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Treatment Process, Engagement, and Retention
Drug and Alcohol Dependence (1999)   

Simpson, D. D. & Brown, B. (Guest Eds.). (1999).  Special issue:  Treatment process and outcome studies from DATOS.  Drug and Alcohol Dependence, 57(2), 81-174.

Editors' Summary:  This year's last issue of the journal Drug and Alcohol Dependence (December 1999) features a collection of new studies from the Drug Abuse Outcome Treatment Studies (DATOS) project, a collaborative research effort funded by the National Institute on Drug Abuse (NIDA) from 96 treatment programs in 11 U.S. cities. IBR at TCU, NDRI (National Development and Research Institutes), and the Drug Abuse Research Center at UCLA joined with NIDA in this 5-year project, which continued in the spirit of earlier national multi-site studies such as DARP (Drug Abuse Reporting Program) and TOPS (Treatment Outcome Prospective Study). The issue also reports on recent findings from a national treatment outcome study in England.

1)  Fletcher, B. W., & Battjes, R. J. (1999).  Introduction to the special issue: Treatment process in DATOS.  Drug and Alcohol Dependence, 57(2), 81-87.

Abstract:  Several important findings from the Drug Abuse Treatment Outcome Studies (DATOS) are presented in this issue of drug and alcohol dependence.  These studies focus on the drug abuse treatment process in areas of engagement in treatment and participation in program activities, the effect of the patient's age and treatment history in predicting treatment retention and outcomes, and the impact of prior treatment experience on the level of treatment engagement and subsequent outcomes.  A cost-benefit model for drug abuse treatment is developed.  Significant contributions are made in the development of a comprehensive model of the treatment process, including the relationship of patient attributes, program factors, and outcomes.  Findings on retention from the United Kingdom's national treatment outcome research study (NTORS), a study similar in design to DATOS, also are presented. [Keywords: DATOS; treatment process; cost-benefit model]

2)  Gossop, M., Marsden, J., Stewart, D., & Rolfe, A. (1999).  Treatment retention and 1 year outcomes for residential programmes in England.  Drug and Alcohol Dependence, 57(2), 89-98.

Abstract:  This paper reports changes in substance use behaviours at 1-year follow-up, and investigates the relationship between time in treatment and observed outcomes.  A total of 408 clients were interviewed at intake to 23 residential treatment programmes, and 286 (70%) of these were interviewed at 1 year.  Substantial improvements were found in terms of abstinence from opiates, psychostimulants and benzodiazepines.  At 1 year, half of the clients were abstinent from heroin.  Reductions in injecting, sharing injecting equipment, heavy drinking and criminal behaviour were found.  Critical treatment thresholds were identified using multiple logistic regression analyses.  Longer stays in treatment were predictive of better 1 year outcomes.

3)  Etheridge, R. M., Craddock, S. G., Hubbard, R. L., & Rounds-Bryant, J. L. (1999).  The relationship of treatment and self-help participation to patient outcomes in DATOS.  Drug and Alcohol Dependence, 57(2), 99-112.

Abstract:  Using a sample of 927 cocaine patients enrolled in programs in three modalities included in the national Drug Abuse Treatment Outcome Studies (DATOS), this investigation examined the relationship of three dimensions of treatment process on after-treatment cocaine and heavy alcohol use and predatory illegal activity.  Logistic regression revealed significant reductions in all three outcomes and strong effects of treatment duration and after-treatment self-help, conditional on the modality.  Results did not support the hypothesized relationship between treatment outcomes and amounts of counseling and during-treatment self-help.  Findings support the robustness of duration effects and after-treatment self-help and contribute to the measurement methodology for calibrating treatment intensity.  The strong after-treatment self-help effect in the two residential and inpatient modalities suggests these programs can improve treatment outcomes by making referral to after-treatment self-help participation a standard practice and installing mechanisms to increase the likelihood of attendance at least twice weekly during the year after treatment.  [Keywords: Drug treatment; treatment process; counseling; self-help groups; retention]

4)  Joe, G. W., Simpson, D. D., & Broome, K. M. (1999).   Retention and patient engagement models for different treatment modalities in DATOS.  Drug and Alcohol Dependence, 57(2), 113-125. 

Abstract:  A model to explain treatment retention in terms of process components – therapeutic involvement and session attributes for the 1st month – and patient background factors were tested in long-term residential (LTR), outpatient drug free (ODF), and outpatient methadone (OMT) treatments. The data was collected in the national Drug Abuse Treatment Outcome Studies (DATOS), and included 1362 patients in LTR, 866 in ODF, and 981 in OMT programs. Structural equation models showed there were positive reciprocal effects between therapeutic involvement and session attributes in all three modalities, and these variables had direct positive effects on treatment retention. Motivation at intake was a strong determinant of therapeutic involvement. Other patient background factors were significantly related to retention, including pretreatment depression, alcohol dependence, legal pressure, and frequency of cocaine use. [Keywords: Treatment process; therapeutic engagements; treatment retention; motivation; DATOS].

5)  Broome, K. M., Simpson, D. D., & Joe, G. W. (1999).   Patient and program attributes related to treatment process indicators in DATOS.  Drug and Alcohol Dependence, 57(2), 127-135.

Abstract:  Patient ratings of their personal confidence in treatment and commitment to recovery were examined in a national sample of long-term residential, outpatient drug-free, and outpatient methadone programs.  It was found that patients expressing greater confidence and commitment after 3 months of treatment generally began with higher motivation at intake, had formed better rapport with counselors, and attended counseling sessions more frequently.  In addition, overall levels of patient involvement (as indicated by confidence and commitment) varied across programs; those programs with higher average involvement by patients used more social and public health services, maintained more consistent attendance at counseling sessions, and served patients who collectively had more similar kinds of needs.  Thus, patient and program attributes both play a role in determining therapeutic engagement of persons who enter drug treatment. [Keywords: Treatment engagement; motivation; program differences; Drug Abuse Treatment Outcome Studies].

6)  Hser, Y., Grella, C. E., Hsieh, S., Anglin, M. D., & Brown, B. S. (1999).   Prior treatment experience related to process and outcomes in DATOS.   Drug and Alcohol Dependence, 57(2), 137-150.  

Abstract:  Using data collected from cocaine-abusing patients who participated in the Drug Abuse Treatment Outcome Studies (DATOS), we contrasted patients in treatment for the first time and patients having extensive histories of prior treatment to identify factors associated with better outcomes in each group.  Compared with first-timers, treatment-experienced patients had less favorable post-treatment outcomes.  Indicators of early engagement in DATOS treatment predicted post-treatment abstinence for both groups. Importantly, the interaction of treatment history and several process measures affected post-treatment abstinence.  For example, individual counseling and program compliance had greater impacts on abstinence among treatment repeaters in outpatient drug-free programs than for first-timers.  Social support and environmental context were significantly related to abstinence.  These findings confirm the importance of considering treatment process and aftercare in developing and implementing strategies to optimize treatment for patients with different treatment histories.  [Keywords: Drug treatment history; treatment process; treatment outcome; social support; environmental context; cocaine use]

7)  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(2), 151-166.

Abstract:  Structural equation modeling with multiple groups was used to examine relationships among pretreatment patient characteristics, treatment retention, and treatment outcomes among younger and older adults in the Drug Abuse Treatment Outcome Studies.  Separate models were tested for 551 patients treated in long-term residential (LTR) programs and 571 patients treated in outpatient drug-free (ODF) programs.  There was a stronger positive relationship between treatment retention and abstinence at follow-up for younger adults in both treatment modalities.  Prior treatment history had a negative effect on self-efficacy to resist drug use for older adults in LTR.  Negative reference group influence was reduced for all groups following treatment, however, it was more strongly related to abstinence for younger adults in LTR and for older adults in ODF.  Clinical implications of age-related differences in these relationships are discussed. [Keywords: Young adults; drug use history; treatment career; self-efficacy; reference group].

8)  Flynn, P. M., Kristiansen, P. L., Porto, J. V., & Hubbard, R. L. (1999).  Costs and benefits of treatment for cocaine addiction in DATOS.  Drug and Alcohol Dependence, 57(2), 167-174. 

Abstract:  Our objective was to examine the cost of long-term residential (LTR) and outpatient drug-free (ODF) treatments for cocaine-dependent patients participating in the Drug Abuse Treatment Outcome Studies (DATOS), calculate the tangible cost of crime to society, and determine treatment benefits.  Subjects were 502 cocaine-dependent patients selected from a national and naturalistic nonexperimental evaluation of community-based treatment.  Financial data were available for programs from 10 US cities where the subjects received treatment between 1991 and 1993.  Treatment costs were estimated from the 1992 National Drug Abuse Treatment Unit Survey (NDATUS), and tangible costs of crime were estimated from reports of illegal acts committed before, during, and after treatment.  Sensitivity analyses examined results for three methods of estimating the costs of crime and cost-benefit ratios.  Results showed that cocaine-dependent patients treated in both LTR and ODF programs had reductions in costs of crime from before to after treatment.  LTR patients had the highest levels and costs of crime before treatment, had the greatest amount of crime cost reductions in the year after treatment, and yielded the greatest net benefits.  Cost-benefit ratios for both treatment modalities provided evidence of significant returns on treatment investments for cocaine addiction.  [Keywords: Drug treatment costs; treatment benefits; crime costs; cocaine addiction; cost-benefit]

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