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1.  Twelve-Step Participation and Outcomes over Seven Years among Adolescent Substance Use Patients with and without Psychiatric Comorbidity 
This study examines the association between twelve-step participation and outcomes over seven years among 419 adolescent substance use patients with and without psychiatric comorbidities. Although level of participation decreased over time for both groups, co-morbid adolescents participated in twelve-step groups at comparable or higher levels across time points. Results from mixed-effects logistic regression models indicated that for both groups, twelve-step participation was associated with both alcohol and drug abstinence at follow-ups, increasing the likelihood of either by at least three times. Findings highlight the potential benefits of twelve-step participation in maintaining long-term recovery for adolescents with and without psychiatric disorders.
PMCID: PMC3558833  PMID: 23327502
long-term outcomes; adolescents; psychiatric comorbidity; twelve-step participation
2.  Twelve-step attendance trajectories over seven years among adolescents entering substance use treatment in an integrated health plan 
Addiction (Abingdon, England)  2012;107(5):933-942.
This study examines twelve-step attendance trajectories over seven years, factors associated with the trajectories, and relationships between the trajectories and long-term substance use outcomes among adolescents entering outpatient substance use treatment in a private, non-profit integrated managed care health plan.
Longitudinal observational study.
Four Kaiser Permanente Northern California substance use treatment programs.
391 adolescents entering treatment between 2000 and 2002 who completed at least one follow-up interview in year one, and at least one during years three to seven, after treatment entry.
Alcohol and drug use, twelve-step meeting attendance and activity involvement, and post-treatment medical service utilization.
Semiparametric group-based modeling identified three distinct twelve-step attendance trajectory groups over seven years: low/no attendance (60%), early but not continued (26%), and continued (14%). There were lower proportions of males and of adolescents with prior substance use treatment experience in the low/no attendance group (p=0.019 and p=0.003, respectively). In addition, those in the low/no attendance group had lower perception on circumstances, motivation and readiness for treatment at baseline (p=0.023). Multivariate logistic generalized estimating equation analyses found that those in the continued group were more likely to be abstinent from both alcohol and drugs during follow-ups than those in the low/no attendance group (OR=2.40, p=0.003 and OR=1.96, p=0.026, respectively). However, no differences in long-term outcomes were found between those in the other two groups.
Robust connection with twelve-step groups appears to be associated with better long-term outcomes among adolescents with substance use disorders.
PMCID: PMC3311783  PMID: 22151625
long-term outcomes; adolescents; twelve-step attendance trajectories; continuing care
3.  Nine-Year Psychiatric Trajectories and Substance Use Outcomes 
Evaluation review  2008;32(1):39-58.
This study identifies longitudinal psychiatric trajectories of 934 adult individuals entering chemical dependency treatment in a private, managed care health plan and examines the relationship of these trajectories with substance use (SU) outcomes. The authors apply a group-based modeling approach to identify trajectory groups based on repeated measures of psychiatric severity for 9 years and identify four distinct groups. Results of multivariate logistic generalized estimating equation models find an association between psychiatric trajectories and long-term SU. Older cohorts and life course measures of marital status and employment status as individuals changed over time are related to drug and some alcohol outcomes.
PMCID: PMC2946827  PMID: 18198170
longitudinal substance use outcomes; psychiatric trajectories; group-based modeling; managed care; adult chemical dependency patients
4.  Twelve-step Affiliation and Three-year Substance Use Outcomes among Adolescents: Social Support and Religious Service Attendance as Potential Mediators 
Addiction (Abingdon, England)  2009;104(6):927-939.
Twelve-step affiliation among adolescents is little understood. We examined twelve-step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed care health plan. We also examined the effects of social support and religious service attendance on the relationship.
We analyzed data for 357 adolescents, aged 13-18, who entered treatment at four Kaiser Permanente Northern California CD Programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews.
Measures at follow-up included alcohol and drug use, twelve-step affiliation, social support and frequency of religious service attendance.
At 3 years, 68 adolescents (19%) reported attending any twelve-step meetings, and 49 (14%) reported involvement in at least one of seven twelve-step activities, in the prior 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, twelve-step attendance at 1 year was marginally significant, while twelve-step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P<0.05 and OR 2.53, P<0.05, respectively]. Similarly, twelve-step activity involvement was significantly associated with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment twelve-step affiliation and 3-year outcomes.
The findings suggest the importance of twelve-step affiliation in maintaining long-term recovery, and help understand the mechanism through which it works among adolescents.
PMCID: PMC2722376  PMID: 19344442
long-term outcomes; adolescents; twelve-step affiliation; social support; religious service attendance
5.  Continuing Care and Long-Term Substance Use Outcomes in Managed Care: Early Evidence for a Primary Care–Based Model 
How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry.
In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or non-problematic use, was the outcome measure.
A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without.
Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.
PMCID: PMC3242696  PMID: 21969646
6.  Addiction treatment ultimatums and U.S. health reform: A case study 
Increased access to health care, including addiction treatment, has long been a goal of health reform in the U.S. An unanswered question is whether reform will change the way people get to addiction treatment; when treatment is easily accessible, do individuals self-refer, or do they still enter treatment via ultimatums, and if so, from which sources? To begin examining this, we used a single case study of a U.S. health plan that provides access similar to that called for in health reform.
Using a case study method of data from studies conducted in a large, private non-profit, integrated managed care health plan which includes addiction services, we examined the prevalence and source of ultimatums to enter treatment, and the characteristics of those receiving them. The plan is highly representative of changes to U.S. health care and other countries due to health reform.
Many individuals entering addiction treatment had received an ultimatum stemming from employment, legal, medical, and family sources. Having more employment problems, an occupation with public safety concerns, being older, male, and ethnicity predicted an employment ultimatum. Higher legal problem severity predicted a legal ultimatum. More men (and younger people) had family ultimatums, and more women (and older people) had medical ultimatums. Being younger, male, married, having higher employment and family problem severity, and being drug or combined drug/alcohol dependent rather than dependent on alcohol-only predicted an ultimatum from one’s family. On the whole, an ultimatum from one source was not related to having one from another source. Those most likely to receive ultimatums from multiple sources were women, those separated/divorced, and those having higher psychiatric and legal problem severity.
Even in an insured population with good access to addiction treatment, individuals often receive ultimatums to enter treatment rather than being self-referred. Understanding the treatment entry process, and how it is affected by health care systems, could benefit from international and other comparative research.
PMCID: PMC3225963  PMID: 22135620
alcohol and drug treatment systems; treatment entry; coercion
7.  The role of continuing care on 9-year cost trajectories of patients with intakes into an outpatient alcohol and drug treatment program 
Medical Care  2012;50(6):540-546.
The importance of a continuing care approach for substance use disorders (SUDs) is increasingly recognized. Our prior research found that a Continuing Care model for SUDs that incorporates three components (regular primary care, and specialty SUD and psychiatric treatment as needed) is beneficial to long-term remission. The study builds on this work to examine the cost implications of this model.
To examine associations between receiving Continuing Care and subsequent healthcare costs over 9 years among adults entering outpatient SUD treatment in a private non-profit, integrated managed care health plan. We also compare the results to a similar analysis of a demographically matched control group without SUD’s.
Study Design
Longitudinal observational study.
Measures collected over 9 years include demographic characteristics, self-reported alcohol and drug use and Addiction Severity Index, and health care utilization and cost data from health plan databases.
Within the treatment sample, SUD patients receiving all components of Continuing Care had lower costs than those receiving fewer components. Compared to the demographically matched non-SUD controls, those not receiving Continuing Care had significantly higher inpatient costs (excess cost=$65.79/member-month; p < .01) over 9 years, while no difference was found between those receiving Continuing Care and controls.
Although a causal link cannot be established between receiving Continuing Care and reduced long-term costs in this observational study, findings reinforce the importance of access to health care and development of interventions that optimize patients receiving those services and that may reduce costs to health systems.
PMCID: PMC3354333  PMID: 22584889
continuing care; cost; primary care; longitudinal study
8.  12-Step Participation Reduces Medical Use Costs among Adolescents with a History of Alcohol and Other Drug Treatment 
Drug and alcohol dependence  2012;126(1-2):124-130.
Adolescents who attend 12-step groups following alcohol and other drug (AOD) treatment are more likely to remain abstinent and to avoid relapse post-treatment. We examined whether 12-step attendance is also associated with a corresponding reduction in health care use and costs.
We used difference-in-difference analysis to compare changes in seven-year follow-up health care use and costs by changes in 12-step participation. Four Kaiser Permanente Northern California AOD treatment programs enrolled 403 adolescents, 13 to 18-years old, into a longitudinal cohort study upon AOD treatment entry. Participants self-reported 12-step meeting attendance at six-month, one-year, three-year, and five-year follow-up. Outcomes included counts of hospital inpatient days, emergency room (ER) visits, primary care visits, psychiatric visits, AOD treatment costs and total medical care costs.
Each additional 12-step meeting attended was associated with an incremental medical cost reduction of 4.7% during seven-year follow-up. The medical cost offset was largely due to reductions in hospital inpatient days, psychiatric visits, and AOD treatment costs. We estimate total medical use cost savings at $145 per year (in 2010 U.S. dollars) per additional 12-step meeting attended.
The findings suggest that 12-step participation conveys medical cost offsets for youth who undergo AOD treatment. Reduced costs may be related to improved AOD outcomes due to 12-step participation, improved general health due to changes in social network following 12-step participation, or better compliance to both AOD treatment and 12-step meetings.
PMCID: PMC3430743  PMID: 22633367
alcohol; substance abuse; adolescent; cost; 12-step; health care utilization
9.  Sub-diagnostic Alcohol Use by Depressed Men and Women Seeking Outpatient Psychiatric Services: Consumption Patterns and Motivation to Reduce Drinking 
This study examined alcohol use patterns among men and women with depression seeking outpatient psychiatric treatment, including factors associated with recent heavy episodic drinking and motivation to reduce alcohol consumption.
The sample consisted of 1183 patients ages 18 and over who completed a self-administered, computerized intake questionnaire and who scored ≥ 10 on the Beck Depression Inventory-II (BDI-II). Additional measures included current and past alcohol questions based on the Addiction Severity Index, heavy episodic drinking (≥ 5 drinks on one or more occasions in the past year), alcohol-related problems on the Short Michigan Alcoholism Screening Test (SMAST), and motivation to reduce drinking using the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES).
Among those who consumed any alcohol in the past year (73.9% of the sample), heavy episodic drinking in the past year was reported by 47.5% of men and 32.5% of women. In logistic regression, prior-year heavy episodic drinking was associated with younger age (p=.011), male gender (p=.001) and cigarette smoking (p=.002). Among patients reporting heavy episodic drinking, motivation to reduce alcohol consumption was associated with older age (p=.008), greater usual quantity of alcohol consumed (p<.001), and higher SMAST score (p<.001).
In contrast to prior clinical studies, we examined sub-diagnostic alcohol use and related problems among psychiatric outpatients with depression. Patients reporting greater drinking quantities and alcohol-related problems also express more motivation to reduce drinking, providing intervention opportunities for mental health providers that should not be overlooked.
PMCID: PMC3066306  PMID: 21223306
depression; alcohol; hazardous drinking; prevalence; motivation
10.  Stopping smoking during first year of substance use treatment predicted 9-year alcohol and drug treatment outcomes 
Drug and alcohol dependence  2010;114(2-3):110-118.
This study examined the association between stopping smoking at 1 year after substance use treatment intake and long-term substance use outcomes. Nine years of prospective data from 1,185 adults (39% female) in substance use treatment at a private health care setting were analyzed by multivariate logistic generalized estimating equation models. At 1 year, 14.1% of 716 participants who smoked cigarettes at intake reported stopping smoking, and 10.7% of the 469 non-smokers at intake reported smoking. After adjusting for sociodemographics, substance use severity and diagnosis at intake, length of stay in treatment, and substance use status at 1 year, those who stopped smoking at 1 year were more likely to be past-year abstinent from drugs, or in past-year remission of drugs and alcohol combined, at follow-ups than those who continued to smoke (OR = 2.4, 95% CI: 1.2 – 4.7 and OR = 1.6, 95% CI: 1.1 – 2.4, respectively). Stopping smoking at 1 year also predicted past-year alcohol abstinence through 9 years after intake among those with drug-only dependence (OR = 2.4, 95% CI: 1.2 – 4.5). We found no association between past-year alcohol abstinence and change in smoking status at 1 year for those with alcohol dependence or other substance use diagnoses when controlling for alcohol use status at 1 year. Stopping smoking during the first year after substance use treatment intake predicted better long-term substance use outcomes through 9 years after intake. Findings support promoting smoking cessation among smoking clients in substance use treatment.
PMCID: PMC3062692  PMID: 21050681
longitudinal data; tobacco; alcohol; substance use; treatment
11.  Substance Use, Symptom, and Employment Outcomes of Persons With a Workplace Mandate for Chemical Dependency Treatment 
This study examined the role of workplace mandates to chemical dependency treatment in treatment adherence, alcohol and drug abstinence, severity of employment problems, and severity of psychiatric problems.
The sample included 448 employed members of a private, nonprofit U.S. managed care health plan who entered chemical dependency treatment with a workplace mandate (N=75) or without one (N=373); 405 of these individuals were followed up at one year (N=70 and N=335, respectively), and 362 participated in a five-year follow up (N=60 and N=302, respectively). Propensity scores predicting receipt of a workplace mandate were calculated. Logistic regression and ordinary least-squares regression were used to predict length of stay in chemical dependency treatment, alcohol and drug abstinence, and psychiatric and employment problem severity at one and five years.
Overall, participants with a workplace mandate had one- and five-year outcomes similar to those without such a mandate. Having a workplace mandate also predicted longer treatment stays and improvement in employment problems. When other factors related to outcomes were controlled for, having a workplace mandate predicted abstinence at one year, with length of stay as a mediating variable.
Workplace mandates can be an effective mechanism for improving work performance and other outcomes. Study participants who had a workplace mandate were more likely than those who did not have a workplace mandate to be abstinent at follow-up, and they did as well in treatment, both short and long term. Pressure from the workplace likely gets people to treatment earlier and provides incentives for treatment adherence.
PMCID: PMC2878200  PMID: 19411353

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