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Notes: This research relies on a useful focus for finding the contribution of the psychotherapist to the outcome of the treatment: the outcomes of each therapist's caseload. Our data consist of 22 therapists' caseloads within seven samples of drug-addicted and depressed patients. We concluded that (a) there were important differences in the improvement levels and post-treatment outcomes of patient caseloads among the therapists sampled, and (b) these differences in improvement could not be explained by differences in patient background or severity. Some of the differences appeared to reflect the therapists' efficacy with their patients because (a) a unique feature of the design was that three therapists took part in more than one study and therefore more than one caseload; these three therapists showed a similar efficacy in each new caseload, (b) At this time, it may be that the safest basis for choosing therapists for research studies or for clinical purposes is their “work sample” record of efficacy with their previous caseloads.

Notes: While some aspects of addiction can be studied in laboratory or controlled settings, the study of long-term recovery management and the health services that support it requires going out into the community and dealing with populations and systems that are much more diverse and less under our control. This in turn raises many methodological challenges for the health service researchers studying alcohol and other drug abuse treatment. This paper identifies some of these challenges related to the design, measurement, implementation and effectiveness of health services research. It then recommends 25 strategies (and key primers) for addressing them: (1) identifying in advance all stakeholders and issues; (2) developing conceptual models of intervention and context; (3) identifying the population to whom the conclusions will be generalized; (4) matching the research design to the question; (5) conducting randomized experiments only when appropriate and necessary; (6) balancing methodological and treatment concerns; (7) prioritizing analysis plans and increasing design sensitivity, (8) combining qualitative and quantitative methods; (9) identifying the four basic types of measures needed; (10) identifying and using standardized measures; (11) carefully balancing measurement selection and modification; (12) developing and evaluating modified and new measures when necessary; (13) identifying and tracking major clinical subgroups; (14) measuring and analyzing the actual pattern of services received; (15) incorporating implementation checks into the design; (16) incorporating baseline measures into the intervention; (17) monitoring implementation and dosage as a form of quality assurance; (18) developing procedures early to facilitate tracking and follow-up of study participants; (19) using more appropriate representations of the actual experiment; (20) using appropriate and sensitive standard deviation terms; (21) partialing out variance due to design or known sources prior to estimating experimental effect sizes; (22) using dimensional, interval and ratio measures to increase sensitivity to change; (23) using path or structural equation models; (24) integrating qualitative and quantitative analysis into reporting; and (25) using quasi-experiments, economic or organizational studies to answer other likely policy questions. Most of these strategies have been tried and tested in this and other areas, but are not widely used. Improving the state of the art of health services research and bridging the gap between research and practice do not depend upon using the most advanced methods, but rather upon using the most appropriate methods.

Notes: Aims. To evaluate the effectiveness and value of social services added to standard addiction rehabilitation. Design. A controlled, quasi-experimental, field study with repeated measures. Setting. Conducted in two groups of publicly supported outpatient addiction treatment programs. Control programs provided standard, twice-weekly, outpatient group counseling. "Enhanced" programs provided standard counseling but also case managers to coordinate and expedite use of pre-contracted medical screenings, housing assistance, parenting classes and employment services. Measurements. The Addiction Severity Index was used to record the nature and severity of patient problems in seven areas at treatment admission and at 6-month follow-up. Services provided during treatment were measured with the Treatment Services Review. Measures were taken on consecutive samples of patients admitted to all programs-before enhancements (wave 1, N = 431)-and at 12 months (wave 2, N = 710); and 26 months following enhancements (wave 3, N = 187). Findings. There were no significant differences in patient characteristics, treatment services or 6-month outcomes of the two sets of programs in wave 1. Wave 2 and especially wave 3 enhanced programs provided significantly more social and medical services than control programs. Patients treated in enhanced programs showed significantly less substance use, fewer physical and mental health problems and better social function at 6-months than Controls. Conclusions. Adding social services to public sector programs substantially improved the outcomes of addiction treatment. Changes in "real world" systems require time to implement; early evaluations may fail to capture the full impact of those changes.

Notes: Historically, addiction treatments have been delivered and evaluated under an acute-care format. Fixed amounts or durations of treatment have been provided and their effects evaluated 6–12 months after completion of care. The explicit expectation of treatment has been enduring reductions in substance use, improved personal health and social function, generally referred to as ‘recovery’. In contrast, treatments for chronic illnesses such as diabetes, hypertension and asthma have been provided for indeterminate periods and their effects evaluated during the course of those treatments. Here the expectations are for most of the same results, but only during the course of continuing care and monitoring. The many similarities between addiction and mainstream chronic illnesses stand in contrast to the differences in the ways addiction is conceptualized, treated and evaluated. This paper builds upon established methods of during-treatment evaluation developed for the treatment of other chronic illnesses and suggests a parallel evaluation system for out-patient, continuing-care forms of addiction treatment. The suggested system retains traditional patient-level, behavioral outcome measures of recovery, but suggests that these outcomes should be collected and reported immediately and regularly by clinicians at the beginning of addiction treatment sessions, as a way of evaluating recovery progress and making decisions about continuing care. We refer to this paradigm as ‘concurrent recovery monitoring’ and discuss its potential for producing more timely, efficient, clinically relevant and accountable evaluations.

Notes: Abstract Aims. This study examined the functional and substance use status of methadone maintenance (MM) patients at treatment entry and 2 and 7 months later. Design. Two groups of subjects were identified for longitudinal follow-up, those in continuous MM treatment and those who left treatment. Setting. The study was conducted at the Philadelphia Veterans Affairs Medical Center MM Program. Participants. Subjects were 157 men admitted to treatment. Measurements. Change was evaluated using the Addiction Severity Index and urinalysis results. Findings. Both groups of subjects reported significant reductions in drug use and increases in psychosocial functioning from admission to month 2, but demonstrated no significant changes from months 2 to 7. Subjects who left treatment, however, had more heroin use and criminal activity at all evaluation points than subjects who remained in treatment. Urinalysis data also suggested that subjects who left treatment were using drugs more frequently while in treatment than were those subjects who remained continuously enrolled in MM. Finally, subjects who left treatment spent more time in restricted environments (e.g. inpatient treatment, jail) at follow-up. Conclusions. Services may need to be enhanced to foster continuing progress in patients who remain in MM treatment and to retain those patients with more severe problems who leave treatment early.