Patients' perspective on the process of change in substance abuse treatment

The Discursive Configuration of the Therapeutic Community for Substance Users: Positioning and Ethnopsychological Processes Concerning Entry

Therapeutic communities face high drop-out rates and general distrust of their effectiveness among substance users. Actively involving users early in treatment promotes greater compliance with the treatment and is predictive of better outcomes. However, users often occupy a passive and subordinate role, exacerbated by the lack of research that explores their perspectives, beliefs, and experiences. This study examined the discourses of 57 consumers who were part of a community for less than 15 days, investigating the meanings attributed to service entry and treatment. A protocol of four written open-ended questions was employed and analysed through discourse analysis and positioning theory. The results indicate that participants configure the community as a place symbolically and spatially distinct from the rest of the world, where they isolate themselves to seek support during times of extreme difficulty. However, what they are seeking is a solution to acute distress caused by substance use, intertwined with social, economic, and relational issues. The concept of treatment is built on the image of the substance user as an individual making a weak request for help, attributing the problem solely to drugs and exhibiting reduced agency in addressing their issues. The collected texts provide a better understanding of the experiences of new users, highlighting the importance of co-constructing personalised projects that empower consumers to feel actively involved in their own change, exploring their theories and definitions of self to structure pathways based strictly on their needs.

A systematic review and meta-analysis of the efficacy of the long-term treatment and support of substance use disorders

RATIONALE

The reconceptualization of substance use disorders (SUD) as a chronic phenomenon calls for a paradigm shift in service provision, particularly by way of long-term treatment and support. Studies that have evaluated the efficacy of long-term treatment models seem to indicate that they are an improvement on more standard short-term treatments, even though these studies do not take the durations into consideration.

OBJECTIVE

Measure the efficacy of SUD treatments and support lasting 18 months or more regarding their ability to decrease substance use as compared to shorter treatments.

METHODS

A meta-analysis based on a systematic literature review was conducted. Eight databases were consulted for peer-reviewed studies. Certain variables were coded as moderators: intervention length, participant characteristics, and treatment characteristics.

RESULTS

The main results suggest that the people who received a planned long-term treatment or support had a 23.9 % greater chance of abstaining or consuming moderately than did people who received a shorter standard treatment (OR = 1.347 [CI 95 % = 1.087-1.668], p < .006, adjusted OR = 1.460 [CI 95 % = 1.145-1.861]). None of the moderation analyses revealed any variation in the efficacy of the long-term treatments and support.

CONCLUSIONS

The reconceptualization of the SUD as a chronic disorder among people with this problem leads us to reconsider both the length of the services provided and the paradigms underlying their organization.

The quality in psychiatric care-Addiction outpatient instrument: Psychometric properties and patient views of the quality of care

Aim

The aim of the study was to evaluate the psychometric properties and factor structure of the Quality in Psychiatric Care—Addiction Outpatient (QPC‐AOP) instrument and to describe the experiences with the quality of care among addiction outpatients.

Design

The study has a cross‐sectional design.

Methods

A sample of 244 patients with addiction and psychiatric disorders completed the QPC‐AOP.

Results

Confirmatory factor analysis showed adequate to excellent goodness‐of‐fit indices supporting the 9‐factor structure of the QPC‐AOP. The results thus demonstrate that the concept of quality of care to a large extent is equivalent among outpatients from general psychiatry and from outpatient addiction services. Internal consistency for the full QPC‐AOP was adequate, but poor for some of the separate factors. The patients’ ratings of quality of care were generally high; the highest rating was for Encounter and the lowest for Discharge.

Treatment trajectories and barriers in opioid agonist therapy for people who inject drugs in rural Puerto Rico

BACKGROUND

Research has shown medication for opioid use disorder (MOUD) to have positive effects, including reducing HIV and HCV transmission, but important barriers to access remain among people who inject drugs (PWID). Barriers include lack of social and familial support, bureaucracy, distance to treatment, poverty, and homelessness. However, we know little about how these barriers interact with each other to shape PWID's drug treatment access and retention.

METHODS

We used qualitative methods with a dataset from a study conducted during 2019 with 31 active PWID residing in rural Puerto Rico. The study gathered ethnographic data and narratives about treatment trajectories to document the lived experiences of PWID as they moved in and out of treatment.

RESULTS

Participants were at least 18 years old; 87.7% were male, the mean age was 44.1 years, and the mean age at first injection was 22 years. Participants identified homelessness, lack of proper ID or other identifying documents, and previous negative experiences with MOUD as the main barriers to treatment entry and retention. In addition, PWID's belief that MOUD simply substitutes an illegal drug for a legal one, while furthering drug dependence by chronically subjecting patients to treatment, constitutes an additional barrier to entry. Findings from this study demonstrate that MOUD barriers to access and retention compound and are severely affected by poverty and other forms of vulnerability among PWID in rural Puerto Rico.

CONCLUSION

Policies to increase access and retention should consider barriers not in isolation but as an assemblage of many factors.

A meta-analysis of the effect of substance use interventions on emotion outcomes

OBJECTIVE

Emotional distress has been posited as a key underlying mechanism in the development and maintenance of substance use disorder (SUD), and patients seeking SUD treatment are often experiencing high levels of negative emotion and/or low levels of positive emotion. But the extent to which SUD interventions impact emotional outcomes among general SUD populations is yet unquantified. The current meta-analysis aims to fill this gap.

METHOD

A total of 11,754 records were screened for randomized, controlled trials examining the effect of behavioral SUD interventions on emotion outcomes. Our search yielded a total of 138 effect sizes calculated based on data from 5,146 individuals enrolled in 30 independent clinical trials. Random-effects meta-analysis was used to calculate pooled effect sizes, and metaregression analyses examined study-level moderators (e.g., intervention type).

RESULTS

Findings indicated a small but significant effect of SUD interventions on emotion outcomes, d = 0.157, 95% CI [0.052, 0.262] (k = 30). The effect size for negative emotion was nominally bigger, d = 0.162, 95% CI [0.056, 0.269] (k = 30), whereas the effect for positive emotion did not reach statistical significance, d = 0.062, 95% CI [-0.089, 0.213] (k = 7). Studies featuring SUD interventions designed to specifically target emotions (i.e., affect-regulation, mindfulness-based treatments) produced larger reductions in negative emotion compared with studies featuring interventions that did not contain specific emotion modules (e.g., contingency management).

CONCLUSIONS

Findings suggest that SUD interventions-especially mindfulness-based and affect-regulation treatments-indeed significantly reduce negative emotion, although relatively small effect sizes indicate potential room for improvement. Conclusions regarding positive emotion should be considered preliminary because of the limited numbers of samples assessing these outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Helpful Ingredients in the Treatment of Long-Term Substance Use Disorders: A Collaborative Narrative Study

Relatively few individuals with a substance use disorder (SUD) seek or receive treatment, and knowledge about the effective ingredients in SUD treatment, from the perspective of those who receive it, is scarce. Our study purpose was to explore the experiences of those with long-term SUDs and the aspects they found helpful during treatment and long-term recovery. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a long-term SUD, and who had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to study planning, preparation, and initial analyses. Participants preferred individualized, long-term treatment, and support from both therapists and other clients. They further acknowledged the importance of their own sense of responsibility for their treatment and recovery success. Greater focus should be placed on viewing long-term SUD as a long-term condition, similar to somatic diseases, and SUD treatment services should place greater emphasis on developing partnership care models, long-term monitoring and support, and actively engaging recovered clients in the care of others in SUD treatment.

How Social Relationships Influence Substance Use Disorder Recovery: A Collaborative Narrative Study

Individuals with a substance use disorder (SUD) often have fewer social support network resources than those without SUDs. This qualitative study examined the role of social relationships in achieving and maintaining stable recovery after many years of SUD. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a SUD and each of whom had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to the study planning, preparation, and initial analyses. The relationship that most participants described as helpful for initiating abstinence was recognition by a peer or a caring relationship with a service provider or sibling. These findings suggest that, to reach and maintain abstinence, it is important to maintain positive relationships and to engage self-agency to protect oneself from the influences of negative relationships. Substance use disorder service providers should increase the extent to which they involve the social networks of clients when designing new treatment approaches. Service providers should also focus more on individualizing services to meet their clients on a personal level, without neglecting professionalism or treatment strategies.

Rehabilitation of drug abusers: the roles of perceptions, relationships and family supports

The increase in the use, abuse and misuse of psychoactive substances is not just of concern to national government of different countries but poses a big problem to the international community as well as of a global public health challenge. The study explored the perceived influence of perceptions, relationships and family support on rehabilitation of drug abusers undergoing rehabilitation in a rehabilitation centre. The non-experimental study design was used. The study population was that of drug abuse patients undergoing rehabilitation in the Neuropsychiatric Hospital in Lagos. Purposive sampling technique was used to select the respondents. Forty drug abusers who were met the criteria of not being a psychotic, had undergone detoxification, in the last stages of rehabilitation and consented to voluntarily participate were interviewed using In-depth Interview Guide to collect qualitative data based on the objectives of the study. The data were manually content analysed. The drug abusers viewed their condition as a mental disorder, an illness, a bad and dangerous habit that can be treated. They viewed their relationship with their rehabilitation officers as professional and cordial, which is essential for the rehabilitation process. Financial, material and moral supports given by the family were identified as important catalysts for quick rehabilitation. Rehabilitation officers and policy makers should consider on improving on the role of professional relationships and family support in the rehabilitation process of drug abusers undergoing rehabilitation.

Navigation and Engagement: How Does One Measure Success?

At first glance, substance abuse treatment outcomes appear fairly easy to measure. Typical outcome measures include successful program completion, reduced drug use and illegal activity, and improved employment or school status. However, ethnographic examination of an adolescent treatment program shows that traditional outcome measures may differ from clients' experiences in treatment. While observing an outpatient adolescent treatment program and interviewing the clients, the authors documented the lived experiences of the youth and analyzed the cases comparatively. In this paper, two contrasting cases are presented to illustrate the complexity and contradictions between traditional outcome measures and perspectives on success held by clients and counselors. The concepts of navigation and engagement are applied to explore these perspectives of success. At the end of the article, some implications of these experience-based concepts for programs are considered, based not only on youth interviews, but also on our interviews with counselors. Finally, a general model that ties outcome evaluations more directly to the details of program experience is developed.

Preliminary findings on the association between clients' perceived helpfulness of substance abuse treatment and outcomes: does race matter?

BACKGROUND

Few studies examine the helpfulness and effectiveness of substance abuse treatment from the clients' perspective.

METHODS

The current secondary analysis examined the perceived helpfulness of substance abuse treatment components and its relationship to treatment outcomes among 387 Black and White adults participating in a multisite randomized clinical trial (RCT) of Motivational Enhancement Therapy. Throughout the 16-week RCT, participants self-reported substance use. Upon completion of treatment, participants completed a self-report measure assessing the perceived helpfulness of treatment components.

RESULTS

Black participants rated 9 out of 12 treatment components (e.g., "learning skills that will help me cope with my problems") as being more helpful than their White counterparts, even after controlling for age, gender, employment status, primary drug type, and treatment assignment. However, perceived helpfulness ratings were not associated with substance use outcomes among Black or White participants.

CONCLUSIONS

Clients' perceived helpfulness of treatment components is an important factor to consider in improving the delivery of substance abuse treatment, especially for Black adults.

Practical support aids addiction recovery: the positive identity model of change

BACKGROUND

There is a need for studies that can highlight principles of addiction recovery. Because social relationships are involved in all change processes, understanding how social motivations affect the recovery process is vital to guide support programs.

METHODS

The objective was to develop a model of recovery by examining addicted individuals' social motivations through longitudinal assessment of non-professional support dyads. A qualitative, longitudinal study design was used, combining focus groups and in-depth interviews with addicted individuals and their sponsors. Data were analyzed using the principles of grounded theory: open coding and memos for conceptual labelling, axial coding for category building, and selective coding for theory building. The setting was an addiction recovery social support program in Oslo, Norway. The informants included nine adults affected by addiction, six sponsors, and the program coordinator. The participants were addicted to either alcohol (2), benzodiazepines (1), pain killers (1) or polydrug-use (5). The sponsors were unpaid, and had no history of addiction problems.

RESULTS

Support perceived to be ineffective emerged in dyads with no operationalized goal, and high emotional availability with low degree of practical support. Support perceived to be effective was signified by the sponsor attending to power imbalance and the addict coming into position to help others and feel useful.

CONCLUSIONS

The findings appear best understood as a positive identity-model of recovery, indicated by the pursuit of skill building relevant to a non-drug using identity, and enabled by the on-going availability of instrumental support. This produced situations where role reversals were made possible, leading to increased self-esteem. Social support programs should be based on a positive identity-model of recovery that enable the building of a life-sustainable identity.

Treatment and recovery as perceived by patients with substance addiction

Social relations to therapists and other patients in treatment are important for positive and negative experiences among patients with substance addiction. * Improvements in mental health and substance use were considered as the more important areas of recovery among these patients. * One of the core reasons for premature dropout could be a failure to establish positive social relations and temptations to relapse to substance use. Abstract Research concerning patients with substance addiction and how they perceive their treatment remains scant. The objective of this study was therefore to examine positive and negative perceptions of treatment and recovery from the perspectives of these patients. Data were collected with semi-structured interviews among seven patients who completed treatment and six patients who prematurely dropped out from their programme (n= 13). Patients were strategically sampled from five inpatient facilities and one outpatient opioid maintenance treatment clinic located in two Norwegian counties. All interviews were transcribed and thereafter analysed with contextual content analysis aided by the qsr nvivo 8.0 software. This was carried out to obtain information about the manifest positive and negative content in the interviews. The results showed that the therapeutic alliance and mutual influences among patients were important for perceptions of treatment. Frequent staff turnover also related to these perceptions. The more important domains of recovery were psychosocial functioning and substance use. The implications of the results were discussed in relation to clinical practice and further research.

Patient satisfaction and sustained outcomes of drug abuse treatment

The authors investigated the relationship between patients' self-rated satisfaction with treatment services during and shortly after treatment with their drug use outcomes at one year follow-up, using a US national panel survey of patients in 62 methadone, outpatient, short-term residential, and long-term residential programs. A favorable evaluation of treatment near the time of discharge had a significant positive relationship with drug use improvement outcomes approximately one year later, independent of the separately measured effects of treatment duration, counseling intensity, patient adherence to treatment protocols, pre-treatment drug use patterns, and other characteristics of patients and treatment programs.

Effectiveness of an outreach treatment program for inner city crack abusers: compliance, outcome, and client satisfaction

In a randomized controlled trial the effectiveness of an outreach treatment program (OTP) was compared with standard addiction care services for hard-drug addicts in Rotterdam (The Netherlands). The study aimed at chronic, high-risk crack abusers who were insufficiently engaged in standard addiction treatment services. Data were collected from February 2000 to December 2001. A total of 124 subjects participated in the study at baseline. Follow-up data were available for 94 subjects. Outcome measures included treatment compliance, outcome, and satisfaction. Data were collected by means of monthly registrations, EuropAsi interviews and an evaluation form. There was a high compliance with OTP in the treatment group; the average length-of-stay was 6 months, with visits three times a week. Although both groups were well represented in standard care, participation was mainly based on methadone maintenance. Subjects treated in OTP showed significant improvements in physical health, general living conditions, and psychiatric status, but no change in employment, substance abuse, and legal status. The control group remained almost unchanged. Clients of OTP reported feeling very satisfied with their treatment. On-the-spot incentives and a positive relationship with the care provider were directly associated with treatment retention. An outreach treatment program, as conducted in this study, is associated with high compliance, general improvement, and treatment satisfaction. Characteristics of this treatment modality are (1) assertive outreach, (2) a mixed program with incentives, and (3) a strong focus on individual-bound therapy. Further research is needed with larger groups and similar conditions at baseline assessment.

On blending practice and research: the search for commonalities in substance abuse treatment

There has been a growing interest in the substance abuse treatment field in bringing together the treatment and research communities. While dialogues about logistical and philosophical issues are important, the development of shared core concepts could potentially be quite helpful in facilitating communication and creating common treatment and research goals. It is the contention of this paper that all psychosocial and, potentially, pharmacological treatments ideally address, in part or in full, three aspects of the self--the capacity to regulate emotional and behavioral expression, the ability to engage in future-oriented, goal-directed behavior, and the development of nonaddict and/or recovery-oriented identities. Examples from the research and treatment literature are provided.

Theory-based active ingredients of effective treatments for substance use disorders

This paper describes four related theories that specify common social processes that protect individuals from developing substance use disorders and may underlie effective psychosocial treatments for these disorders: social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. It then provides an overview of the rationale and evidence for four effective psychosocial treatments for substance use disorders: motivational interviewing and motivational enhancement therapy, 12-step facilitation treatment, cognitive-behavioral treatment and behavioral family counseling, and contingency management and community reinforcement approaches. The presumed active ingredients of these treatments are described in terms of how they exemplify the social processes highlighted by the four theories. The identified common components of effective treatment include support, goal direction, and structure; an emphasis on rewards that compete with substance use, a focus on abstinence-oriented norms and models, and attempts to develop self-efficacy and coping skills. Several issues that need to be addressed to enhance our understanding of the active ingredients involved in effective treatment are discussed, including how to develop measures of these ingredients, how well the ingredients predict outcomes and influence conceptually comparable aspects of clients' life contexts, and how much their influence varies depending upon clients' demographic and personal characteristics.

Buprenorphine substitution treatment in France: drug users' views of the doctor-user relationship

The French system for drug substitution, or maintenance treatment, established in 1996, differs from the often strict conditions attached to methadone clinics in other countries. Because of the predominant role of general practitioners and the flexible prescription rules for Subutex in France, the relationship between the physician and the drug user becomes a central element in the treatment. This article deals with the expectations that these users have of the physician, and their perception of his or her attitude towards them. In order to identify possible reasons for the absence of treatment compliance and of Subutex misuse, it focuses on the users' assessment of the physician's response to the problems they report. This study, based on a diversified convenience sample of 28 persons (19 men, 9 women) in treatment, showed 4 patterns of relationships between physicians and users, which differed in their focus: (1) closely focused on the posology of the prescription; (2) compliance with the prescribed regimen is the main issue in a relationship dominated by the physician; (3) an alliance between the physician and the user who is acknowledged as a person, and (4) a instrumental solely on the part of the user, who comes to procure a free, legal drug from a doctor's office. In all four case types, users had difficulty reporting other drug use or intravenous Subutex injection within this relationship, in which the stigma attached to drug dependence seems to reappear. Moreover, the lack of clarity about the treatment objectives and the time frame of the consultation limits the users' ability to integrate the treatment into their lives and to commit themselves to it. The heterogeneity and fragility of the users' situations, and the treatment objectives require regular assessment during contact with the physician. This constant reappraisal of the situation with the physician should help to optimize the treatment and avoid the hiatus that can generate or continue "misuse."

When treatment meets research: clinical perspectives from the CSAT Methamphetamine Treatment Project

Integrating research-based treatments into clinical settings has become a priority in the substance abuse treatment field. This article examines the introduction of research, via manualized treatment (i.e., the Matrix Model), into community treatment settings that participated in the Center for Substance Abuse Treatment Methamphetamine Treatment Project, a multi-site randomized controlled trial (RCT) that provided free treatment to 1016 methamphetamine-dependent individuals. With both empirical (qualitative) and anecdotal data from those involved clinically in the project, the article utilizes the framework of practitioner concerns set forth by Addis, Wade, and Hatgis (1999) to assess the issues realized during the implementation of this manualized treatment. Despite fairly smooth implementation of the model, the authors conclude that introducing manualized treatment in the context of an RCT may not be the best way to bring research-based treatment into the practice world.

Therapist rotation--a new element in the outpatient treatment of alcoholism

For nine years, the so-called "therapist rotation" has been a central part of OLITA, the Outpatient Longterm Intensive Therapy for Alcoholics. Thus far, the participation of several equally responsible therapists in the treatment of a patient has rarely been seen as a specific therapeutic approach. The present article analyzes the therapist rotation from a theoretical and clinical perspective. Articles concerned with the therapeutic alliance in the treatment of substance use disorders are reviewed. Furthermore, the literature on multiple psychotherapy, which may be seen as the precedent of the therapist rotation is surveyed. Based on the efficacy of multiple psychotherapy and the importance of the therapeutic alliance in the treatment of substance use disorders, the present work discusses the therapist rotation as an essential factor for the success of OLITA. It considers both potential advantages and disadvantages for patients and therapists and tries to identify conditions under which this approach appears to promote therapeutic interactions. Finally, the implementation of therapist rotation into OLITA is described, including the theoretical background of the program itself and the treatment procedure. New areas of application for the therapist rotation are discussed.

A self-administered instrument for assessing therapeutic approaches of drug-user treatment counselors

In this article we describe the development and psychometric properties of a self-administered instrument for assessing drug-user treatment counselors' therapeutic approaches such as psychodynamic or interpersonal, cognitive-behavioral, family systems or dynamics, 12-step, and case management. We generated an initial pool of items corresponding to these five approaches and modified them based on expert ratings. We developed three sets of items. The first concerned the beliefs underlying each therapeutic approach. The second and third concerned the practices of each applicable approach within individual and group counseling, respectively. With the exception of case management, an approach that originated within social work and which is only applicable to individual counseling, the other four approaches are applicable, at least theoretically, to both individual and group counseling. Additionally, we included items that describe techniques used exclusively with groups (i.e., group techniques). Finally, we included some items that are not associated with any of the traditional approaches but which reflect the practical approach that drug-user treatment programs often take to both individual and group counseling (i.e., practical counseling). The initial instrument consisted of 17 subscales with a total of 76 items. This instrument was administered to 226 counselors from 45 drug-user treatment programs in Los Angeles County. Based on this data, we further refined these scales using confirmatory factor analysis to ensure both construct validity and discriminant validity. The final instrument consisted of 14 subscales with a total of 48 items.

Drug abuse treatment entry and engagement: report of a meeting on treatment readiness

Although the effectiveness of drug abuse treatment has been demonstrated repeatedly, many drug abusers do not enter treatment, many who do enter leave prematurely, and relapse following treatment is common. To further research treatment entry and engagement, the National Institute on Drug Abuse convened scientists representing diverse research traditions in December 1996. This article summarizes meeting presentations and recommendations. Presentations focused on treatment readiness/motivation for change, ethnographic reports of drug abusers' perceptions of and attitudes toward treatment, and reports on alternative treatments for high-risk drug abusers. Recommendations focused on the potential contribution of qualitative research, integration of qualitative and quantitative research approaches, development of flexible treatment approaches that are cognizant of patients' life circumstances, and services research to improve the organization and delivery of drug abuse treatment.