(1) Physicians still need to overcome attitudinal and practical barriers to trial participation, (2) more support for physicians is needed, (3) surgeons may play a pivotal role in the recruitment of patients to adjuvant therapy trials, and (4) garnering patient enthusiasm for trial participation and involving them in the choice of adjuvant therapy may be key components to increasing trial enrollment.

Philadelphia attempted to expand the access to and continuity of addiction treatment by focusing on the 15% of patients who received multiple, detoxification-only (MDO) treatments each year. Clinical Case Managers at five detoxification centers encouraged MDO patients to continue care following detoxification in methadone, residential, or outpatient rehabilitation, and sustain improvements, and they recommended opening detoxification access for additional patients as well. System administrative information was available for one year prior and three years during the intervention. Counts of unduplicated patients within each year and measures of the length and type of treatment episodes determined the intervention effects. Records from a sub-sample of 100 MDO patients were examined to assess specific changes in system utilization. Over three years, 890 MDO patients were case managed and had received assessment, referral, and transport to health care and sober living. The sub-sample of case-managed MDO patients showed a 55% reduction in detoxification-only admissions, a 70% increase in use of rehabilitation, and a twenty-day increase in the average length of stay per episode. Though there are noted limitations in the evaluation design, the findings are consistent with the view that individual case management of MDO patients may improve the clinical appropriateness and administrative efficiency of public addiction treatment.

Objectives. Based on the concept of "stage of change," this study examines the relationship between patients' motivation for substance abuse treatment and their posttreatment improvements in the areas measured by the Addiction Severity Index (ASI; alcohol, drug, medical, psychiatric). We attempt to answer the following questions: Do clients' perceptions of "need for drug, alcohol, psychiatric, and medical treatment" at admission predict their improvements on these problems at 6-month follow-up? How do clients' perceived needs contribute to their use of treatment and their reported change? Methods. Clinical interview data (N = 696) collected using the ASI from the Target Cities Project in the city of Philadelphia in 1993 and 1995. Results. Clients' motivation made a substantial difference in their improvement following treatment in all problem areas. Clients who said treatment was even slightly important on the ASI at admission made more changes than clients who reported that treatment was "not at all" important. Even when the motivation groups were approximately equated for lifetime problem severity there was still a significant effect of recent motivation as expressed on the ASI. Conclusions. These data are consistent with other findings from the "stage of change" literature suggesting that treatment is only important for patients who are ready or at least somewhat motivated to receive it. These findings underscore the importance of efforts to increase patients' readiness for treatment in order to achieve better treatment effects.

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