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Treatment Retention and Follow-up Outcomes

The length of time clients stayed in treatment was directly related to improvements in follow-up outcomes, replicating findings from previous national treatment evaluations (DARP and TOPS). These findings applied to OMT, LTR, and ODF treatment programs in DATOS, but not to the brief STI services (Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997).

  • In OMT, clients who remained in treatment for a year or longer were 4 times less likely than early dropouts (i.e., treated under 3 months) to use heroin weekly during the 1-year follow-up.
     
  • In LTR and ODF, clients who remained in treatment for 3 months or longer had significantly better follow-up outcomes on a variety of criteria than did early dropouts (i.e., treated under 3 months). In both modalities, posttreatment outcomes continued to improve as treatment retention increased.
     
  • In LTR, follow-up outcome differences between short-term (i.e., treated under 3 months) versus longer-term (i.e., treated 3 months or longer) clients were statistically significant for weekly cocaine use (36% vs 14%), heavy alcohol use (31% vs 11%), predatory illegal acts (23% vs 12%), sex-related HIV/AIDS risks (33% vs 26%), and unemployment on a full-time job (86% vs 71%).
     
  • In ODF, follow-up outcome differences between short-term (i.e., treated under 3 months) versus longer-term (i.e., treated 3 months or longer) clients were statistically significant for weekly cocaine use (25% vs 14%), heavy alcohol use (18% vs 13%), suicidal thoughts or attempts (14% vs 9%), and sex-related HIV/AIDS risks (26% vs 19%).

The relationship of treatment retention with improvements in 12-month follow-up outcomes in the aggregate DATOS sample also was examined by using a quasi-experimental design to control for possible program-level effects within each modality (Simpson, Joe, & Brown, 1997). Subsamples of clients from the three major modalities – OMT, LTR, and ODF – were selected from programs with sufficient representation of both short and longer retention groups (n=788 clients). STI programs were excluded from this study because of their characteristic short duration of treatment.

  • Clients with longer stays in LTR (i.e., 3 months or more) and OMT (i.e., 12 months or more) had significantly better follow-up outcomes, replicating the findings on the aggregate DATOS sample reported above and those from previous national evaluation studies. (These results were based on analyses that controlled for variations between programs that might otherwise account for retention effects. Because of sampling restrictions and high program diversity, however, analyses for ODF in this study were inconclusive.)
     
  • Several indicators of higher quality treatment delivery – most notably better client-counselor relationships, providing a wider range of services, and higher client satisfaction with the program – characterized programs with longer treatment retention rates.

Given the widely established findings on the importance of treatment retention in OMT, LTR, and ODF, individual programs were examined on the basis of how well they succeeded in retaining clients beyond the "minimum retention thresholds" shown to be associated with improved outcomes (Simpson, Joe, Broome, Hiller, Knight, & Rowan-Szal, 1997). Only programs with large sample representation (i.e., with 50 or more clients who completed intake) were included in these analyses. STI programs were excluded because of the short planned duration for services and lack of retention effects on outcomes. The study was based on 5,104 clients drawn from 10 OMT, 17 LTR, and 14 ODF programs.

  • There was high diversity within each modality in how well programs were able to engage and hold clients beyond a minimum treatment retention criterion.
     
  • At least half of the OMT programs in DATOS expected clients to stay in treatment for 24 months or more (ranging from 24 to 30 months). However, the median length of stay for OMT clients was 12 months; in the program with the lowest average retention rate, only 15% of the clients stayed 12 months or longer, versus 76% of the clients in the program with the best retention rate.
     
  • Comparisons between OMT programs identified several factors related to their overall retention rates; these involved complex variations in age and gender, treatment history, psychological problems, cocaine and alcohol dependence, and needle sharing of clients admitted to different programs.
     
  • At least half of the LTR programs in DATOS expected clients to stay in treatment for 9 months or more (ranging from 4 to 24 months). However, the median length of stay for LTR clients was 3 months; in the program with the lowest average retention rate, only 21% of the clients stayed 3 months or longer, versus 65% of the clients in the program with the best retention rate.
     
  • Comparisons between LTR programs identified several factors related to their overall retention rates; these involved complex variations in age as well as cocaine and alcohol dependence of clients admitted to different programs.
     
  • At least half of the ODF programs in DATOS expected clients to stay in treatment for 6 months or more (ranging from 3 to 12 months). However, the median length of stay for ODF clients was 3 months; in the program with the lowest average retention rate, only 16% of the clients stayed 3 months or longer, versus 76% of the clients in the program with the best retention rate.
     
  • Comparisons between ODF programs identified several factors related to their overall retention rates; these involved complex variations in cocaine and alcohol dependence as well as legal status of clients admitted to different programs.
     
  • After controlling statistically for client differences (i.e., case-mix adjustments), there were still significant differences in retention rates between programs in all three modalities. These results suggest that treatment-specific factors at some programs may be more effective in retaining clients.
     
  • Comprehensive studies of the interactions of client characteristics, treatment structure and process, and program response to client needs are being conducted to better understand differences in program effectiveness.

Age differences were examined by Grella, Hser, Joshi, and Anglin (1999) as a moderator of the relationships between client characteristics, treatment retention, and treatment outcomes in DATOS. Separate structural equation models were tested for 551 clients from 19 long-term residential (LTR) programs and 571 clients from 27 outpatient drug-free (ODF) programs. Younger adults (less than 30 years of age) comprised 51% of LTR subjects, and 39% of ODF subjects.

  • Longer retention in treatment and higher self-efficacy to resist drug use had a positive effect on abstinence for both groups, however, the relationship between treatment retention and abstinence at follow-up was stronger for younger adults in both modalities.
     
  • Both age groups reduced their contact with other drug users following treatment, but the influence of drug-using peers was more strongly related to lowered feelings of self-efficacy to resist drug use among younger adults in LTR and among older adults in ODF.
     
  • Older adults in LTR and ODF and younger adults in LTR who spent more time in DATOS treatment had stronger feelings that they would be able to resist drug use following treatment.
     
  • Older adults in LTR who had longer prior treatment histories had lower levels of self-efficacy to resist drug abuse following DATOS treatment.
     
  • The findings suggest that age-specific treatment protocols need to be implemented to address lowered self-efficacy among older adults with longer treatment histories, the influence of negative reference groups, and to increase treatment retention, particularly for younger adults.

 

References

Hubbard, R. L., Craddock, S. G., Flynn, P. M., Anderson, J., & Etheridge, R. M. (1997). Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11(4), 261-278. [Abstract]

Simpson, D. D., Joe, G. W., & Brown, B. S. (1997). Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11(4), 294-307. [Abstract]

Simpson, D. D., Joe, G. W., Broome, K. M., Hiller, M. L., Knight, K., & Rowan-Szal, G. A. (1997). Program diversity and treatment retention rates in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11(4), 279-293. [Abstract]

Grella, C. E., Hser, Y., Joshi, V., & Anglin, M. D. (1999). Patient histories, retention, and outcome models for younger and older adults in DATOS. Drug and Alcohol Dependence, 57, 151-166.  [Abstract]

 

More about Retention in Special Populations

Criminal Justice:
Hiller, M. L., Knight, K., Broome, K. M., & Simpson, D. D. (1998). Legal pressure and treatment retention in a national sample of long-term residential programs. Criminal Justice and Behavior, 25(4), 463-481.  [Abstract]

Comorbid Clients:
Broome, K. M., Flynn, P. M., & Simpson, D. D. (1999).  Psychiatric comorbidity measures as predictors of retention in drug abuse treatment programs.  Health Services Research, 34(3), 791-806.   [Abstract]

Crack/Cocaine Users:
Rowan-Szal, G. A., Joe, G. W., & Simpson, D. D. (2000).  Treatment retention of crack and cocaine users in a national sample of long term residential clients.  Addiction Research, 8(1), 51-64. [Abstract]

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14 December 2001

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