify alcohol' dependent patients has been substantial. Since the mid'1970s, medical settings such as residential treatment facilities or even outpatient treatment centers have conducted detoxification or stabilization treatments for alcohol, opiates, and more recently, cocaine.
From page 277...
... Despite this statistically significant advantage for the inpatient setting, it was 10 times more costly than outpatient detoxification in an .
From page 278...
... Potential Quality Indicators for Detoxification and Sta6iiization The therapeutic goals of detoxification and stabilization are focused primarily on the amelioration and stabilization of the acute medical, psychiatric, or substance use symptoms that were out of control and thus responsible for preventing the patient from entering directly into rehabilitation. Thus, the goal of detoxificationstabilization is removal of the physiological and emotional instability that has impeded direct entry to rehabilitative treatment.
From page 279...
... This might be measured by standard inventories of symptoms and signs or at least by breathalyzer and urinary' sits measures. REHABILITATION Goals of Rehabilitation Patients and Treatment Settings Rehabilitation is appropriate for patients who are no longer suffering from the acute physiological or emotional eEects of recent substance use and who need behavioral change strategies to regain control of their urges to use substances.
From page 280...
... ~ setting. Treatment Elements and Methods The purposes of this stage of treatment are to prevent a return to active substance use that would require detoxification-stabilization; to assist the patient in developing control over urges to use alcohol or drugs, or both, usually through sustaining total abstinence from all drugs and alcohol; and to assist the patient in regaining or attaining improved personal health and social function, both as a secondary part of the rehabilitation function and because these improvements in lifestyle are important for maintaining sustained control over substance use.
From page 281...
... This review, however, includes methadone maintenance, as well as maintenance with its long-acting form, LAAM, as part of the general category of rehabilitation treatments, because the psychosocial elements of methadone treatment and the overall rehabilitative goals of methadone treatment are quite similar to those for other forms of rehabilitation. Many of the same patient and treatment
From page 282...
... Defining Outcomes For substance abuse treatment, particularly rehabilitative forms of treatment, to be worthwhile to society, outcomes must be lasting improvements in those problems that led to the treatment admission and that are important to the patient and to society. Each component of the definition will be explained below.
From page 283...
... In this review, operational evidence for improvement in this domain includes both objective data from urinalysis and breathalyzer readings as well as patients' self reports of alcohol and drug use, when those reports were recorded by independent interviewers under conditions of privacy and impartiality. Sustained Improvements in Personal Health and Social Function.
From page 284...
... Although a number of patient factors have been reliably related to posttreatment outcomes, very few of these, by themselves, are directly translatable into potential quality or performance indicators. However, any review of potential quality indicators should in' clude variables that might be important as case mix adjusters, or factors that could be used to adjust two or more groups of patients in a comparative evaluation of factors that would likely affect outcome, independent of the treatment process.
From page 285...
... Pregnant and parenting women are an important subgroup of the larger patient population. For these individuals different features of treatment programs are required to allow them to gain access to treatment, as are different constellations of treatment services needed to address their often significant treatment problems (Gomberg and Nirenberg, 1993; Wilsnack and Wilsnack, 1993~.
From page 286...
... For opiate-dependent patients on methadone maintenance, the psychiatric severity scale from the Addiction Severity Index (ASI) , a general measure of the number and severity of psychiatric symptoms, has been found to be among the best predictors of 6-month substance use, personal health, and social adjustment in studies by McLellan and colleagues (1983a, b)
From page 287...
... There is evidence for this position among opiate-dependent patients and for patients following abstinence from cocaine. Potential Quality Indicators In summary, almost any general measure of severity of psychiatric symptomatology (i.e., the psychiatric severity scale from the ASI, total score on the Symptom Checklist 90, general pathology scale on the Minnesota Multiphasic Personality Inventory, number of diagnostic symptoms, etc.)
From page 288...
... Patient Motivation or Stage of Change Motivation for treatment has traditionally been conceptualized and measured as the extent to which patients had entered treatment under their own free will, without external pressure from legal, family, or employment sources. Many studies have measured motivation in this way, with results that are generally quite consistent: performance during treatment and posttreatment outcomes are comparable for patients who are seemingly forced to enter a substance abuse treatment against their will, based on legal or work-related pressure (Anglin and Hser, 1990; Inciardi, 1988; Lawental et al., 1996; Roman, 1988)
From page 289...
... Potential Quality Indicators A potential quality indicator could be the proportion of recently admitted patients shown to be precontemplators who have received a form of treatment (such as MET or at least a motivational interview) designed to change their motivational readiness.
From page 290...
... The level of social pathology in the family of origin is associated with the use of heroin during methadone treatment (Stanton, 1979; Stanton and Todd, 1982~. The family relationship scale on the ASI predicts posttreatment drug use and general personal and social function among opiate-dependent patients in either inpatient therapeutic communities or outpatient methadone maintenance treatment programs (McLellan et al., 1983a, b)
From page 291...
... Similar findings have been reported in field studies of private substance abuse treatment programs treating primarily cocaine~dependent and cocaine~plus alco' hol~dependent patients (McLellan et al., 1993; Pettinati et al., in press)
From page 292...
... has been found to be the single best predictor of continued favorable posttreatment function for substance abuse treatments as well as for other forms of chronic medical conditions, such as diabetes, hypertension, and asthma (McLellan and Durell, 1995; O'Brien and McLellan, 1996~. These relationships suggest that length of stay and patient adherence would appear to be exactly the type of measure that would be well suited to use as a quality indicator (e.g., the percentage of patients who have completed treatment or the percentage of patients who have attended 90 AA meetings in 90 days)
From page 293...
... The distinc' tion between adherence and length of treatment needs further exploration. Potential Quality Indicators Length of stay and adherence with treatment recommendations are perhaps the two most easily measured aspects of treatment and are both suitable for inclu' sion in contemporary clinical management information systems.
From page 294...
... Thus, quality indicators for rehabilitation treatment (at least for alcohol-dependent patients) could be the proportion of patients who have acquired an AA sponsor and the proportion of patients in aftercare who have attended more than three AA meetings in the first month of treatment.
From page 295...
... Medications NIAAA and the National Institute on Drug Abuse have sponsored a great deal of research aimed at developing useful medications for the treatment of sub' stance~dependent persons. Great progress has been made over the past 10 years in the development of new medications and in the application of existing medical tions for the treatment of particular conditions associated with substance depen' dence and for particular types of substance~dependent patients.
From page 296...
... and the craving for opiates. Thus, a potential quality indicator would be the proportion of patients on methadone maintenance who have continued regular opiate use (as evidenced by past two or three opiatepositive urine specimens)
From page 297...
... Specialized Services The majority of patients admitted to substance abuse treatment have significant addiction-related problems in one or more areas such as medical status, employment and self support, family relations, and psychiatric function (McLellan and Weisner, 1996~. As indicated above, the severity of these problems is generally predictive of the response during treatment as well as posttreatment outcome.
From page 298...
... . Although many substance abuse treatment programs do not have the re' sources to provide specialized treatment services, it is at least possible for these programs to perform an active referral to an appropriate agency or practitioner to attempt to access these services.
From page 299...
... If the outcomes research field is really to inform the search for quality or performance indicators in substance abuse treatment, then it will be necessary to move beyond the question of whether treatment works to the question of how treatment works. To accomplish this, researchers will need to make a methodology shift from the simple evaluation or comparison of treatment outcomes to the parametric study of the various types of treatment services and therapeutic processes delivered within those treatments and their relationship to the target outcomes.
From page 300...
... 2. Significant confusion and disagreement exist within the field on im, portent and basic concepts that are essential for the identification of potential quality indicators.
From page 301...
... Quality indicators can be used in two ways: ( 1 ) at the individual patient level to provide clinicians with early warning signs for poor outcome and thus allow for modification of the treatment plan, and (2)
From page 302...
... The second of these are interim changes in patient status: aspects of the patient's affect, knowledge, motivation, and behavior that are presumed to be problematic in the patient at the start of treatment and are thus the direct focus of the treatment elements within rehabilitation. The great majority of the quality indicators used thus far in the evaluation of substance abuse and mental health treatments have been treatment process indi' cators (counseling provided to urge smokers to quit, referral to outpatient care following inpatient discharge, etch.
From page 303...
... For example, patients who attend rehabilitation following detoxification have better posttreatment outcomes than those who stop treat' ment following detoxification. Thus, it can be said that the treatment process or the treatment practice of referring a patient to outpatient treatment is associated with a better posttreat' ment outcome.
From page 304...
... 1. What types of interim changes in patients should be effected during treatment to provide the highest probability of lasting gains following treat meet, Not all of the changes in patients' attitudes, affects, motivation, knowledge, and behavior that are the interim goals of substance abuse treatments are impor' tent for attaining favorable posttreatment outcomes.
From page 305...
... Journal of Substance Abuse 16 123-131. DATOS (Drug Abuse Treatment Outcome Study)
From page 306...
... Journal of Substance Abuse Treatment 9 293-303. Gawin FH, Kleber HD.
From page 307...
... 1989. Drug Abuse Treatment: A National Study of Effectiveness.
From page 308...
... 1983a. Predicting response to alcohol and drug abuse treatments Role of psychiatric severity.
From page 309...
... In press. The natural history of outpatient alcohol and drug abuse treatment in a private health care setting.
From page 310...
... 1980. The case for drug abuse treatment effectiveness, based on the DARP research program.
From page 311...
... Journal of Substance Abuse Treatment 11-443-447.


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