Catálisis

First, dropout, which is common in studies including patients with a substance use disorder and may be greater in real world clinical samples, is an outcome that validates the ASAM matching hypothesis in this study, but also appears to have impacted our statistical power. Given the trends we see for stimulants and sedatives in the first paper, larger samples at reassessment might have yielded greater statistical power, particularly with the GLM analysis. Prior  studies  reporting  rates  with  only  60%  of  the  “easiest  to  locate”  subsample  of  an  enrolled   population have been found to provide valuable information and only to be minimally

different when compared to complete samples, and study attrition may also be unpredictable from patient characteristics (Hanstein, Downey, Rosengren, & Donovan, 2000). It is

important to know that our study offered no incentives in the form of money or other benefits to induce patients to complete their follow-up interviews, although compensation might have increased the follow-up rate. However, this can be viewed as strength of our study as patients participated without compensation. Although future research should strive for higher follow- up rate by recruiting significant others and employ other outreach efforts, as Lauritzen,

Discussion

72 Ravndal, and Larsson (2012) did. Their study had high rates (over 90% at first interview) at all time-points with a Norwegian drug population.

Second, the lack of randomization might have biased against the results, as the matched group at baseline showed a tendency to be younger and had higher ASI CS Employment, Drug, legal and Psych scores than the mismatched conditions. Also the use of paired t-test does not allow for covariate adjustment, it only allows us to say that correct LOC placement appears to have had an effect in reducing severity on several dimension in the matched group. There can also be other demographic variables causing the effect we see, together with differences in how well the clinics used in this study follow the Criteria described by ASAM. These differences might have reduced the extent to which matching could demonstrate a clinical outcome advantage over mismatching. The naturalistic design might also have caused the lack of significant reduced severity on multiple variables in the Dual Diagnosis Capable group that we saw from the third article, caused by a small group size and different gender distribution compared to the two other groups studied. However, the use of such a design made it possible to investigate the naturalistic prevalence of treatment needs among patients with co-occurring substance use disorder and psychological disorders in the treatment seeking population in this region. Nevertheless, the outcome findings are substantially in line with previous validation studies on the ASAM Criteria, and the naturalistic design can also be viewed as beneficial as it reflects the naturally-occurring treatment-seeking population in this region.

Third, a relevant methodological problem is that differences between the ASAM Software- obtained treatment recommendation and clinically derived LOC can be a result of the numbers of categories available and how experienced the TAU centers was. If the clinicians had the full continuum of four LOC available in the community as the ASAM Criteria recommend, then discrepancies could have been different from those seen here. Also how experienced the clinics are with assessing the patients will affect their recommendation. A

solution to this could have been to categories them from their experience, but since no golden standard exited and a harmonization of practice was the goal, this was left untouched. Also the lack of control over important clinical issues like; execution of treatment therapy, the effect of clinical relations the patient has on treatment attendance and outcomes, and if the LOC are fully categorized and functioning like described by the ASAM Criteria might have affected the results. In order to be a fully functioning LOC based on the ASAM Criteria means that setting, therapies, personnel groups, and documentation need to be following the description made by the criteria to fully be capable to handle the patient’s needs. Otherwise it does not follow the criteria set for a successful treatment outcome for the patients.

Fourth, The ASI is the most widely-used severity assessment in addiction (McLellan et al., 1992), and the reliability and validity of the European ASI and its Composite Subscale score method are well documented (Lauritzen & Ravndal, 2004). In the measurement of convergent validity, the ASI CSs were used, and some of these questions are used in the ASAM

computerised algorithm. The ASI questions obtain approximately 50% of the data needed for the ASAM Criteria Software algorithm; however, the two instruments have very different scoring logics:  the  ASI’s  is  actuarial whereas  the  ASAM  Criteria’s  is  hierarchical. Therefore, these two approaches have similar, reliable data acquisition, but different scoring – making them relevant and valuable for comparison but non-overlapping. The ASI CSs should therefore be different across patients who are recommended by the ASAM Criteria for different levels of care. Thus, while worthy of mention, the danger of overlap is minimal. Fifth, since we lack categorisation of the LOC included in this study with regards to their Dual Diagnosis capability we do not have the ability to conclude if the results are a direct result of co-occurring needs being met, but we suspect this might be the case since the Dual Diagnosis Enhanced group improved as well as the Addiction Only Services group. The high number of patients in need for intense services in this study can be due to the fact that

Discussion

74 symptoms are higher when entering treatment. But patients have also been found to

underestimate their psychological problems when entering treatment, influenced by their more optimistic view after treatment has been assigned with treatment expectancies (Rokkan & Brandtsberg-Dahl, 2003). This can lend support for a true picture of the prevalence of needs for integrated services in this region.