Jesse Milby - US grants

Prospects for methadone maintenance patients completing detoxification and initiating a drug-free adjustment are less than 50% in outcome studies and completion rates range to 19%. Research proposed here has direct implications and practical application for improving detoxification outcome. Since maintenance was first used, investigators discovered increased anxiety at prospects of detoxification. Cushman and Dole (1973) found 11% of their sample of rehabilitated maintenance patients aborted detoxification because of increased anxiety. Investigators subsequently identified detoxification fear's correlates and developed reliable and valid measures for it, suspecting it as one of the culprits in poor maintenance detoxification outcome. But to date we have no direct evidence of detoxification fear's role in detoxification outcome. We will follow a random sample cohort of 271 treated addicts in 3 large maintenance programs from our previous research and discover their methadone maintenance and detoxification outcome. We will determine if those with previously identified detoxification fear show expected difficulty in completing detoxification. We will accomplish this through on site detailed chart reviews and personal interviews with fear subjects from the cohort who remain. We will carefully assess fear subjects to determine if they have not received treatment for their fear and analyze the data separately from those who have. Whether or not investigators' hypotheses are supported, the study will provide scientifically useful methadone maintenance and detoxification outcome data on a large random sample of treated patients from 3 geographically, culturally and racially different subpopulations.

The overall goal of this three-year cooperative agreement application for a demonstration project is to compare the effects of two interventions, a usual care intervention and an intensive outpatient intervention consisting of both initial and extended intervention components, for homeless individuals with alcohol and/or substance abuse problems in the greater Birmingham area. This application arises from a collaborative effort between the University of Alabama at Birmingham (UAB) and the sub-contractor for the application, the Birmingham Health Care for the Homeless Coalition (BHCHC). Investigative team members at UAB have extensive experience in scientific, evaluation, administrative, and substance abuse aspects relevant. to the proposed project. investigative team members from the BHCHC have extensive experience in providing medical, substance abuse, mental health, and supportive services for homeless persons in the greater Birmingham area. Collectively, the investigative team represents an extremely strong group to participate collaboratively with representatives of NIAAA and NIDA to conduct the proposed cooperative demonstration project. A randomized, controlled design is proposed with a total of 150 homeless participants to be recruited and randomized to one of the two interventions, usual care or intensive outpatient intervention. Both process and outcome measures will be used throughout the intervention period and six months after discharge to compare the groups. Our major hypotheses include: 1) the intensive outpatient intervention will result in greater reduction in consumption of alcohol and/or other drugs than usual care; 2) the intensive outpatient intervention will increase levels of shelter and residential stability more than usual care; and 3) the intensive outpatient intervention will enhance the economic and employment status of homeless persons more than usual care.

This research proposes to enhance an ongoing innovative day treatment program for substance abusing homeless persons, including work and housing interventions, with new state-of-the-art treatment for cocaine dependance. Results from a NIAAA/NIDA research demonstration in 1991 revealed that day treatment was significantly more effective than usual care in establishing abstinence, improving independent housing, and increasing days employed and earned income. Findings also showed that 77% of the clients were cocaine abusers or cocaine dependent and most had associated DSM III-R mental disorders. This research proposes to target treatment more precisely to the population found in the 1991 demonstration and to extend the most effective treatment for initiating cocaine abstinence from recent research to a more dysfunctional dually diagnosed homeless population. This study is also designed to address the question: What are the sufficient conditions for effective treatment of homeless substance abusers? Is effective treatment for Substance Use Disorders sufficient to produce improvement in, not only substance abuse, but homelessness and unemployment? The proposal establishes a new cohort of 150 cocaine abusing homeless persons with a co-existing non-psychotic mental illness. It will compare a behavioral social reinforcement day treatment program for cocaine abuse, plus abstinence contingent housing and work therapy vs. a day treatment control, which does not include abstinence contingent housing and work therapy, on initiating abstinence and reducing homelessness and unemployment. This study will yield important information on the necessary and sufficient conditions needed for effective treatment of homeless persons with Substance Use Disorders. The proposed study takes a first step in separating interventions for homelessness vs. substance abuse, and discovering if these combined interventions are necessary and sufficient or, if effective intervention for substance abuse is sufficient alone for treatment of substance abusing homeless. Thus, information from this study will provide important knowledge on how to most effectively treat this difficult population, knowledge which has important clinical, economic and public policy implications.

DESCRIPTION: (Applicant's Abstract) This study addresses the question: what are necessary and sufficient conditions for effective treatment services for homeless substance abusers? It refines an ongoing innovative day treatment program for dually diagnosed, cocaine-abusing homeless persons, including work and housing interventions. It enhances aftercare and studies the critical variable of program-provided housing. It establishes a cohort of 225 cocaine-abusing homeless persons, including work and housing interventions. It enhances aftercare, and studies the critical variable of program-provided housing. It establishes a cohort of 225 cocaine-abusing homeless persons, with DSM III-R Axis I Mental Disorders in addition to Substance Use Disorders, then randomly assigns them to 3 groups of 75 based on the main independent variable, housing intervention. The studied variable compares abstinent-contingent housing, non-abstinent contingent housing and no housing, all in the context of intensive day treatment, vocational interventions, and aftercare derived from successful intervention in two previous studies by the research team. Except for the studied variable, all groups will share in the same interventions by the same counselors in 3 phases: Phase I, mo. 1-2 intensive daily day treatment; Phase II, mo. 3-6, aftercare 3 days/wk; Phase III, mo. 7-12, aftercare 2 days/wk. Subjects will be assessed with the previously used battery at 2, 6, 12 and 18 months on primary outcomes of alcohol and substance use, homelessness and employment. A cost-effectiveness/benefits analysis for primary outcomes will be completed. Secondary outcomes of psychiatric functioning and HIV risk will be measured. The study investigates whether day treatment plus program-provided abstinent-contingent housing is necessary and sufficient for maximum treatment effects or, if day treatment plus non-abstinent contingent-provided housing or day treatment alone are sufficient for treating substance abusing homeless. Results will provide important knowledge on how to most cost-effectively provide treatment services for this difficult population, knowledge which has important clinical, economic, and public policy implications.

DESCRIPTION: (Applicant's Abstract) Substance abuse in homeless persons is associated with multiple health risks and presents daunting challenges to agencies providing services. Proposed research with this vulnerable population is based on two previous randomized controlled studies showing an innovative behavioral day treatment's (BDT+) effectiveness in a community setting with different comparison groups. The second demonstrated superiority of abstinent contingent housing and work compared to BDT alone, while controlling for alternative explanations of treatment effectiveness. This study determines if BDT+ for dually diagnosed, homeless substance abusers can be successfully transported to a new site. It develops training materials and methods for new staff to implement BDT at the University of Texas, Houston Recovery Campus. Expected products are: treatment manual, 35mm slides, video tapes etc., and brief observation scales to assess fidelity of each transported BDT+ component. Objective criteria and methods assure BDT+ components have been implemented with measured specified fidelity. Implementation is studied via a 2 group randomized control comparison with usual care. From a population meeting criteria from previous studies, 100 each will be assigned to either BDT+ or an existing Riverside General Hospital Day Treatment (RGHDT) control. Assessments at baseline, 1, 2, 6 and 12 months use instruments and measures employed in original studies. Outcomes include alcohol and drug abuse, homelessness, employment and HIV/A1DS risk behaviors, and a cost effectiveness analysis. Successful implementation is ultimately defined by hypothesized, superior outcomes for BDT+. If BDT+ can be replicated, products and methods would permit transport to other settings. Results will provide important knowledge and technology for transporting complex psychosocial treatment and how to most effectively treat this dysfunctional population, knowledge which has important clinical, economic, public health and public housing policy implications.

DESCRIPTION: (Applicant's Abstract) Substance abuse in homeless persons is associated with multiple health risks and presents daunting challenges to agencies providing services. Proposed research with this vulnerable population is based on 2 previous randomized controlled studies showing an innovative behavioral day treatment's (BDT+) effectiveness in a community setting with different comparison groups. The second demonstrated superiority of abstinent contingent housing and work compared to BDT alone, while controlling for alternative explanations of treatment effectiveness. This study determines if BDT+ for dually diagnosed, homeless substance abusers, can be successfully transported to a new site. It develops training materials and methods for new staff to implement BDT at the University of Texas, Houston Recovery Campus. Expected products are: treatment manual, 35mm slides, videotapes etc., and brief observation scales to assess fidelity of each transported BDT+ component. Objective criteria and methods assure BDT+ components have been implemented with measured specified fidelity. Implementation is studied via a 2 group randomized control comparison with usual care. From a population meeting criteria from previous studies, 100 each will be assigned to either BDT+ or an existing Riverside General Hospital Day Treatment (RGHDT) control. Assessments at baseline, 1, 2, 6 and 12 months use instruments and measures employed in original studies. Outcomes include alcohol and drug abuse, homelessness, employment and HIV/AIDS risk behaviors, and a cost effectiveness analysis. Successful implementation is ultimately defined by hypothesized, superior outcomes for BDT+. If BDT+ can be replicated, products and methods would permit transport to other settings. Results will provide important knowledge and technology for transporting complex psychosocial treatment and how to most effectively treat this dysfunctional population, knowledge which has important clinical, economic, public health and public housing policy implications.