Substance Abuse Outreach Programs: Comparative Effectiveness
Gottheil et al (1997) examined the effects of an outreach program designed to engage substance abuse clients who failed to attend their initial appointment. An outpatient treatment facility attempted to contact by phone clients who did not show up for their first appointment. Overall, 36% of clients showed up for their initial appointment. The clinic was then able to contact and reschedule 44% of the clients who failed to show. Out of this group, 49% kept their appointment. By instituting this simple outreach program, the clinic was able to increase the percentage of patients engaged in treatment from 36% to 46%. The study also found that the group that was brought to treatment through the additional outreach was no more likely to drop out of treatment then the group who kept their scheduled initial appointment.
There are several outreach programs that attempt to reduce barriers to treatment and therefore engage a larger population of substance abusers. Freidmann et al (2001) analyzed outreach efforts which provided free transportation to treatment. The goal of the study was to determine if providing either transportation to treatment from a contracted service or vouchers for free public transportation would improve retention. The authors examined data
collected from the Drug Abuse Treatment Outcome Study (DATOS), a nationally representative study of persons entering drug abuse treatment between 1991 and 1993. 1,144 clients in 22 outpatient methadone maintenance programs (OMM) and 2,031 clients in 22 outpatient drug-free programs (ODF) were included in the sample. Treatment retention was examined at 365 days for OMM and 90 days for ODF programs. Approximately 32% of OMM and 50% of ODF programs offered one of the two transportation options studied. Provision of car, van or contracted transportation services improved client retention in outpatient drug treatment. Offering vouchers or payment for public transportation had no effect on OMM retention and a negative effect on ODF retention rates.
Outreach programs that offer free treatment or coupons to potential clients have recently received some attention. An early study by Jackson et al (1989) found that coupons issued by the New Jersey Department of Health for free treatment at a 21-day detoxification program was an effective incentive in attracting street drug users. In fact, 45% of those who redeemed coupons had no previous drug abuse treatment. Of those entering through the use of coupons, 28% continued in the treatment program by phasing into methadone maintenance after the detoxification period.
Sorensen et al (1993) attempted to determine not only the degree to which a coupon distribution program reached drug users at risk of HIV infection but also how well coupon recipients performed in treatment compared to others. Outreach workers distributed approximately 400 coupons for free services at a 21-day detoxification outpatient treatment facility. Results show that patients who presented to treatment were more likely to have never been in treatment before (28% to 13%) and more likely to have shared needles in the last thirty days (39% to 31%). No difference was found between the coupon group and the non-coupon group when comparing number of days in treatment. The program was effective in engaging a larger number of treatment naïve patients from a more at risk population. One problem with this program was that because of limited treatment slots, after the 21-day detoxification many patients returned to a drug-using environment. As seen in the Jackson et al (1989) research, coordination of care would most likely increase long term results.
Maddux et al (1994) found that the elimination of fees to a methadone maintenance program improved retention rates. In the study, 152 patients were randomly assigned to a fee or no-fee group. The fee group was required to pay $2.50 per day for treatment. 54% of the no-fee subjects were retained in treatment for one year compared to 34% of the fee group. The authors did not discuss any demographic differences between the groups.
Wells et al (1994) examined demographic characteristics ofpatients entering free treatment at a methadone maintenance clinic. The results were compared with the demographic characteristics of patients entering the clinic through normal means the previous two years. Similar to Sorensen et al (1993) 23% of patients had no previous experience with a methadone maintenance treatment program. The authors did not provide a percentage of first time users for the control group. They also found that patients in the free treatment program were more likely to be African-American, older
and had fewer years of education than the control group. The authors conclude that these differences indicate that free treatment opened opportunities to patients who have difficulty accessing treatment under normal conditions.
Street outreach efforts designed to increase treatment entry to a Denver methadone maintenance program were discussed by Booth et al (2003). Participants were recruited through street outreach and were randomly assigned to free treatment for 90 days or required to pay. All patients were provided transportation to treatment, rapid intake and a waiver of the treatment entry fee. One third of those reached through outreach efforts entered treatment. Of those entering treatment, 65.5% had received a free treatment coupon. As seen in previous studies the patients desire to enter treatment was the greatest predictor of treatment entry. This study lends credence to outreach efforts encouraging treatment entry to chronic out-of-treatment drug injectors.
Other outreach programs did not have the same results. Melchior et al (1999) describe an outreach program targeting women with multiple vulnerabilities, including substance abuse, domestic violence, HIV risk and mental illness. The authors attempted to determine how much outreach was needed to link the substance abusing women with a treatment program. Participants were contacted through street outreach or at one of the program’s two drop-in centers. A total of 665 women were enrolled in a community-based outreach program focused on preparing women for entry into treatment, based on the States of Change Model. The States of Change model determines a client’s readiness for change which is then used to determine when a patient should be engaged in treatment. The outreach program was designed to help
them move through the various stages until they were ready to enter treatment. Of the original 665 participants, 82.9% received referrals to treatment and of these 51.4% were verified as having entered treatment. They also found that women who received referrals did so fairly early in the outreach program. Fewer outreach contacts tended to predict receiving a drug treatment referral. Similar results were found for women who received referrals who then entered treatment. Again, participants who received fewer contacts from the time of receiving a referral to drug treatment were more likely to actually enter treatment. The study seems to support the States of Change model in that women who initially stated that they had a high desire to make a change were the ones receiving referrals and entering treatment. The authors also state that individuals seem many times on the streets were less likely to be referred to services. This study supports the theory that a clients’ internal motivation is the main predictor of successful treatment entry.
Outreach, either from specific programs initiated by treatment facilities or from the educated response of the community, can have a dramatic effect on engaging and retaining substance abusers in treatment. The literature reviewed shows that there are several cost effective outreach measures that will educate the community to respond in a way that will facilitate treatment entry and retention. There are also several examples of successful outreach programs initiated by treatment facilities that directly target the substance abusing population. Both show promise as ways treatment facilities can strive to meet the goals outlined by the Network for the Improvement of Addiction Treatment.
