Being at work improves stress, craving, and mood for people with opioid use disorder: Ecological momentary assessment during a randomized trial of experimental employment in a contingency-management-based therapeutic workplace

A longitudinal observational study with ecological momentary assessment and deep learning to predict non-prescribed opioid use, treatment retention, and medication nonadherence among persons receiving medication treatment for opioid use disorder

BACKGROUND

Despite effective treatments for opioid use disorder (OUD), relapse and treatment drop-out diminish their efficacy, increasing the risks of adverse outcomes, including death. Predicting important outcomes, including non-prescribed opioid use (NPOU) and treatment discontinuation among persons receiving medications for OUD (MOUD) can provide a proactive approach to these challenges. Our study uses ecological momentary assessment (EMA) and deep learning to predict momentary NPOU, medication nonadherence, and treatment retention in MOUD patients.

METHODS

Study participants included adults receiving MOUD at a large outpatient treatment program. We predicted NPOU (EMA-based), medication nonadherence (Electronic Health Record [EHR]- and EMA-based), and treatment retention (EHR-based) using context-sensitive EMAs (e.g., stress, pain, social setting). We used recurrent deep learning models with 7-day sliding windows to predict the next-day outcomes, using Area Under the ROC Curve (AUC) for assessment. We employed SHapley additive ExPlanations (SHAP) to understand feature latency and importance.

RESULTS

Participants comprised 62 adults with 14,322 observations. Model performance varied across EMA subtypes and outcomes with AUCs spanning 0.58-0.97. Recent substance use was the best performing predictor for EMA-based NPOU (AUC = 0.97). Life-contextual factors were best performers for EMA-based medication nonadherence (AUC = 0.68) and retention (AUC = 0.89), and substance use risk factors (e.g., nicotine and alcohol use) and self-reported MOUD adherence performed best for predicting EHR-based medication nonadherence (AUC = 0.79). SHAP revealed varying latencies between predictors and outcomes.

CONCLUSIONS

Findings support the effectiveness of EMA and deep learning for forecasting actionable outcomes in persons receiving MOUD. These insights will enable the development of personalized dynamic risk profiles and just-in-time adaptive interventions (JITAIs) to mitigate high-risk OUD outcomes.

Undervaluing nondrug rewards or overvaluing cocaine? Cocaine demand relates to cocaine use severity more strongly than anhedonia in individuals with cocaine use disorder

Cocaine use disorder (CUD) is a major public health issue, and greater cocaine use severity has been associated with worse treatment retention and outcomes. Therefore, greater understanding of processes that influence cocaine use is needed. Both anhedonia (i.e., undervaluation of nondrug rewards) and cocaine demand (i.e., cocaine valuation) are related to cocaine use severity and thematically related to each other at face value, but no studies have directly compared these outcomes to our knowledge. The present study represents a secondary analysis from a two-phase sequential, multiple assignment, randomized trial aimed at developing adaptive interventions for CUD. We examined the relationship between anhedonia and cocaine demand and how these measures were related to cocaine use severity. Participants (N = 116) were treatment-seeking adults with CUD. All measures were taken at baseline before treatment initiation. Analyses revealed (a) moderate and very strong evidence of relationships between cocaine demand factors (i.e., persistence, amplitude) and anhedonia (PP values ≥ 77.8%); (b) positive association between cocaine demand (both persistence and amplitude) and measures of cocaine use severity, with the exception of one relationship, which was in the opposite direction; and (c) demand amplitude continued to be positively related to cocaine use severity, even when considering anhedonia. Overall, findings from this study indicate cocaine demand relates to cocaine use severity more strongly than anhedonia. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Recovery support services as part of the continuum of care for alcohol or drug use disorders

BACKGROUND

The definition of 'recovery' has evolved beyond merely control of problem substance use to include other aspects of health and wellbeing (known as 'recovery capital') which are important to prevent relapse to problematic alcohol or other drug (AOD) use. Developing a Recovery Oriented System of Care (ROSC) requires consideration of interventions or services (Recovery Support Services, RSS) designed to build recovery capital which are often delivered alongside established treatment structures. Lived experience and its application to the process of engaging people, changing behaviour and relapse prevention is an essential part of these services.

AIM

To map out the evidence base for RSS as part of guidance for commissioners of addiction services in each of the 152 local authorities in England.

METHODS

The authors updated the findings of a 2017 systematic review of RSS through a further rapid scoping review, aiming to map out the extent, range and nature of research under six headings: (1) Peer-based recovery support services (P-BRSS); (2) Employment support approaches; (3) Recovery housing; (4) Continuing care and recovery check-ups; (5) Recovery community centres (RCC); and (6) Recovery support services in educational settings. A systematic search of the PubMed, Embase, CINAHL, CENTRAL and PsychINFO databases was conducted. The abstracts of all articles published since 2017 were reviewed by two of the authors, and the full text versions of all relevant articles were obtained and relevant data extracted. A narrative review of the findings was then prepared, mapping them on to the ROSC continuum of care. The review was restricted to adults (over 18 years), but all substances and available outcomes were included.

RESULTS

Four of the six forms of RSS were well supported by evidence. RCTs of interventions to increase levels of employment demonstrated large effect sizes, and continuing care interventions that extend treatment intervention into the early recovery phase have shown small but significant benefit. Peer-delivered interventions to link people to ongoing support were associated with decreased rates of relapse and re-admission, increased engagement, and increased social support for change. However, the variability in the design of these studies means that further work is required to clarify the effective components of the intervention. Studies of recovery housing have also shown positive results, including significant differences from standard care. No controlled studies exist to support RCCs or RSS in educational settings, but the complexity of these interventions and the wide range of potential outcome measures mean that other study designs may be more relevant.

CONCLUSIONS

This monograph provides a structure to help policy makers, commissioners and service providers describe and understand an emerging field of research. Recovery Support Services (RSS) are proving to have clinical, public health and cost utility. A rational social and fiscal response to endemic alcohol or other drug challenges should therefore include the more intensive acute care clinical services linked with more extensive community-based RSS.

Outpatient substance abuse treatment completion rates for racial-ethnic minorities during the Great Recession

There has been minimal research linking the effects on racial-ethnic minorities' health outcomes, particularly research focused on racial-ethnic minorities seeking outpatient substance abuse treatment in the United States. The Great Recession from December 2007 to June 2009 in the United States provides the backdrop against the completion of substance abuse treatments among racial-ethnic minorities that may be associated with the impacts on users' social realities. We utilized data from the 2006-2011 Treatment Episode Datasets-Discharge (TEDS-D) dataset which collects data on outpatient substance abuse treatment institutions throughout the United States. The substance abuse treatment completion rates were higher prior to the Great Recession and lower following the Great Recession. Hispanics were more likely than non-Hispanic whites to complete substance abuse treatment, while other minority groups such as Non-Hispanic Blacks, were less likely to do so. Clients in the Northeast and West regions were more likely to successfully complete substance abuse treatment than those in the South. These findings have implications for impacting outpatient substance abuse treatment completion rates following the Great Recession to reduce racial-ethnic disparities which were impacted by region. Even amid an economic recession, treatment for substance abuse should continue to be a top concern.

Reward deprivation is associated with elevated alcohol demand in emerging adults

Policies vary substantially in terms of providing sources of psychosocial enrichment. Behavioral economic models of substance use and addiction emphasize that deficits in access to substance-free sources of reward increase substance reinforcing value and risk for addiction. The current study used an alcohol demand curve approach to test the hypothesis that various indices of reward deprivation would be associated with elevated alcohol reinforcing efficacy. We examined associations between alcohol demand indices and several facets of reward deprivation in a sample of young adults (N = 1,331; ages 19-25 years) recruited from the United States and Canada who reported recent binge drinking. Additionally, we created an index of cumulative reward deprivation that integrated the various reward facets and examined its association with alcohol demand intensity and maximum expenditure on alcohol. Our findings indicate that reward deprivation is associated with elevated alcohol demand and provide support for alcohol prevention and intervention approaches that emphasize environmental enrichment.

Study protocol and preliminary baseline characteristics of a VA multi-site, mixed methods, randomized controlled study evaluating supported employment provided to veterans with opioid use disorder

Opioid Use Disorder (OUD) is a pervasive and devastating public health crisis that continues to take a heavy toll on individuals and communities across the United States. In 2021, approximately 473,000 veterans misused opioids in the past year. In the context of their military service and post-service life, Veterans with OUD often encounter unique barriers to recovery, including the reintegration into civilian society and the pursuit of stable, meaningful employment. The path to recovery from OUD is inextricably linked to the restoration of a stable and purposeful life, a fact underscored by the interplay of substance use, mental health, and employment outcomes. These factors necessitate a comprehensive approach to treatment that extends beyond mere pharmacological interventions. One such approach is Individual Placement and Support (IPS), a well-established evidence-based practice that focuses on supporting individuals with severe mental illness in their pursuit of competitive employment. The primary objective of this manuscript is to describe a two-arm, multi-site RCT designed to rigorously evaluate the efficacy of IPS when provided to veterans with OUD and provide the baseline demographics and characteristics of the participants who have enrolled to date. The central hypothesis guiding this research is that IPS can significantly improve vocational, psychosocial, and treatment outcomes of veterans in recovery from OUD, ultimately leading to a more successful reintegration into civilian life. Our study is timely as the VA has expanded IPS services to veterans with SUD this past year. Thus, this study is one of the first to examine IPS in a subpopulation of veterans with a SUD and may provide actionable data to support sustainment of IPS with this population.

Novel methods for the remote investigation of emerging substances: Application to kratom

The botanical product commonly called "kratom" is still relatively novel to the United States. Like other natural products marketed as supplements, kratom is highly variable, both in terms of the alkaloids naturally occurring in kratom leaves and in terms of processing and formulation. Kratom products sold in the United States are not well-characterized, nor are daily use patterns among regular users. Surveys and case reports have comprised most of the literature on kratom use among humans. To advance our understanding of real-world kratom use, we developed a protocol for the remote study of regular kratom-using adults in the United States. Our study had three aspects implemented in one pool of participants nationwide: an in-depth online survey, 15 days of ecological momentary assessment (EMA) via smartphone app, and the collection and assay of the kratom products used by participants during EMA. Here, we describe these methods, which can be used to investigate myriad drugs or supplements. Recruiting, screening, and data collection occurred between July 20, 2022 and October 18, 2022. During this time, we demonstrated that these methods, while challenging from a logistical and staffing standpoint, are feasible and can produce high-quality data. The study achieved high rates of enrollment, compliance, and completion. Substances that are emerging or novel, but still largely legal, can be productively studied via nationwide EMA combined with assays of shipped product samples from participants. We discuss challenges and lessons learned so other investigators can adapt these methods. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Association Between Patient-Level Factors and Positive Treatment Response Among Individuals With a Psychostimulant Use Disorder: A Cross-Sectional Study

Objectives

The purpose of this study was to provide insights into which patient-level characteristics are associated with a positive treatment response among patients whose primary drug of choice was a psychostimulant with a particular emphasis on understanding the impact of age at first use and co-occurring psychiatric comorbidities.

Methods

We used a cross-sectional study design and the 2019 US Treatment Episode Data Set: Discharges (n = 167 802) to identify outpatient treatment episodes for which the primary drug of choice was a psychostimulant. We defined a positive treatment response as (1) a reduction in drug use between treatment admission and discharge or (2) no use at both admission and discharge. Multivariable logistic regression was conducted, overall and stratified by presence of psychiatric comorbidity, to identify demographic, clinical, and treatment-level factors associated with positive treatment response.

Results

Treatment episodes among patients 11 years and under at the time of first use had a 22% higher odds of having a positive response to treatment as compared to those treatment episodes in which the person was 30 years or older at the time of first use. The presence of psychiatric comorbidity resulted in substantial differences in direction and magnitude of the relationships between treatment response and covariates. Positive response to treatment was less likely for episodes among Non-Hispanic Black/African American persons, in detoxification settings, for unemployed individuals, or for individuals living in the South, but a positive response was more likely for episodes occurring in rehabilitation/residential settings.

Conclusions

Race/ethnicity, geographic region, treatment setting, and employment status were the strongest predictors of response to treatment. Treatment programs should maximize treatment of psychiatric conditions, intensify support for persons of color seeking treatment in detoxification settings, and increase efforts to find adequate employment for patients.

Effects of economic context and reward amount on delay and probability discounting

Steep delay and shallow probability discounting are associated with myriad problem behaviors; thus, it is important to understand factors that influence the degree of discounting. The present study evaluated the effects of economic context and reward amount on delay and probability discounting. Two hundred thirteen undergraduate psychology students completed four delay- or probability-discounting tasks. Participants were exposed to hypothetical narratives involving four bank amounts ($750, $12,000, $125,000, and $2,000,000). The delayed/probabilistic amount was $3,000 for the two smaller bank amounts and $500,000 for the two larger bank amounts. The discounting tasks included five delays to, or probabilities of, receipt of the larger amount. The area under the empirical discounting function was calculated for each participant. Participants discounted delayed and uncertain outcomes more when the bank amount was smaller than the outcome (i.e., the economic context was low). Participants discounted the delayed larger amounts less than delayed smaller amounts, even when the relative economic context was the same. In contrast, probability discounting did not differ across magnitudes, which suggests that economic context may attenuate the magnitude effect in probability discounting. The results further highlight the importance of considering the economic context in delay and probability discounting.

Variability in intensively assessed mood: Systematic sources and factor structure in outpatients with opioid use disorder

In intensive longitudinal studies using ecological momentary assessment, mood is typically assessed by repeatedly obtaining ratings for a large set of adjectives. Summarizing and analyzing these mood data can be problematic because the reliability and factor structure of such measures have rarely been evaluated in this context, which-unlike cross-sectional studies-captures between- and within-person processes. Our study examined how mood ratings (obtained thrice daily for 8 weeks; n = 306, person moments = 39,321) systematically vary and covary in outpatients receiving medication for opioid use disorder (MOUD). We used generalizability theory to quantify several aspects of reliability, and multilevel confirmatory factor analysis (MCFA) to detect factor structures within and across people. Generalizability analyses showed that the largest proportion of systematic variance across mood items was at the person level, followed by the person-by-day interaction and the (comparatively small) person-by-moment interaction for items reflecting low arousal. The best-fitting MCFA model had a three-factor structure both at the between- and within-person levels: positive mood, negative mood, and low-arousal states (with low arousal considered as either a separate factor or a subfactor of negative mood). We conclude that (a) mood varied more between days than between moments and (b) low arousal may be worth scoring and reporting separately from positive and negative mood states, at least in a MOUD population. Our three-factor structure differs from prior analyses of mood; more work is needed to understand the extent to which it generalizes to other populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).