Treatment strategy profiles in substance use disorder treatment programs: A latent class analysis
Introduction
Substance use disorder (SUD) treatment in the United States (U.S.) is controversial. While few question the growing SUD problem, some do not believe that formal treatment is the appropriate response (Pescosolido et al., 2010). Others charge that much SUD treatment has limited effectiveness because of its adherence to the recovery principles of Alcoholics Anonymous (AA; Fletcher, 2013, Dodes, 2014). Nevertheless, care options include evidence-based practices (EBPs), like psychosocial and medication-assisted treatment (MAT), as well as alternative therapies, though center implementation of these is challenging. This is partly because translational processes from randomized clinical trials (RCT) to center implementation are notoriously problematic. For example, RCT generalizability is threatened when treatment realities are not reflected in study designs and research subject exclusions (Miller et al., 2006, Swearingen et al., 2003). Additionally, RCT findings may indicate statistically significant but substantively trivial differences when compared with treatment-as-usual. Promising RCT results may be ultimately lost when regulatory bodies, including insurance providers, reshape EBP delivery, such as altering treatment dosage by constricting the amount of time patients are allowed in treatment (Gotham, 2006). Finally, once an EBP is available, client preference (Rieckmann et al., 2007) or financial constraints, such as required co-payments (Morgan et al., 2013), may limit center utilization.
Previous literature has tended to address center adoption of single EBPs, and the majority of programs offer limited treatment options (Bradley and Kivlahan, 2014). This is despite research indicating that access to diverse treatment facilitates recovery by maximizing the likelihood of addressing clients’ complex, individual needs (Webb, 2001). Little is known about how combinations of EBPs are available as treatment strategy profiles (TSPs) within individual centers. The purpose of the current study is to generate a classification of treatment centers based on their use of EBPs and to examine the philosophical and structural correlates of centers’ offerings. Using representative, secondary data from three aggregated samples and latent class analysis, we examine the TSPs of SUD treatment centers across the U.S. We then employ multinomial logistic regression to consider center-specific philosophical and structural supports as likely correlates of diverse EBP offerings.
As SUD treatment has evolved over the past 40 years, paradigms have emerged that support differing beliefs about SUD and its appropriate treatment. These include behavioral, medical, and comprehensive orientations. AA's 12-steps exemplifies the behavioral paradigm and encourages belief in a Higher Power, recognition of helplessness, importance of sustained motivation with social support, and complete abstinence. AA's philosophy has been intensely integrated into SUD treatment in the U.S. (The National Center on Addiction and Substance Abuse at Columbia University, 2012), but other behavioral therapies have attracted sufficient research attention to be recognized as EBPs, including contingency management (CM), multisystemic therapy (MST), and motivational enhancement therapy (MET). These share strategies for changing behavioral patterns for continued sobriety and relapse prevention, but may not always be compatible with the 12-steps, particularly when motivation is encouraged via external rather than internal processes, as is the case with CM and MST (McGovern et al., 2004, Vaughn and Howard, 2004). The behavioral paradigm seems particularly acceptable to those supporting treatment options for criminal justice (CJ) clients whose treatment is closely controlled by the state (Ducharme et al., 2007, Kubiak et al., 2009, Rich et al., 2005). Conversely, use of treatments emphasizing personal responsibility, like the 12-steps, has been criticized for female clients because they are more likely to have histories of trauma and victimization, suggesting risks of self-blame (Sanders, 2006, Sanders, 2010).
In contrast to the behavioral model, the medical model frames SUD as an illness that is largely outside of individual control, a paradigm of long duration that has manifested in a variety of treatments (White, 2014). A key distinction between the medical and behavioral paradigm is the use of MAT. Starting with disulfiram in 1951, the U.S. Food and Drug Administration has approved several medications for SUD treatment. These include acamprosate, naltrexone, and buprenorphine. It is important to note that the medical model does not preclude psychosocial accompaniments and is usually recommended in conjunction with psychosocial treatments (Jhanjee, 2014), but because of its use of chemicals, this paradigm may be seen as antithetical to a behavioral orientation and complete abstinence.
Integrating aspects of the behavioral and medical model, comprehensive treatment may have its origins from the counselors and administrators in SUD treatment with backgrounds in social work. This model draws focus to the multi-faceted environment in which long term recovery occurs and the need to address individuals’ medical, personal, and social problems that may be either linked or co-existing with their SUD. It has a strong emphasis on social support and access to multiple sources of help to maximize individual resilience. Recently, the U.S. government has encouraged broader treatments that utilize integrated approaches. The Patient Protection and Affordable Care Act (ACA; 2010) promotes greater healthcare integration for SUD clients, and the National Institute on Drug Abuse (NIDA, 2012) encourages wraparound service provision. The wraparound services that are core to the comprehensive paradigm shift from one-dimensional approaches to those that address individuals’ multiple role demands in the spheres of family, the workplace and community life.
Treatment philosophies alone do not determine which treatments a center selects to implement and sustain. With the exception of the Minnesota Model (Cook, 1988), no clear models have been available to guide decisions on different arrays of treatment strategies. Centers’ treatment strategies are thus dependent on varying access to information about new practices, structural opportunities to accommodate them, and funding to support them. A number of studies shed light on the importance of these factors, indicating that centers with national accreditation and more staff with advanced degrees tend to have greater access to information about new treatments and absorptive capacity to adopt them (Ducharme et al., 2006, Knudsen and Roman, 2004). Similarly, structural resources, like access to prescribing staff and infrastructural supports for coordinated care found in larger, older, and hospital-based programs, have been demonstrated to facilitate innovation (Abraham et al., 2010, Knudsen et al., 2007, Roman and Johnson, 2002). Finally, center reliance on competitive funding may increase pressure to provide a wide-range of treatments as is the case with entrepreneurial centers dependent on private funds, clients with insurance, or with for-profit status (Aletraris et al., 2015, Knudsen et al., 2006, Knudsen et al., 2007).
Section snippets
Sample and procedures
Data were aggregated from three studies from the National Treatment Center Study, a family of studies of SUD programs in the U.S., for the purpose of secondary analysis. These studies produced three datasets, a sample of: nationally representative centers, privately funded centers, and centers operating within NIDA's Clinical Trials Network (CTN), which were combined in one dataset (N = 775). The data from each were collected between 2009 and 2012. The period of data collection is timely as the
Results
Descriptive statistics are shown in Table 1. Overall use of MAT was low. Less than 30% of centers utilized each MAT. More variability was evident for psychosocial treatments; 34% used contingency management, 78% used MI, 45% used MET, and 18% used MST. Among alternative approaches, art therapy was the most prevalent with 38% using it, while 18% used music therapy, and 10% used acupuncture. Measures of treatment philosophy indicated that 56% of centers provided space for 12-step meetings.
Discussion
We found three profiles representing varying degrees of treatment diversity. First, most centers relied heavily on MI/MET, which are behavioral treatments compatible with the 12-steps (Miller, 1999, Schilling et al., 2002). These centers were unlikely to use MAT or other psychosocial treatments, consistent with previous findings that MAT or psychosocial treatments that promote external motivation are often incompatible with internally motivated treatments (McGovern et al., 2004, Oser and Roman,
Conclusion
In the current study, analyses revealed three discrete TSPs evident in U.S. SUD treatment centers sampled between 2009 and 2012. We conducted analyses of philosophical and structural characteristics associated with these profiles and revealed considerable variation. We found that the majority of facilities relied primarily on MI/MET, while smaller proportions offered comprehensive treatment options, including MAT, or focus on psychosocial and alternative care. We found that centers with
Role of funding source
Data collection for these analyses was funded by the National Institute on Alcohol Abuse and Alcoholism (Grant R01AA015974) and the National Institute on Drug Abuse (R37DA013110 and R01DA14482).
Conflict of interest
The authors have no conflict of interest to declared.
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