Antidepressant treatment of co-occurring depression and alcohol dependence.

Residential treatment models fill a niche for some consumers with substance use disorders, but documenting their effectiveness has been a challenge. An abundance of studies have evaluated this treatment approach, according to this literature review, but overall they lacked methodological rigor and appropriate control groups. Part of the difficulty in studying residential treatment is the lack of uniformity in basic features, such as staffing and length of stay, and a lack of information about longer-term outcomes. So far, the evidence base for residential treatment is moderate, at best.

https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201300242

Residential treatment for individuals with substance use disorders: assessing the evidence.

Intensive outpatient programs (IOPs) have emerged as a critical facet of 21st-century treatment of substance use disorders, serving up to 12% of patients receiving specialty addiction treatment. In this literature review, the authors compared outcomes of participants in IOPs or inpatient or residential care. Not only were the IOPs as effective as inpatient treatment for most individuals, they have the advantage of allowing participants to avoid or step down successfully from inpatient services.

/pdf/substance-abuse-intensive-outpatient-programs-assessing-the-54lq794r8t.pdf

Substance Abuse Intensive Outpatient Programs: Assessing the Evidence

Alcohol and substance use are common and affect the lives of many Americans. Approximately 14 million Americans currently abuse illicit drugs and a similar number abuse alcohol (Substance Abuse Chartbook 2001; Grant et al. 1994). Estimating the overall cost of substance disorders is difficult since these disorders impact not only the lives of the individual substance abusers and their families, but also the communities in which they live. One estimate puts the figure for the overall cost to the U.S. economy at about $414 billion a year (Substance Abuse Chartbook 2001). Only a small fraction of the total cost of substance abuse—about $12 billion a year—is directly spent on treatment of these disorders (Substance Abuse Chartbook 2001). The rest includes productivity losses due to premature death and disability and the cost of criminal activities to society. Although there is good evidence that, at a societal level, treatment of substance abusers is more cost-effective than enforcement efforts to reduce substance supply (Rydell, Caulkins, and Everingham 1996), policymakers often ask for evidence of effectiveness and cost-effectiveness for specific treatments.

A number of such cost-effectiveness studies have been conducted (Barnett and Swindle 1997; Barnett 1999; Flynn et al. 1999; Harwood et al. 1995; Holder et al. 1991; Pettinati et al. 1999; Schinka et al. 1998; Shepard, Larson, and Hoffman 1999) and excellent reviews of this literature have been published (French 1995; Cartwright 2000). A principal conclusion from many of these studies is that more intensive treatments are not necessarily more cost-effective than the less intensive alternatives (Annis 1986; McLellan et al. 1983; McCrady et al. 1986; Schinka et al. 1998). While effectiveness across modalities appears to be similar, outpatient care is generally less expensive than inpatient care. Many of the past studies, however, excluded clients with previous treatment failure, multiple drug use, history of homelessness, and psychiatric comorbidity. These exclusion criteria limit generalizability. Furthermore, these exclusion criteria limit our ability to examine the common assumption that the more severe and complicated cases may respond better to intensive treatments.

In the present study, we assess effectiveness and cost-effectiveness of treatment of substance disorders in usual treatment settings, addressing some of the limitations of previous studies. The data for this study come from the Services Research Outcomes Study (SROS; Substance Abuse and Mental Health Services Administration 1998), which is the first large-scale national study that drew a stratified random sample out of a pool of more than ten thousand enumerated drug treatment facilities across the nation.

In contrast to previous economic studies using national data (Harwood et al. 1995; Flynn et al. 1999), we focus on direct clinical outcomes of substance abuse treatment, rather than reduction in criminal activity. Furthermore, in our comparison of treatment modalities we employ propensity score analysis to control for the factors that influence selection into various modalities, such as type and severity of substance disorder and psychiatric comorbidity. Measures of effect are based on a five-year follow-up, hence addressing one of the major limitations of previous economic analyses—that is, follow-up periods that are too brief (Sindelar and Manning 1997). Finally, successful outcome was measured in two ways, as abstinence and as any reduction in use. To our knowledge, the present analysis is the first attempt at a comprehensive cost-effectiveness study of substance abuse treatment programs based on a large sample of clients from a nationally representative sample of facilities.

/pdf/effectiveness-and-cost-effectiveness-of-four-treatment-2qrywkbgi9.pdf

Effectiveness and Cost-effectiveness of Four Treatment Modalities for Substance Disorders: A Propensity Score Analysis

Aims This study tested the hypothesis that patients with more severe substance use disorders (SUDs) at intake respond better when treated in more structured and intensive settings (i.e. in-patient/residential versus out-patient), whereas patients with less severe SUD problems have similar outcomes regardless of treatment setting.



Design, setting and participants  Up to 50 new patients were selected randomly from each of a random and representative sample of 50 Department of Veterans Affairs (VA) SUD treatment programs (total n = 1917 patients), and were followed-up an average of 6.7 months later (n = 1277).



Measures  Patients completed a brief self-report version of the Addiction Severity Index (ASI) at baseline and at follow-up.



Findings  In mixed-model regression analyses, baseline substance use severity predicted follow-up substance use severity and there were no main effects of treatment setting. However, interaction effects were found, such that more severe patients experienced better alcohol and drug outcomes following in-patient/residential treatment versus out-patient treatment; on the other hand, patients with lower baseline ASI drug severity had better drug outcomes following out-patient treatment than in-patient treatment. Treatment setting was unrelated to alcohol outcomes in patients with less severe ASI alcohol scores.



Conclusions  Results provide some support to the matching hypothesis that for patients who have higher levels of substance use severity at intake, treatment in in-patient/residential treatment settings is associated with better outcomes than out-patient treatment. More research needs to be conducted before in-patient/residential settings are further reduced as a part of the SUD continuum of care in the United States.

Treatment setting and baseline substance use severity interact to predict patients' outcomes.

This study investigated whether selected patients have better outcomes with inpatient than outpatient treatment. There were 93 inpatients and 80 outpatients with alcohol dependence who were evaluated at treatment entry to a private healthcare setting. Patients with multiple drinking-related consequences were less likely to return to significant drinking in the first 3 months after treatment ended if they had attended inpatient compared to outpatient treatment. Thus, inpatient appeared to have some advantage over outpatient treatment in the early recovery period for patients with multiple drinking-related consequences. The gap between inpatient and outpatient costs was also reduced when computed as a cost-effectiveness ratio, although treatment costs continued to remain proportionally higher with inpatient than outpatient treatment.

Inpatient Alcohol Treatment in a Private Healthcare Setting: Which Patients Benefit and at What Cost?

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Inpatient Alcohol Treatment in a Private Healthcare Setting: Which Patients Benefit and at What Cost?