San Francisco Treatment Research Center

Objective: Accepted treatments for cigarette smoking rarely achieve abstinence rates of >35% at 1 year. Low rates may reflect failure to provide extended and multifocal treatment for this complex and chronic addiction. Using a chronic disease model of smoking, the authors undertook a study to determine the effects of long-term antidepressant and psychological treatment. Method: One hundred sixty smokers of greater than or equal to10 cigarettes/day were randomly assigned to one of four treatment conditions in a two-by-two (nortriptyline versus placebo by brief versus extended treatment) design. All subjects received 8 weeks of a transdermal nicotine patch, five group counseling sessions, and active or placebo treatment. Interventions for subjects in brief treatment ended at this point. Subjects in extended treatment continued taking drug or placebo to week 52 and received an additional 9 monthly counseling sessions, with checkup telephone calls midway through each session. Subjects were assessed at baseline and weeks 12, 24, 36, and 52. The principal outcome variables were repeated abstinence at each assessment after the first over a 1-year period and a point prevalence of 7 days of abstinence. Results: At week 52, point-prevalence abstinence rates with missing subjects imputed as smokers were 30% for placebo brief treatment, 42% for placebo extended treatment, 18% for active brief treatment, and 50% for active extended treatment. With missing subjects omitted, these rates were 32%, 57%, 21 %,and 56%, respectively. Conclusions: Comprehensive extended treatments that combine drug and psychological interventions can produce consistent abstinence rates that are substantially higher than those in the literature.

Aims This study compared 5-year treatment outcomes of older adults to thoseof middle-aged and younger adults in a large managed care chemical dependency program. We examined age group differences in individual, treatment and extra-treatment factors, which may influence long-term outcome. Design Seventy-seven per cent of original study participants completed a telephone interview 5 years after out-patient chemical dependency treatment at Kaiser Permanente. This sample (N = 925) included 65 patients aged 55-77, 296 patients aged 40-54 and 564 patients aged 18-39 (age at baseline). Measurements Measures at follow-up included alcohol and drug use, Addiction Severity Index (ASI), Alcoholics Anonymous Affiliation Scale, social resource and self-reported health questions. Mortality data were obtained from contact with family members of patients as well as automated health plan records. Findings Older adults were less likely to be drug-dependent at baseline than younger and middle-aged adults, and had longer retention in treatment than younger adults. At 5 years, older adults were less likely than younger adults to have close family or friends who encouraged alcohol or drug use. Fifty-two per cent of older adults reported total abstinence from alcohol and drugs in the previous 30 days versus 40% of younger adults. Older women had higher 30-day abstinence than older men or younger women. Among participants dependent only on alcohol, there were no significant age differences in 30-day abstinence. In logistic regression analysis, age group was not significant. Variables associated with greater age that independently predicted 30-day abstinence in the logistic regression model included longer retention in treatment and having no close family or friends who encouraged alcohol or drug use at 5 years: female gender was also significant. Conclusions Results indicate that older adults have favorable long-term outcome following treatment relative to younger adults, but these differences may be accounted for by variables associated with age such as type of substance dependence, treatment retention, social networks and gender. Age differences in these characteristics inform intervention strategies to support long-term recovery of older adults and provide direction for investigation of how age affects outcome.

Objective: Psychiatric clinical studies, including those in drug abuse research, often provide data that are challenging to analyze and use for hypothesis testing because they are heavily skewed and marked by an abundance of zero values. The authors consider methods of analyzing data with those characteristics. Method: The possible meaning of zero values and the statistical methods that are appropriate for analyzing data with many zero values in both cross-sectional and longitudinal designs are reviewed. The authors illustrate the application of these alternative methods using sample data collected with the Addiction Severity Index. Results: Data that include many zeros, if the zero value is considered the lowest value on a scale that measures severity, may be analyzed with several methods other than standard parametric tests. It zero values are considered an indication of a case without a problem, for which a measure of severity is not meaningful, analyses should include separate statistical models for the zero values and for the nonzero values. Tests linking the separate models are available. Conclusions: Standard methods, such as t tests and analyses of variance, may be poor choices for data that have unique features. The use of proper statistical methods leads to more meaningful study results and conclusions.

This study examines how individual patient characteristics predict substance abuse treatment initiation among older adults, in an investigation based on the behavioral health service use model. Analyses tested the impact of demographic factors, substance abuse symptoms, depression and cognitive status on subsequent treatment initiation. The sample included 250 older male veterans screened for substance abuse problems during inpatient medical treatment, who also participated in a clinical evaluation for substance abuse treatment. Measures included demographics and CAGE alcohol screening score. A subset of patients also completed the Michigan Alcohol Screening Test-Geriatric Version (MAST-G), Hamilton Depression Scale (HAM-D), and Folstein Mini Mental State Exam (MMSE). Patients who initiated treatment following evaluation had more years of education, better cognitive status, and more symptoms of substance abuse and depression, compared with patients who did not initiate treatment. In logistic regression analysis, CAGE and MMSE scores independently predicted treatment initiation. Findings contribute to the understanding of how clinical characteristics of older adults affect substance abuse treatment initiation.

Understanding the long-term course of problematic drinking is a fundamental concern for health services research in the alcohol field. The stability of, or change in, the course of drinking-especially heavy drinking-has both theoretical and applied relevance to alcohol research. We explore the application of latent class growth modeling to 5 years of survey data collected from dependent and problem drinkers-some not in treatment at baseline-in an attempt to uncover prototypical longitudinal drinking patterns. Results indicated that five profiles of drinkers can be used to represent their longitudinal course of alcohol consumption: early quitters (N = 88), light/non-drinkers (N = 76), gradual improvers (N = 129), moderate drinkers (N = 229), and heavy drinkers (N = 572). Significant baseline factors included ASI drug severity, dependence symptoms, and marital status. Attendance at AA meetings, the size of one's heavy drinking and drug using social network, past treatment, receiving suggestions about one's drinking, and contacts with the medical system were significant influences. The size of heavy drinking and drug using social networks was noticeably larger for the heavy drinkers. Findings also support the usefulness of a semi-parametric latent group-based approach as a tool for analyzing alcohol-related behaviors. (C) 2004 Elsevier Ireland Ltd. All rights reserved.

Objective: To examine the predictive value of demographic characteristics and substance abuse indicators to explain treatment seeking for substance abuse problems among older male medical patients. Design: Longitudinal analysis of screening data and treatment seeking behavior. Setting: Inpatient medical and outpatient substance abuse treatment center. Participants: Participants in the study were 855 medically ill male veterans aged 55 and over, who were screened for alcohol problems during inpatient medical treatment after clinician referral. Measurements: The CAGE alcohol screen, drug use and demographic measures administered at time of screening. Predictors of treatment seeking in the sample were examined using structural equation modeling. Results: Expressed interest in treatment and later attendance at a pre-treatment evaluation were associated with younger age and a higher CAGE alcohol screening score. Being unmarried and using drugs in addition to alcohol were associated with treatment interest but not with evaluation attendance. In the path model tested, the effect of higher CAGE score partially explained the effect of younger age on treatment seeking. Conclusions: The model examined shows utility in predicting alcohol treatment seeking in this sample. Age-related factors may deter treatment seeking among older male medical inpatients.

Cognitive behavioral psychotherapy is readily adaptable to use with older adults. This review integrates discussion of cognitive and behavioral intervention techniques with recent research and clinical observations in the field of gerontology. Cognitive changes with aging, personality and emotional development, cohort effects, and the social environment of older adults are discussed in relation to psychotherapy. Applications of cognitive behaivor therapy to specific late life problems such as chronic illness and disability, depression, alcoholism and insomnia are presented. The effectiveness of cognitive and behavioral techniques in treating these disorders in older adults is discussed.