A conceptual framework for drug treatment process and outcomes

Opioid use disorder Cascade of care: defining a taxonomy for measurement

Background: The opioid use disorder Cascade of care (OUD Cascade) is a public health framework used by federal/state/other agencies and researchers to facilitate monitoring and evaluating responses to the opioid epidemic, including surveillance and performance evaluation. As the use of the framework proliferates, there is an urgent need to standardize stage definitions to accurately monitor and improve patient outcomes and to align interpretation of findings across settings.Objectives: Define a taxonomy to uniformly apply the OUD Cascade to improve delivery of OUD services and better compare patient outcomes across settings and populations.Methods: We conducted a narrative review and synthesis focused on research and guidelines defining and measuring four key OUD Cascade stages: OUD identification, service engagement, medication initiation, and retention. Included articles come from peer-reviewed literature and define and/or operationalize OUD Cascade stages and associated measures across six characteristics based on an adaptation of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist including: 1) settings, 2) specific population, 3) perspective, 4) time horizon, 5) assumptions, and 6) analytic method.Results: Our review (n = 27 articles) and synthesis provide an overview of how OUD Cascade definitions and framework designs have been variously applied. We found considerable heterogeneity in study approaches for all four OUD Cascade stages. We define a taxonomy to guide future research emphasizing standardized definitions to harmonize efforts across settings. In particular, we emphasize the need for clarity in defining criteria for sample construction (i.e. Identification), clear distinctions between receipt of care services generally (i.e. Engagement) from MOUD Initiation specifically, and Retention definitions that use a 30+ day gap in treatment to define discontinuation.Conclusion: Establishing a shared taxonomy for key terms specifying OUD Cascade stages will help the field advance, compare approaches and results across settings, and improve population-level patient outcomes.

Beyond the first try: How many quit attempts are necessary to achieve substance use cessation?

Substance use disorder (SUD) is a chronically relapsing disorder; thus, individuals with SUD may require several attempts before achieving abstinence. The goal of the present study was to investigate what variables are associated with the number of quit attempts before successful abstinence was achieved. Data were collected from 421 International Quit & Recovery Registry participants. Participants answered several questions for each substance they reported being in recovery, including how many times they had attempted to quit that substance and whether they still used that substance. The results showed that the number of quit attempts was associated with the substance one was trying to quit, SUD severity (i.e., mild, moderate, severe SUD) for that substance, the number of years using that substance, and the age of use onset. Pairwise comparisons among substances indicated that pain medication and opioids had a significantly higher number of quit attempts than all other substances (ps < .001) but were not different from each other (p = 1.0). Pairwise comparisons across levels of SUD severity showed a significantly higher number of attempts for those with moderate than mild SUD (p < .001) and for those with severe than mild or moderate SUD (ps < .001). Overall, the results indicate that individuals who use opioids and pain medication, have more severe SUD, and more years of use need significantly more attempts before achieving successful abstinence. Thus, those might benefit from more targeted and effective interventions.

BACKGROUND AND AIMS

Substance use disorder (SUD) is a chronically relapsing disorder. Thus, individuals with SUD may need several attempts before achieving abstinence. The present study investigated the variables associated with the number of quit attempts before achieving successful abstinence.

METHODS

Data were collected from 421 International Quit & Recovery Registry participants. Participants answered several questions for each substance they reported being in recovery from, such as the age of first use, how many times they had attempted to quit that substance, and whether they still used that substance.

RESULTS

The number of quit attempts was associated with the substance one was trying to quit, SUD severity (i.e., mild, moderate, severe SUD) for that substance, the number of years using that substance, and the age of use onset. Pairwise comparisons among substances indicated that pain medication and opioids had a significantly higher number of quit attempts than all other substances (ps < .001) but were not different from each other (p = 1.0). Pairwise comparisons across levels of SUD severity showed a significantly higher number of attempts for those with moderate than mild SUD (p < .001) and for those with severe than mild or moderate SUD (ps < .001).

CONCLUSIONS

Opioids and pain medication require significantly more attempts than all other substances, according to our findings. Thus, such substances might need more targeted and effective interventions. Additionally, more severe SUD and more years of use were also associated with more quit attempts. Such findings suggest the need for more effective early interventions to decrease the number of attempts before successful abstinence.

How Has the COVID-19 Pandemic Impacted Addiction Services? A Study of the Different Periods of the Pandemic and Patient Treatment Follow-up Over 1 Year

Background

Various studies have provided evidence of the impact of COVID-19 and the measures adopted by governments on drug use and its treatment. After 4 years, a more precise assessment of the evolution of patients and addiction treatment services can be made. The objective of this study is to compare different periods during the COVID-19 pandemic to identify changes in patient profiles and the care activity of addiction treatment centres.

Methods

A retrospective observational study was conducted using data from March 14, 2019 to June 22, 2022, from addiction centres of Andalusia (Spain). Information related to the treatment of each patient was collected during 1 year after the initiation of treatment (until June 22, 2023). Electronic health records of 29 740 outpatients were analysed and divided into 4 periods (pre-pandemic, lockdown, return to normal and post-lockdown).

Results

Differences were found across the analysed periods. Admissions declined during the lockdown period but subsequently increased, without reaching pre-pandemic levels. Admission to treatment due to opioid dependence increased during the lockdown. In contrast, the percentage of patients with dual pathology decreased. An increase in the dropout rate of patients from treatment was observed compared to the pre-pandemic period.

Conclusions

The results revealed a similar patient profile across the different analysed periods. The most notable changes are observed in healthcare activity, which appears to have decreased. Therefore, a greater investment is likely required for the reformulation of addiction centres and increased funding to provide adequate assistance to these patients.

Rural-urban differences in out-of-network treatment initiation and engagement rates for substance use disorders

OBJECTIVE

To examine rural-urban disparities in substance use disorder treatment access and continuation.

DATA SOURCES AND STUDY SETTING

We analyzed a 2016-2018 U.S. national secondary dataset of commercial insurance claims.

STUDY DESIGN

This cross-sectional study examined individuals with a new episode of opioid, alcohol, or other drug use disorders. Treatment initiation and engagement rates, and rates of using out-of-network providers for these services, were compared between rural and urban patients.

DATA COLLECTION

We included individuals 18-64 years old with continuous employer-sponsored insurance.

PRINCIPAL FINDINGS

Patients in rural settings experienced lower treatment initiation rates for alcohol (36.6% vs. 38.0%, p < 0.001), opioid (41.2% vs. 44.2%, p < 0.001), and other drug (37.7% vs. 40.1%, p < 0.001) use disorders, relative to those in urban areas. Similarly, rural patients had lower treatment engagement rates for alcohol (15.1% vs. 17.3%, p < 0.001), opioid (21.0% vs. 22.6%, p < 0.001), and other drug (15.5% vs. 17.5%, p < 0.001) use disorders. Rural patients had higher out-of-network rates for treatment initiation for other drug use disorders (20.4% vs. 17.2%, p < 0.001), and for treatment engagement for alcohol (27.6% vs. 25.2%, p = 0.006) and other drug (36.1% vs. 31.1%, p < 0.001) use disorders.

CONCLUSIONS

These findings indicate that individuals with substance use disorders in rural areas have lower rates of initial and ongoing treatment, and are more likely to seek care out-of-network.

Buprenorphine treatment and clinical outcomes under the opioid use disorder cascade of care

BACKGROUND

Challenges to engagement and retention on buprenorphine undermine treatment of individuals with opioid use disorder (OUD). Under the OUD Cascade of Care framework, we sought to identify patient characteristics and treatment response associated with superior clinical outcomes.

METHODS

A retrospective cohort study of specialty buprenorphine treatment patients entering treatment (n=19,487) based on EHR records from a large multi-state buprenorphine treatment network (2011-2019). Person-level care episodes were evaluated across treatment intake, engagement (i.e. 2+ visits in the month following intake), and retention at 6, 12, and 24 months. Time to achieving 90 days of continuous opioid abstinence was assessed using Cox proportional hazards regressions models and also assessed as a predictor of long-term retention.

RESULTS

Most patients engaged (82.4 %), but retention steadily declined over 6-month (38.7 %), 12-month (26.2 %), and 24-month (17.1 %) timepoints. Opioid-positive baseline tests were associated with lower hazards of achieving continuous abstinence for both buprenorphine-positive (aHR=0.33, p<.001) and buprenorphine-negative (aHR=0.49,p<.001) intakes. Opioid abstinence was associated with buprenorphine-positive baseline testing (aHR=1.59,p<.001), especially for those testing opioid-negative (aHR=1.82,p<.001). Patients who achieved and sustained abstinence at 6 months in care were 4.1 and 5.5 times as likely to achieve 12-month and 24-month retention, respectively, compared to patients with intermittent opioid use.

CONCLUSION

Treatment discontinuation was concentrated early in care and buprenorphine and opioid status at intake were prognostic of achieving and sustaining abstinence. Early abstinence was associated with higher likelihood of subsequent stage progression. Implementing interventions to support early clinical stability for high-risk patients is critical to improve clinical outcomes.

The impact of State of Surrender on the relationship between engagement in substance use treatment and meaning in life presence: a pilot study

The current study examined the construct of State of Surrender (SoS)-defined as a willingness to accept, without resistance, what is to come-and investigated SoS as a statistical mediator of the relationship between engagement in substance use treatment and meaning in life (MIL). Using a cross-sectional design, participants were 123 people involved with the legal system participating in a 6-month residential treatment program for substance use. Results showed that measures of treatment engagement, including treatment participation, counselor rapport, and peer support, were all positively associated with SoS scores (R 2s ≥ 21.16). Moreover, while controlling for time spent in treatment, SoS statistically mediated the positive association between aspects of treatment engagement and MIL. State of Surrender may be a targetable process in substance use treatment that aids in recovery by orienting clients toward what they find meaningful in life. Future directions and practical considerations are discussed.

Modeling the Therapeutic Process of Patients with Cocaine Use Disorders: A Guide for Predicting Readmission

INTRODUCTION

Patients with cocaine use disorders have very high readmission rates. Our aim was to model the relationships between attributes of patients with cocaine use disorder at the beginning of treatment, therapeutic process indicators of time in treatment or proportion of appointments attended, and treatment outcomes, including outcomes at discharge and non-readmissions posttreatment as indicators of therapeutic success.

METHOD

A retrospective observational design was used with 10,298 cocaine use disorder patients. Electronic health records were used for statistical analysis of the data. Randomized subsample 1 (n = 5,150) was used for exploratory analysis and subsample 2 (n = 5,148) for modeling relationships between the variables.

RESULTS

Patients attributes at intake (e.g., legal services as the source of referral) were of limited significance in explaining time in treatment, proportion of appointments attended, and treatment outcomes. Time in treatment and proportion of appointments attended emerged as significant factors in explaining outcomes at discharge. However, readmissions were primarily explained by time in treatment and outcomes at discharge, although referrals to addiction centers by health services also appeared to be relevant for explaining readmission.

DISCUSSION/CONCLUSION

Our study has shown that maintaining a sufficient appointment attendance rate and remaining in treatment for a longer duration are critical therapeutic process indicators for explaining outcomes at the point of discharge and therapeutic success, as indicated by a reduced likelihood of readmissions. Patients who remained in treatment for an extended period were found to have a reduced risk of future readmissions. In addition, our study highlights the importance of maintaining a satisfactory appointment attendance rate to attain successful short- and medium-term therapeutic discharge outcomes. These guidelines could help to increase the efficiency of patient treatment and alleviate the suffering of both patients and their families.

Retention and critical outcomes among new methadone maintenance patients following extended take-home reforms: a retrospective observational cohort study

Background

Approximately 1800 opioid treatment programs (OTPs) in the US dispense methadone to upwards of 400,000 patients with opioid use disorder (OUD) annually, operating under longstanding highly restrictive guidelines. OTPs were granted novel flexibilities beginning March 15, 2020, allowing for reduced visit frequency and extended take-home doses to minimize COVID exposure with great variation across states and sites. We sought to use electronic health records to compare retention in treatment, opioid use, and adverse events among patients newly entering methadone maintenance in the post-reform period in comparison with year-ago, unexposed, controls.

Methods

Retrospective observational cohort study across 9 OTPs, geographically dispersed, in the National Institute of Drug Abuse (NIDA) Clinical Trials Network. Newly enrolled patients between April 15 and October 14, 2020 (post-COVID, reform period) v. March 15-September 14, 2019 (pre-COVID, control period) were assessed. The primary outcome was 6-month retention. Secondary outcomes were opioid use and adverse events including emergency department visits, hospitalizations, and overdose.

Findings

821 individuals were newly admitted in the post-COVID and year-ago control periods, average age of 38.3 (SD 11.1), 58.9% male. The only difference across pre- and post-reform groups was the prevalence of psychostimulant use disorder (25.7% vs 32.9%, p = 0.02). Retention was non-inferior (60.0% vs 60.1%) as were hazards of adverse events in the aggregate (X2 (1) = 0.55, p = 0.46) in the post-COVID period. However, rates of month-level opioid use were higher among post-COVID intakes compared to pre-COVID controls (64.8% vs 51.1%, p < 0.001). Moderator analyses accounting for stimulant use and site-level variation in take-home schedules did not change findings.

Interpretation

Policies allowing for extended take-home schedules were not associated with worse retention or adverse events despite slightly elevated rates of measured opioid use while in care. Relaxed guidelines were not associated with measurable increased harms and findings could inform future studies with prospective trials.

Funding

USDHHSNIDACTNUG1DA013035-15.

Efficacy of mindfulness-based relapse prevention in a sample of veterans in a substance use disorder aftercare program: A randomized controlled trial

BACKGROUND

Complementary integrative medicine, such as mindfulness-based interventions, (MBI) have demonstrated efficacy in the treatment of depression, anxiety, substance use disorders (SUDs), and pain. Mindfulness-based relapse prevention (MBRP) is an aftercare intervention targeting SUD relapse that integrates cognitive-behavioral relapse prevention and mindfulness meditation practices, raising awareness of substance use triggers and reactive behavioral patterns. This study evaluated the efficacy of MBRP in reducing relapse in veterans following completion of an SUD treatment program.

METHODS

This study was a two-site, randomized controlled trial comparing MBRP to 12-step facilitation (TSF) aftercare in military veterans following completion of intensive treatment for SUDs. The 8 weeks of 90-minute, group-based MBRP or TSF sessions were followed by 3-, 6- and 10-month follow-up periods with assessments of alcohol/substance use and secondary outcomes of depression, anxiety, and mindfulness.

RESULTS

Forty-seven percent of veterans attended ≥75 % of sessions. Veterans in both the MBRP and TSF aftercare groups maintained reductions in alcohol and illicit substance use during the aftercare treatment. Nineteen participants (11 %; 19/174) reported returning to alcohol use during the study treatment period and the study found no difference between study groups [MBRP: 9 % vs. TSF 13 %; p = 0.42]. Thirteen participants (7.5 %; 13/174) reported a return to illicit substance use during study treatment [MBRP: 5.4 % vs. TSF 10.3 % p = 0.34]. The number of days of drinking and illicit substance use was not different between groups (alcohol, p = 0.53; illicit substance use, p = 0.28).

CONCLUSION

Although retention in treatment limits interpretation of the findings, both MBRP and TSF were effective in maintenance of treatment gains following an intensive treatment program for veterans with SUDs. Future studies should focus on strategies to improve treatment participation.

Comparing substance use treatment initiation and retention between telehealth delivered during COVID-19 and in-person treatment pre-COVID-19

BACKGROUND AND OBJECTIVES

A large portion of veterans referred to substance use disorder (SUD) treatment do not attend their first appointment or leave treatment prematurely. Telehealth options may increase access to care and treatment attendance. This study compared treatment initiation and retention between in-person treatment pre-COVID-19 and telehealth treatment during COVID-19 in a VA hospital outpatient alcohol and drug treatment clinic.

METHODS

Electronic health record data were collected on 373 veterans out of 481 referrals. Mixed logistic and negative binomial regression models were used for estimating the effect of treatment modality on treatment initiation and retention, respectively.

RESULTS

The odds of initiating treatment were 2.6 times greater when referred to a telehealth appointment during COVID-19 compared to an in-person appointment pre-COVID-19. Months retained in treatment postinitiation was similar between treatment modalities. Each month in treatment corresponded to a subsequently lower rate of treatment session attendance and by the fourth month, the average number of sessions attended was significantly lower for those receiving in-person treatment compared to those receiving telehealth treatment.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The odds of initiating SUD treatment and rate of treatment attendance over time was greater for services delivered via telehealth during COVID-19 compared to in-person pre-COVID-19. Extending telehealth services as an option for individual and group SUD treatment may promote treatment initiation and potentially higher rate of attendance over time. This study provides additional evidence for the feasibility and utility of rapidly expanding telehealth for veterans seeking outpatient substance use treatment.

Retention in treatment and therapeutic adherence: How are these associated with therapeutic success? An analysis using real-world data

INTRODUCTION

Treatment retention and adherence are used as outcomes in numerous randomized clinical trials and observational studies conducted in the addiction field. Although usual criteria are 3/6 months of treatment retention or number of sessions attended, there is not a methodological support for conclusions using these criteria. This study analyzed the usefulness of retention and adherence to predict therapeutic success.

METHODS

Retrospective observational study using real-world data from electronic health records of 11,907 patients in treatment diagnosed with cocaine, alcohol, cannabis and opiate use disorders or harmful use.

RESULTS

Moderate effect size relations were found between the different type of clinical discharge and months in retention (η2  = 0.12) and proportion of attendance (η2  = 0.10). No relationship was found with the number of sessions attended. Using cut-off points (i.e., 3 or 6 months in treatment or attending 6 therapy sessions) worsens the ability to predict the type of discharge.

DISCUSSIONS/CONCLUSION

Treatment retention and adherence are indicators moderately related to therapeutic success. Research using these indicators to assess the effectiveness of therapies should complement their results with other clinical indicators and quality of life measures.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students

BACKGROUND

The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students.

METHODS

Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated.

RESULTS

Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students.

CONCLUSIONS

AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

Twelve-month Treatment Retention and Associated Factors: A Comparison of 2 Medically Assisted Therapy Clinics in Dar es Salaam, Tanzania

OBJECTIVES

Retention in methadone maintenance treatment is instrumental in achieving better treatment outcomes. In this study, we compared 2 medication-assisted treatment (MAT) clinics in Dar es Salaam, Tanzania with respect to patient characteristics, outcomes, and factors that predict 12-month treatment retention.

METHODS

This retrospective registry-based cohort study utilized data collected for routine clinical and program monitoring at 2 sites, Mwananyamala and Muhimbili MAT clinics. Cumulative retention in treatment was calculated using life tables. The analysis of treatment retention predictor variables used both Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

We examined the socio-demographic and program-related characteristics of 362 (181 from each clinic) patients. Twelve-month treatment retention was higher at Mwananyamala (73%) than Muhimbili (64%) MAT clinic, but the difference was not significant. In both clinics, a higher methadone dose (>60 mg) significantly predicted treatment retention (P < 0.05). Being employed and traveling an average short distance (<5 km) from home to clinic significantly increased the likelihood of remaining in treatment in Muhimbili MAT clinic (P  < 0.05) only.

CONCLUSIONS

A methadone dose of 60 mg and above was associated with longer retention in treatment. At 1 clinic in a denser and more central location, employment and a short travel distance from home to clinic were associated with longer tenure in treatment. These findings have potential implications for clinical practice, research, and scaling up MAT services in Tanzania.

Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans

OBJECTIVE

Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment.

METHODS

A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.

RESULTS

Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65).

CONCLUSIONS

As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.

Therapeutic relationships between Veterans and buprenorphine providers and effects on treatment retention

OBJECTIVE

To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced treatment retention.

DATA SOURCES

National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017.

STUDY DESIGN

Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.

DATA COLLECTION/EXTRACTION METHODS

Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality.

PRINCIPAL FINDINGS

A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07).

CONCLUSIONS

Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention.

Attachment and Therapeutic Alliance in Substance Use Disorders: Initial Findings for Treatment in the Therapeutic Community

Background: There is convincing evidence that individuals suffering from Substance Use Disorder (SUD) often present insecure attachment patterns. In contrast, a strong therapeutic alliance in treatment of SUD has been found to lead to a more positive treatment outcome. However, insecure attachment has been observed to be linked with weaker therapeutic alliance strength. The primary aim of this explorative study was to gain initial insights regarding the influence of attachment and personality characteristics on therapeutic alliance and therapy motivation in SUD patients undergoing treatment at a therapeutic community. Furthermore, SUD patients were compared to healthy controls regarding attachment, personality and mood pathology. Methods: A total sample of 68 participants, 34 inpatients in SUD treatment and 34 age-gender and education adjusted controls, were investigated. Both groups filled in the Adult Attachment Scale (AAS), the Inventory of Personality Organization (IPO-16), and the Brief Symptom Inventory (BSI-18) questionnaires. Additionally, SUD patients filled in the Working Alliance Inventory (WAI-SR) and the adapted German version of the University of Rhode Island Change Assessment scale (FEVER). Results: In line with our assumptions, SUD patients exhibited a decreased amount of attachment security (AAS) which was related to higher personality (IPO-16) and mood pathology (BSI-18). Furthermore, correlational analysis revealed the WAI-SR dimension Bond being positively associated with more secure attachment. A strong task alliance was linked to the Action stage of change (FEVER) and decreased mood but not personality pathology. Conclusion: Our findings confirm the putative negative effect of attachment and personality pathology on therapy motivation and therapeutic alliance in addiction therapy as well as more specifically in therapeutic community treatment. Future research in enhanced samples might focus more on the long-term effects of the interaction of attachment, personality and therapeutic alliance variables.

Using conventional and machine learning propensity score methods to examine the effectiveness of 12-step group involvement following inpatient addiction treatment

BACKGROUND

Continuing care following inpatient addiction treatment is an important component in the continuum of clinical services. Mutual help, including 12-step groups like Alcoholics Anonymous, is often recommended as a form of continuing care. However, the effectiveness of 12-step groups is difficult to establish using observational studies due to the risks of selection bias (or confounding).

OBJECTIVE

To address this limitation, we used both conventional and machine learning-based propensity score (PS) methods to examine the effectiveness of 12-step group involvement following inpatient treatment on substance use over a 12-month period.

METHODS

Using data from the Recovery Journey Project - a longitudinal, observational study - we followed an inpatient sample over 12-months post-treatment to assess the effect of 12-step involvement on substance use at 12-months (n = 254). Specifically, PS models were constructed based on 34 unbalanced confounders and four PS-based methods were applied: matching, inverse probability weighting (IPW), doubly robust (DR) with matching, and DR with IPW.

RESULTS

Each PS-based method minimized the potential of confounding from unbalanced variables and demonstrated a significant effect (p <  0.001) between high 12-step involvement (i.e., defined as having a home group; having a sponsor; attending at least one meeting per week; and, being involved in service work) and a reduced likelihood of using substances over the 12-month period (odds ratios 0.11 to 0.32).

CONCLUSIONS

PS-based methods effectively reduced potential confounding influences and provided robust evidence of a significant effect. Nonetheless, results should be considered in light of the relatively high attrition rate, potentially limiting their generalizability.

Racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) and their effects on residential drug treatment outcomes in the US

BACKGROUND

This study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion.

METHODS

Data were extracted from SAMHSA's 2015-2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors.

RESULTS

After adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776).

CONCLUSIONS

Access to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.

Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities

Background: Naltrexone, a medication for addiction treatment (MAT), is an FDA-approved medication recommended for the treatment of alcohol use disorder (AUD). Despite the high prevalence of AUD and efficacy of naltrexone, only a small percentage of individuals with AUD receive treatment. Objectives: To identify trends for the prescription of naltrexone in AUD admissions in substance use treatment centers across the U.S. Methods: Data from the 2000–2018 U.S. Treatment Episode Data Set: Admissions (TEDS-A) were used in temporal trend analysis of naltrexone prescription in admissions that only used alcohol. Data from the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) were also used to characterize medication use among AUD clients across different treatment service settings. Results: Treatment of AUD with naltrexone was 0.49% in 2000 and tripled from 0.53% in 2015 to 1.64% in 2018 in AUD admissions (p < 0.0001 for the Cochran–Armitage trend test). Women, middle-aged adults, and admissions for clients living in the Northeast U.S. were more likely to be prescribed naltrexone than their respective counterparts, as were admissions with prior treatment episodes and referrals through alcohol/drug use care providers, who paid for treatment primarily through private insurance, used alcohol daily in the month prior to admission, and waited 1–7 days to enter treatment. Naltrexone was more commonly prescribed by AUD admissions compared to acamprosate and disulfiram and was more frequently prescribed in residential and outpatient services as opposed to hospital inpatient services. Conclusions: Naltrexone remains underutilized for AUD, and factors that influence prescription of medication are multifaceted. This study may contribute to the creation of effective interventions aimed at reducing naltrexone disparities for AUD.

Dynamic Interdependence of Advice Seeking, Loaning, and Recovery Characteristics in Recovery Homes

Recovery homes in the US provide stable housing for over 200,000 individuals with past histories of homelessness, psychiatric co-morbidity and criminal justice involvement. We need to know more about how these settings help those remain in recovery. Our study measured advice seeking and willingness-to-loan relationships and operationalized them as a dynamic multiplex social network-multiple, simultaneous interdependent relationships--that exist within 42 Oxford House recovery homes over time. By pooling relationship dynamics across recovery houses, a Stochastic Actor-Oriented Modeling (SAOM) framework (Snijders et al., 2010) was used to estimate a set of parameters governing the evolution of the network and the recovery attributes of the nodes simultaneously. Findings indicated that advice and loan relationships and recovery-related attitudes were endogenously interdependent, and these results were affected exogenously by gender, ethnicity, and reason for leaving the recovery houses. Prior findings had indicated that higher advice seeking in recovery houses was related to higher levels of stress with more negative outcomes. However, the current study found that recovery is enhanced over time if advice was sought from residents with higher recovery scores. Our study shows that social embedding, i.e. one's position in relationship networks, affects recovery prospects. More specifically, the formation of ties with relatively more recovered residents as an important predictor of better outcomes.

Housing First Combined with Suicide Treatment Education and Prevention (HOME + STEP): study protocol for a randomized controlled trial

BACKGROUND

Youth experiencing homelessness are at high risk for suicide, yet few studies have evaluated risk reduction interventions targeting suicidal ideation in this vulnerable population. A comprehensive approach to risk-reduction is needed that addresses basic needs and provides targeted interventions for those at highest risk. The protocol described builds on the design of the first randomized trial of Housing First (HF) for homeless youth. The primary objective is to determine whether housing combined with supportive services that include suicide screening and targeted psychotherapy (Cognitive Therapy for Suicide Prevention) is effective for reducing suicidal ideation and other secondary outcomes (depression and suicide attempts). Additionally, we will explore mediators of the treatment effect (housing stability and substance use) and determinants of implementation.

METHODS

Youth recruited to the HF trial will be randomized to HF + supportive services (n = 120), or supportive services alone (n = 120). The "Suicide Treatment Education and Prevention" (STEP) protocol will additionally screen youth in both arms at baseline and 3 months for suicidal ideation (SSI-W). Those who screen as moderate risk for suicide (SSI-W ≥ 10) will be offered CTSP, which includes up to 9 sessions over the first 6 months following enrollment. CTSP will be delivered in one-on-one sessions by a trained advocate. Research assessments will be collected to assess outcomes (including suicidal ideation) at baseline, 3, 6, 9 and 12 months. Qualitative interviews with subjects receiving CTSP and other stakeholders will explore implementation determinants.

DISCUSSION

The study will fill an important gap in the literature about the added benefit of HF combined with supportive services including suicide screening and treatment for reducing suicidal ideation in homeless youth. With the urgent need to address both homelessness and suicide risk, evidence is needed about services that can be integrated into delivery settings for youth experiencing homelessness.

TRIAL REGISTRATION

NCT04135703 . Date of registration: October 23, 2019.

SBIRT administered by mental health counselors for hospitalized adults with substance misuse or disordered use: Evaluating hospital utilization and costs

OBJECTIVE

We analyzed the association of Screening, Brief Intervention, and Referral to Treatment (SBIRT) with hospitalizations, emergency department (ED) visits, and related costs, when administered to inpatients with substance misuse or disordered use by professional mental health counselors.

METHODS

Our study used retrospective program and health records data and a difference-in-differences design with propensity score covariates. The study population consisted of hospital inpatients admitted to integrated care services staffed by physicians, nurses, and mental health counselors. The intervention group consisted of patients selected for intervention based on substance use history and receiving SBIRT (n = 1577). Patients selected for intervention but discharged before SBIRT administration (n = 618) formed the comparison group. The outcome variables were hospitalization and ED visits costs and counts. Costs of hospitalizations and ED visits were combined to allow sufficient data for analysis, with counts treated similarly. Patient-level variables were substance use type and substance use severity. A cluster variable was inpatient clinical service. Zero-censored and two-part logistic and generalized linear models with robust standard errors tested the association of SBIRT interventions with the outcomes.

RESULTS

For the full study population of patients using alcohol, illicit drugs, or both, SBIRT administered by mental health counselors was not associated with changes in hospitalizations and ED visits. For patients with alcohol misuse or disordered use, SBIRT by mental health counselors was associated an odds ratio of 0.32 (p < .001) of having subsequent hospitalizations or ED visits. For patients with alcohol use who did return as hospital inpatients or to the ED, SBIRT by counselors was associated with a reduction in costs of $2547 per patient (p < .001) and with an incidence rate ratio of 0.57 for counts (p = .003).

CONCLUSION

Our results suggest that professional mental health counselors on inpatient integrated care teams may provide SBIRT effectively for patients with misuse and disordered use of alcohol, reducing the likelihood of future healthcare utilization and costs.

Associations between patient experience and clinical outcomes in substance use disorder clinics: Findings from the veterans outcomes assessment survey

BACKGROUND

Patient-centeredness is a cornerstone of substance use disorder (SUD) treatment. Patient-experience measures are potential tools for the routine assessment of patient-centered SUD care and may be valuable measures to inform quality monitoring improvement efforts. Little research exists on the predictive validity of patient-experience measures in SUD care.

PURPOSE

We report on findings from the Veterans Outcome Assessment (VOA) survey that provides information on Veterans Health Administration SUD specialty care at treatment initiation and approximately 3-months post-initiation.

METHODS

The VOA includes patient-reported outcomes across multiple domains, including the Brief Addiction Monitor (BAM-R), the Short-Form-12 (SF-12) and the Experience of Care and Health Outcome Survey (ECHO), and provides patient reports of the quality of provider communication and overall quality of SUD care.

RESULTS

Nearly 40% of veterans in SUD care gave the highest possible ratings for communication and quality at both baseline and follow-up. Ratings of communication at 3-months were associated with treatment discontinuation and both ratings of communication and quality at 3-months and were independently associated with SUD symptoms and with mental well-being at 3-months.

CONCLUSIONS

This study provides preliminary support for the inclusion of patient experience measures, particularly ratings of provider communication, as part of routine assessment in SUD care. However, further work on the validity of ratings of provider communication using additional methodologies is likely important before piloting the inclusion of such measures in routine assessment, such as in measurement base care.

The "black box" of treatment: Patients' perspective on what works in opioid maintenance treatment for opioid dependence

BACKGROUND

A lack of conceptual modeling of how the components of opioid maintenance treatment (OMT) for opioid dependence (OD) work causes it to occasionally be labeled the "black-box" of treatment. This study had a two-fold objective: First, to analyze which factors related to OMT for OD contribute to the abstinence of problematic use of non-prescribed opioids and sustain recovery, from the patients' perspective; second, to understand which changes OMT produced in the individuals' lives might significantly contribute to relapse prevention.

METHODS

We used qualitative methods of design, inquiry, and analysis from a convenience sample of 19 individuals in a Swedish treatment setting.

RESULTS

All the participants reported previous cycles of problematic use of non-prescribed opioids and other non-prescribed psychoactive substances, treatment, abstinence, recovery, and relapse before starting the current OMT program. During the pre-treatment stage, specific events, internal processes, and social environments enhanced motivation toward abstinence and seeking treatment. During the treatment stage, participants perceived the quality of the human relationships established with primary social groups as important as medication and the individual plan of care in sustaining recovery. From the participants' perspective, OMT was a turning point in their life course, allowing them a sense of self-fulfillment and the reconstruction of personal and social identity. However, they still struggled with the stigmatization produced by a society that values abstinence-oriented over medication-assisted treatments.

CONCLUSION

OMT is not an isolated event in individuals' lives but rather a process occurring within a specific social context. Structural factors and the sense of acceptance and belonging are essential in supporting the transformation. Treatment achievements and the risk for relapse vary over time, so the objectives of the treatment plan must account for characteristics of the pre-treatment stage and the availability and capacity of individuals to restructure their social network, besides the opioid maintenance treatment and institutional social care.

Effectiveness of value-based purchasing for substance use treatment engagement and retention

INTRODUCTION

Many people drop out of substance use disorder (SUD) treatment within the first few sessions, which suggests the need for innovative strategies to address this. We examined the effectiveness of incentive-based contracting for Maine's publicly funded outpatient (OP) and intensive outpatient (IOP) SUD treatment, to determine its potential for improving treatment engagement and retention.

METHODS

Maine's incentive-based contract with federally block grant-funded OP and IOP treatment agencies created a natural experiment, in which we could compare treatment engagement and retention with a group of state-licensed treatment agencies that were not part of the incentive-based contract. We used administrative data for OP (N = 18,375) and IOP (N = 5986) SUD treatment admissions from FY2005-FY2011 to capture trends prior to and after the FY2008 contract implementation date. We performed multivariable difference-in-difference logistic regression models following propensity score matching of clients.

RESULTS

Two-thirds (66%) of OP admissions engaged in treatment, defined as 4+ treatment sessions, and 85% of IOP admissions satisfied the similar criteria of 4+ treatment days. About 40-45% of OP admissions reached the threshold for retention, defined as 90 days in treatment. IOP treatment completion was attained by 50-58% of admissions. For OP, the incentive and nonincentive groups had no significant differences in percentages with treatment engagement (AOR = 1.28, DID = 5.9%, p = .19), and 90-day retention was significant in the opposite direction of what we hypothesized (AOR = 0.80, DID = -4.6%, p = .0003). For IOP, the incentive group had a significant, but still small, increase in percentage with treatment engagement (AOR = 1.52, DID = 5.5%, p = .003), but the corresponding increase in treatment completion was not similarly significant (AOR = 1.12, DID = 2.7%, p = .53). In all models, individual-level variables were strong predictors of outcomes.

CONCLUSION

We found little to no impact of the incentive-based contract on the treatment engagement, retention, and completion measures, adding to the body of evidence that shows few or null results for value-based purchasing in SUD treatment programs. The limited success of such efforts is likely to reflect the bandwidth that providers and programs have to focus on new endeavors, the importance of the incentive funding to their bottom line, and forces beyond their immediate control.

Personal and Environmental Social Capital Predictors of Relapse Following Departure from Recovery Homes

Substance use recovery homes represent the largest residential, community-based post-treatment option for those with substance use disorders in the United States. It is still unclear what unique factors predict relapse after residents leave such homes. This study presents results of a longitudinal study of 497 residents who departed from 42 Oxford House recovery houses. We hypothesized that the predictors of post-departure relapse would be a multi-item measure of latent recovery, length of stay, and reason for departure from the home (voluntary vs. involuntary). Predictor effects were estimated as part of a two-step model with two outcomes: (a) lack of follow-up data after departure from the house, and (b) the likelihood of relapse. Determinants of missing follow-up data included less education, less time in residence, and involuntary departure. Relapse was more likely for individuals who were younger, had involuntarily left the house, and had lower values on the latent recovery factor. The implications of these important factors related to relapse following departure from residential recovery home settings are discussed.

Pathways to Engagement: An Exploratory Qualitative Analysis of Factors That Facilitate Men's Engagement in IPV Intervention Programs

Research on intimate partner violence (IPV) interventions has long indicated mixed support for their effectiveness at reducing abusive behaviors. Limited prior research has focused on factors associated with participant engagement in the treatment process. Using a qualitative thematic analysis and a sample of 180 participants who completed an IPV intervention program, the purpose of this study was to identify key factors that facilitate men's responsiveness to IPV intervention programs. The findings highlight several commonalities in participants' perceptions of pathways that facilitated and/or hindered their engagement in the treatment process, and provide insights into how program/process elements can be structured to enhance engagement.

Factors associated with quality of life trajectories among inpatients treated for alcohol use disorders: A prospective cohort study

AIMS

The main study purpose was to investigate patient- and treatment-related factors associated with overall quality of life (OQOL) trajectories during and after inpatient alcohol use disorder (AUD) treatment.

DESIGN

A large-scale prospective multicenter cohort study of patients with different substance use disorder (SUD) types who were consecutively admitted for inpatient SUD treatment. Data were obtained at treatment entry (T1), discharge (T2), three months after discharge (T3), and one year after discharge (T4). The inclusion criterion was that the patient be dependent solely on alcohol. OQOL data were collected at all four time points. Independent variables included demographics, mental distress, psychiatric disorders, substance use, treatment history, and patient satisfaction.

RESULTS

Among the 611 patients available, 236 met the AUD inclusion criterion and completed T1 assessments. A linear mixed model showed substantial co-occurrence between higher mental distress and lower OQOL. Higher patient satisfaction with inpatient treatment (T2) was associated with higher trajectories of OQOL, whereas abstinence (T3) was not. There was a substantial increase in OQOL from T1 to T2, which then remained stable during the last two assessment time points.

CONCLUSIONS

Routine OQOL screening at treatment entry, and targeting mental distress both during and after inpatient treatment, may be associated with improved OQOL among individuals with AUD. Further research should investigate inpatient treatment factors that contribute to OQOL improvement and those that moderate the relationship between patient satisfaction and OQOL.

Staff-perceived barriers to nutrition intervention in substance use disorder treatment

OBJECTIVE

While organisational change in substance use disorder (SUD) treatment has been extensively studied, there is no research describing facility-wide changes related to nutrition interventions. This study evaluates staff-perceived barriers to change before and after a wellness initiative.

DESIGN

A pre-intervention questionnaire was administered to participating staff prior to facility-wide changes (n 40). The questions were designed to assess barriers across five domains: (1) provision of nutrition-related treatment; (2) implementation of nutrition education; (3) screening, detecting and monitoring (nutrition behaviours); (4) facility-wide collaboration and (5) menu changes and client satisfaction. A five-point Likert scale was used to indicate the extent to which staff anticipate difficulty or ease in implementing facility-wide nutrition changes, perceived as organisational barriers. Follow-up questionnaires were identical to the pre-test except that it examined barriers experienced, rather than anticipated (n 50).

SETTING

A multisite SUD treatment centre in Northern California which began implementing nutrition programming changes in order to improve care.

PARTICIPANTS

Staff members who consented to participate.

RESULTS

From pre to post, we observed significant decreases in perceived barriers related to the provision of nutrition-related treatment (P = 0·019), facility-wide collaboration (P = 0·036), menu changes and client satisfaction (P = 0·024). Implementation of nutrition education and the domain of screening, detecting and monitoring did not reach statistical significance.

CONCLUSIONS

Our results show that staff training, food service changes, the use of targeted curriculum for nutrition groups and the encouragement of discussing self-care in individual counselling sessions can lead to positive shifts about nutrition-related organisational change among staff.

The Moderating Effect of Substance Abuse Treatment Engagement on the Connection Between Support From Program Participants and Substance-Related Recidivism for Justice-Involved Women

This study examines the prediction of substance-related technical violations and arrests from (a) a three-dimensional measure of substance abuse treatment engagement-treatment satisfaction, treatment participation, and counselor rapport-and (b) support from peers in the treatment program. The study focuses on 204 women on probation or parole who attended a substance abuse treatment program in the first 9 months of supervision. Data were collected in face-to-face interviews and from official records of violations and arrests. Generalized linear mixed-effects modeling was used to assess the main effects and the interaction effect of within-program peer support and other indicators of engagement as predictors of substance-related technical violations and arrests. Peer support was positively related to violations/arrests when treatment engagement was low. Findings suggest that for women who do not score high in treatment engagement, support from peers is related to increased recidivism, and group treatment may be contraindicated.

The effect of medications for opioid use disorder (MOUD) on residential treatment completion and retention in the US

BACKGROUND

This study examines whether MOUD increases treatment completion and retention in both short-term (ST) and long-term (LT) residential programs using a national dataset.

METHODS

Data were extracted from the 2015-2017 TEDS-D (Treatment Episode Dataset-Discharge) datasets for opioid using adults in ST (n = 87,296) and LT (n = 66,623) residential treatment. Primary outcome variables were treatment completion and retention (ST: length of stay >10 days; LT: >90 days). Logistic regression estimated the effects of MOUD on the probability of treatment completion and retention separately for ST and LT residential treatment, controlling for individual background characteristics.

RESULTS

Only 18% of clients in residential treatment programs had MOUD in their treatment plans. For ST residential treatment, MOUD was associated with a 40% increased likelihood of treatment completion (OR = 1.404) and 34% increased retention (OR = 1.337). For LT residential treatment, MOUD was associated with a 26% reduced likelihood of treatment completion (OR = 0.743) and no significant increase in retention. Post hoc analysis suggests insurance coverage may be influencing outcomes.

CONCLUSIONS

Despite MOUD being a standard of care for OUD, MOUD is particularly under-utilized in residential treatment. Further research should focus on how best to integrate MOUD within short-term residential treatment and to explore the potential viability of MOUD in long-term residential programs. Given the risk of overdose following residential treatment, for at least short-term residential programs, this setting may be advantageous for integrating psychosocial treatments with early MOUD engagement in a structured therapeutic environment as part of a long-term continuum of care recovery program.

Barriers, facilitators, and disparities in retention for adolescents in treatment for substance use disorders: a qualitative study with treatment providers

BACKGROUND

Retention in substance use treatment is one of the strongest predictors of improved outcomes among adolescents, making retention an important goal of treatment. We examined treatment providers' perspectives on barriers and facilitators to treatment retention among adolescents, and their views on contributors to racial/ethnic disparities in retention including ways to address disparities.

METHODS

Semi-structured interviews were conducted with 19 providers at state-licensed detoxification, residential, and outpatient facilities serving adolescents for substance use disorders in Massachusetts. Interviews were coded by at least two independent coders.

RESULTS

Providers identified barriers and facilitators at the policy/systems, facility, family, and client levels. Some of the barriers included insurance limits on sessions/length of stay and low reimbursement (policy/systems), staff turnover (facility), low family engagement (family), and low internal motivation (client). Some facilitators mentioned were support from state's substance use agency (policy/systems), flexibility with meeting location (facility), family participation (family), and high internal motivation and presence of external motivators (client). Barriers that contributed to racial/ethnic disparities included lower socio-economic status, language barriers, and mistrust. Having bilingual/bicultural staff and multi-lingual materials, and facilitating transportation were identified as strategies for reducing disparities in treatment retention.

CONCLUSIONS

It is critical that adolescents who access substance use services remain and complete treatment and that there is equity in treatment retention. Provider perspectives in factors associated with retention can inform the development of comprehensive interventions and policies to help improve retention and reduce disparities.

Predictive Outcome Validity of General Health Questionnaire (GHQ-28) in Substance Abuse Patients Treated in Therapeutic Communities

Objective: The use of psychoactive substances has been one of the most important global public health problems over the last few decades. Among the problems associated with substance use, dual diagnosis is one of the most relevant. This study aims to investigate the predictive validity of the GHQ-28 (General Health Questionnaire-28; "probable psychiatric cases") in relation to poor treatment outcome measured by (a) "early treatment dropout" and (b) "nonclinically relevant improvement at discharge." Methods: A longitudinal prospective design was used. A sample of 219 substance use disorder patients, who received treatment in a therapeutic community, was selected. Patients were assessed using the GHQ-28 and the outcome variables were registered. A hierarchical logistic regression model was performed to identify factors independently associated with the outcome measure ("early treatment dropout" and "nonclinically relevant improvement at discharge"). Results: Of the total sample, 79 subjects (36%) were considered "early treatment dropouts" and 56.6% (102) presented a "nonclinically relevant improvement at discharge." The two hierarchical logistic regression results show that being classified as a "probable psychiatric case" was significantly and directly associated with "early treatment dropout" and "nonclinically relevant improvement at discharge," as a poor in-treatment outcome indicator. Conclusions: The results of this study support the notion that the probable psychiatric cases identified by the GHQ-28 scale have a greater probability of "early treatment dropout" and have a greater probability of "nonclinically relevant improvement in discharge" of the therapeutic community. These data indicate that GHQ-28 is a suitable clinical instrument for predicting dropout and treatment effect in residential substance use disorder treatment.

The role of personality functioning in drug misuse treatment engagement

BACKGROUND AND AIM

Personality functioning is predictive of drug misuse and relapse, yet little is known about the role of personality in engagement with the treatment process. This study aimed to estimate the extent to which broad- and facet-level characteristic adaptations contribute to or hinder treatment engagement, while controlling for psychosocial indicators.

DESIGN

Multi-site cross-sectional survey.

SETTING

In-patient treatment units covering 80% of residential treatment entries in Greece.

PARTICIPANTS

A total of 338 service users, 287 (84.9%) male, 51 (15.1%) female, average age 33.4 years.

MEASUREMENTS

Expressions of personality functioning (characteristic adaptations) were assessed using the Severity Indices of Personality Problems (SIPP-118). Treatment engagement was measured using the Client Evaluation of Self and Treatment, in-patient version (CEST).

FINDINGS

Dysfunctional levels of relational capacities predicted counselling rapport [β = 1.50, 95% confidence interval (CI) = 0.326-2.69, P = 0.013], treatment participation (β = 2.09, 95% CI = 1.15-3.11, P < 0.001) and treatment satisfaction (β = 1.65, 95% CI = 0.735-2.57, P < 0.001). Counselling rapport was also predicted by dysfunctional levels in self-control (β = 1.78, 95% CI = 0.899-2.67, P < 0.001), self-reflective functioning at the facet-level (β = 2.24, 95% CI = 1.01-3.46, P < 0.001) and aggression regulation (β = 1.43, 95% CI = 0.438-2.42, P = 0.005). Dysfunctional levels on social concordance (β = -1.90, 95% CI = -2.87 to -0.941, P = 0.001), emotional regulation (β = 1.90, 95% CI = 0.87-2.92, P < 0.001) and intimacy (β = 2.04, 95% CI = 1.31-3.05, P < 0.001) were significant predictors of treatment participation. Treatment readiness and desire for help predicted treatment engagement.

CONCLUSIONS

In people attending substance use treatment services, maladaptive interpersonal patterns and relational intimacy, emotional dysregulation and impulse control may be associated with low levels of counselling rapport and treatment participation. Low frustration tolerance and aggressive impulses also appeared to predict low participation.

Communication Themes of Patient Engagement for Multi-speciality Hospitals: Nurses’ Perspective

Introduction:

Patient engagement is engaging patients in their own medical care to heal them faster and take their valuable inputs to improve the health of population. Nurses contribute significantly in treatment, interact and spend most of their time with inpatients. Therefore, exploring the perspectives of nurses on patient engagement-communication is of vital importance.

Objective:

This article focuses on exploring the communication themes of patient engagement from the perspective of nurses in a multi-speciality hospital in Delhi.

Methodology:

The exploratory qualitative case study was carried out with semi-structured interviews of 12 nurses, observation at receptions of ICUs and emergency department and analysis of documents from the hospital’s official website. Grounded theory—three-level coding—was performed to identify the themes of patient engagement-communication.

Results:

A total of nine themes have been identified: ‘attendant’s role’, ‘communicating with patients of different categories’, ‘doctor’s support to nurses’, ‘nurse action’, ‘nurse behaviour’, ‘nurse challenges’, ‘patient actions’, ‘patient emotions’ and ‘wider role of nurses’.

Conclusion:

Nurses play a critical role in engaging patients through communication. They should change their approach of communication with different types of patients, understand, respect and give due weightage to patient’s emotions and actions and, play a wider role of teacher and guardian than just being the nurse.

Effects of 12-step mutual support and professional outpatient services on short-term substance use outcomes among adults who received inpatient treatment

BACKGROUND

Continuing care is increasingly prioritized in the treatment of substance use disorders (SUDs). Ongoing engagement in continuing care, including mutual support (e.g., 12-step groups) and/or professional outpatient services, may enhance treatment outcomes and facilitate recovery.

OBJECTIVE

This study investigates how engagement in 12-step mutual support and professional outpatient services is associated with short-term substance use outcomes in a sample of patients who completed inpatient SUDs treatment.

METHODS

As part of the Recovery Journey Project - a longitudinal cohort study - participants completed questionnaires upon admission to an inpatient SUDs treatment program, and at 1- and/or 3-months post-discharge (n = 379). Baseline data were collected by self-administered, electronic questionnaires. Follow up data were collected by phone or email. Analyses involved multivariate Generalized Estimating Equations separately modelling self-reported abstinence and percent days abstinent (PDA) over the three time periods.

RESULTS

Overall, rates of self-reported abstinence and PDA increased significantly from baseline to 1- and 3-months follow up. Engagement in 12-step activities (i.e., attended 30 meetings in 30 days, had a home group, had a sponsor, did service work) and professional outpatient substance use support were each significantly associated with abstinence and PDA. Participants who reported a higher degree of 12-step involvement (defined as engagement in more 12-step activities) were also more likely to report being abstinence and greater PDA.

CONCLUSIONS

Engagement in continuing care, including 12-step activities and professional outpatient substance use support, was highly associated with substance use. Clinical teams should encourage participation in such activities to optimize treatment outcomes.

Measurement-based care using DSM-5 for opioid use disorder: can we make opioid medication treatment more effective?

CONTEXT AND PURPOSE

Measurement-based care (MBC) is an evidence-based health-care practice in which indicators of disease are tracked to inform clinical actions, provide feedback to patients and improve outcomes. The current opioid crisis in multiple countries provides a pressing rationale for adopting a basic MBC approach for opioid use disorder (OUD) using DSM-5 to increase treatment retention and effectiveness.

PROPOSAL

To stimulate debate, we propose a basic MBC approach using the 11 symptoms of OUD (DSM-5) to inform the delivery of medications for opioid use disorder (MOUD; including methadone, buprenorphine and naltrexone) and their evaluation in office-based primary care and specialist clinics. Key features of a basic MBC approach for OUD using DSM-5 are described, with an illustration of how clinical actions are guided and outcomes communicated. For core treatment tasks, we propose that craving and drug use response to MOUD should be assessed after 2 weeks, and OUD remission status should be evaluated at 3, 6 and 12 months (and exit from MOUD treatment) and beyond. Each of the 11 DSM-5 symptoms of OUD should be discussed with the patient to develop a case formulation and guide selection of adjunctive psychological interventions, supplemented with information on substance use, and optionally extended with information from other clinical instruments. A patient-reported outcome measure should be recorded and discussed at each remission assessment.

CONCLUSIONS

MBC can be used to tailor and adapt MOUD treatment to increase engagement, retention and effectiveness. MBC practice principles can help promote patient-centred care in OUD, personalized addiction therapeutics and facilitate communication of outcomes.

Cardiorespiratory and autonomic-nervous-system functioning of drug abusers treated by Zen meditation

Addicted drugs like nicotine affect autonomic nervous system that results in arrhythmia and other cardiovascular diseases. Notable effects of Zen meditation on autonomic nervous system have been reported during the past decade. Holistic Detox Association (HDA) in Taiwan offered Zen-meditation program to drug addicts as the core scheme among a variety of drug addiction treatments. This paper reports the results of quantifying the cardiorespiratory interactions and autonomic nervous system function to evaluate the on-site effect of Zen meditation on drug rehab. Methods and schemes for quantifying time-domain heart rate variability were employed to electrocardiograph and respiratory signals. Peak-valley method was developed to quantify the respiratory sinus arrhythmia (RSA) behavior. Poincaré Plot Analysis was adopted to evaluate the cardiorespiratory functioning. Among 18 voluntary drug addicts during the 10-minute Zen meditation session, about two-third subjects have significant improvement in autonomic nervous system function characterized by heart rate variability (SDNN, RMSSD and pNN50). Group average of RSA increases from 33.43 ms(Rest) to 69.14 ms(AR Zen meditation). Poincaré-plot analysis reveals the improvement of SD1, SD2 and SD2/SD1 by respectively 14.7%, 19.8% and 8.8%. The group averages of all the parameters exhibit significantly positive changes in the 10-minute session of abdominal-respiration Zen meditation. Even the subject with heart transplant showed the improvement of all the quantitative indicators during the AR Zen meditation.

How long does it take to complete outpatient substance use disorder treatment? Disparities among Blacks, Hispanics, and Whites in the US

This research investigates racial and ethnic disparities in outpatient substance use disorder treatment completion and duration in treatment, for different substances, across the US, using the national 2014 Treatment Episode Dataset-Discharge (TEDS-D) data set. Moderated fixed effects logistic regression models assessed effects of race/ethnicity on length of stay in treatment and treatment completion for different substances of use. Moderated models also assessed the differential effect of length of stay on treatment completion among Blacks, Hispanics, and Whites. While Blacks and Hispanics both have significantly lower treatment completion rates than Whites, treatment duration is substantially similar across the three groups. Blacks and Hispanics generally take longer to complete treatment than Whites, though this varies by substance for Hispanics. Disparities in treatment completion persist even after controlling for treatment duration. These results indicate that observed racial and ethnic disparities in treatment completion are not due to differences in length of stay in treatment. Economic, cultural, accessibility, or, potentially, discriminatory, factors may suppress the likelihood of treatment completion for minorities and result in longer treatment durations required for completion. Recognition by treatment providers of the unique challenges to treatment completion faced by minorities may enhance treatment outcomes for minorities in the US.

Probation clients' barriers to access and use of opioid use disorder medications

BACKGROUND

There is a gap between evidence-based treatment with medications for opioid use disorders (OUDs) and current practices of probation departments who supervise individuals with OUDs. Many probationers with OUDs cannot access FDA-approved medications to treat their disorders despite the strong evidence of their effectiveness. The barriers to medications for those under probation supervision include practitioners' negative attitudes toward medications, costs, stigma, and diversion risk. Probation officers have an ethical obligation to help their clients reduce barriers to access the care they need which in turn can improve their outcomes and increase public safety.

RESULTS

The current study explores how probation departments respond to probationers with OUDs, focusing on the barriers to accessing OUD medications based on a survey of probation department directors/administrators (hereafter referred to as probation department leaders) in Illinois (N = 26). A majority of probation department leaders reported perceived staff barriers to their clients accessing medications. Reasons included lack of medical personnel experience, cost, need for guidance on medications, and regulations set by their organization or jurisdiction that prohibit client use of medications. Probation department leaders reported knowing less about the use of methadone and how it is administered, compared to buprenorphine and naltrexone. In addition, probation department leaders were generally more open to referring clients for treatment that include buprenorphine or naltrexone compared to methadone. Despite slightly less training or familiarity with methadone than the other medications, the number of probation department leaders who knew where to refer someone for each of the three FDA-approved medications was similar.

CONCLUSIONS

The current study found probation department leaders perceive some barriers to their staff linking or referring their clients to OUD medications. Study findings indicate a need for administration- and staff-level training, interagency collaboration, and policy changes to increase access to, education on, and use of, medications for probation clients. Such efforts will ultimately help probation clients with OUDs stabilize and adhere to other probation requirements and engage in behavioral therapy, which may result in positive outcomes such as reduced recidivism, increased quality of life, and reduced mortality.

Program Capacity to Deliver Prevention Services to Children of Adult Clients Receiving Substance Use Disorder Treatment

Children whose parents have a history of substance use are at elevated risk of developing substance use disorders (SUDs) and related debilitating behaviors. Although specialty treatment programs are uniquely positioned to deliver prevention care to children of adult clients, these programs may have limited capacity to implement prevention and early intervention care services, particularly in racial and ethnic minority communities. We merged data from program surveys and client records collected in 2015 to examine the extent to which program capacity factors are associated with the odds of delivering prevention and early intervention services for children of adult clients attending outpatient SUD treatment in low-income minority communities in Los Angeles County, California. Our analytic sample consisted of 16,712 clients embedded in 82 programs. Our results show that 85% of these programs reported delivering prevention care services, while 71% of programs delivered early intervention services. Programs with organizational climates supporting change and those that served a high number of clients annually were more likely to implement both prevention and early intervention practices. Programs accepting Medicaid payments and serving clients whose primary drug was marijuana were more than three times as likely to implement prevention services. Overall, our findings suggest both program- and client-level characteristics are associated with delivering preventive care offered to children of adult clients receiving SUD treatment in communities of color. As Medicaid has become a major payor of SUD treatment services and marijuana use has been legalized in California, findings identify capacity factors to deliver public health prevention interventions in one of the nation's largest public SUD treatment systems.

The role of physical and psychological health problems in the drug use treatment process

The role of physical and psychological health is examined as a predictor of client engagement in prison-based drug treatment. A treatment process model was expanded to include physical and mental health issues. The sample included 6009 offenders in prison-based drug treatment, comprised of 67% male, 26% African American, 51% white, and 22% Hispanic; average age was 34.6. Half reported "some physical health concerns" and mentioned a variety of ailments. A fifth reported moderate stress on the Kessler Psychological Distress Scale (K10) and 15% reported PTSD based on the PTSD Check List (PCL). Structural equation modeling was used to model treatment engagement in terms of demographics, physical health concerns, psychological distress, HIV risky behaviors, self-esteem, decision making, and treatment motivation. Two random samples were created, with one used for estimation and the other for cross-validation. The findings suggested physical health and HIV risky behaviors have effects on client engagement through psychological functioning, and that psychological functioning has direct effects on treatment engagement.

Levels and predictors of participation in integrated treatment programs for pregnant and parenting women with problematic substance use

Background

Women who are seeking services for problematic substance use are often also balancing responsibilities of motherhood. Integrated treatment programs were developed to address the diverse needs of women, by offering a holistic and comprehensive mix of services that are trauma- and violence-informed, and focus on maternal and child health promotion and the development of healthy relationships.

Methods

Using system-level administrative data from a suite of outpatient integrated programs in Ontario, Canada, we described the clients and rates and predictors of treatment participation over a 7-year period (2008–2014; N = 5162).

Results

All participants were either pregnant or parenting children under 6 years old at admission to treatment. Retention (length of time between the first and last visit) averaged 124.9 days (SD = 185.6), with episodes consisting of 14.6 visits (SD = 28.6). The vast majority of women attended more than one visit (87.2%), typically returning within 2 weeks (mean 12.3 days, SD = 11.1). In addition to being pregnant or new mothers experiencing problematic substance use, most were unemployed, on social assistance, and single.

Conclusions

Programs appeared to be able to successfully engage most women in treatment once they accessed the programs. Although rates of treatment participation did vary across subgroups defined by sociodemographic and admission characteristics, effect sizes tended to be small on average, providing little evidence in general of sociodemographic inequities in participation. Further work is needed to study the influence of program-level factors on participation, and how these link to maternal and child outcomes.

Massachusetts Health Reform's Effect on Hospitalizations with Substance Use Disorder-Related Diagnoses

OBJECTIVE

To examine whether Massachusetts (MA) health reform affected substance (alcohol or drug) use disorder (SUD)-related hospitalizations in acute care hospitals.

DATA/STUDY SETTING

2004-2010 MA inpatient discharge data.

DESIGN

Difference-in-differences analysis to identify pre- to postreform changes in age- and sex-standardized population-based rates of SUD-related medical and surgical hospitalizations, adjusting for secular trends.

DATA EXTRACTION METHODS

We identified 373,751 discharges where a SUD-related diagnosis was a primary or secondary discharge diagnosis.

FINDINGS

Adjusted for age and sex, the rates of drug use-related and alcohol use-related hospitalizations prereform were 7.21 and 8.87 (per 1,000 population), respectively, in high-uninsurance counties, and 8.58 and 9.63, respectively, in low-uninsurance counties. Both SUD-related rates increased after health reform in high- and low-uninsurance counties. Adjusting for secular trends in the high- and low-uninsurance counties, health reform was associated with no change in drug- or alcohol-related hospitalizations.

CONCLUSIONS

Massachusetts health reform was not associated with any changes in substance use disorder-related hospitalizations. Further research is needed to determine how to reduce substance use disorder-related hospitalizations, beyond expanding insurance coverage.

A system-level study of initiation, engagement, and equity in outpatient substance use treatment

Understanding the nature of variations in the quality of substance use treatment is critical to ensuring equity in service delivery and maximizing treatment effectiveness. We used adapted versions of the US Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement measures to assess care quality in specialized outpatient services for substance use in Ontario, Canada. Using administrative data, we calculated rates of outpatient treatment initiation and engagement (N = 120,394 episodes) and investigated variation by client characteristics and treatment mandates. About half of clients who entered outpatient treatment met the criteria for initiation (i.e., had a second visit within 14 days) and 30% met the criteria for engagement (i.e., had another two visits within 30 days of initiation). The likelihood of treatment initiation and engagement was greater among older people, those with more education, those who were not mandated to enter treatment, and those with greater substance use at admission. People who entered treatment for cannabis were less likely to engage. Engagement was less likely among men than women, but gender differences were slight overall. This study demonstrates the feasibility of using adapted versions of two common measures to characterise care quality in substance use treatment services in the Canadian context. Overall, the magnitude of associations with client characteristics were quite small, suggesting that initiation and engagement were not overly localized to specific client subgroups. Findings suggest that the Ontario system has difficulty retaining clients who enter treatment and that most outpatient treatment involves care episodes of limited duration.

Substance abuse treatment engagement, completion and short-term outcomes in the Western Cape province, South Africa: Findings from the Service Quality Measures Initiative

BACKGROUND

Optimizing the effectiveness of substance use disorder (SUD) treatment is critical in low-and middle-income countries (LMICs) with limited opportunities for SUD treatment. This is the first study to identify targets for interventions to improve the quality of SUD treatment in a LMIC.

METHOD

We explored correlates of three indicators of treatment quality (treatment engagement, completion and abstinence at treatment exit) using data from a SUD performance measurement system implemented in the Western Cape Province of South Africa. The sample included data from 1094 adult treatment episodes representing 53% of the treatment episodes in 2016. Using multivariate logistic regression analyses, we modeled socio-demographic, substance use and program correlates of treatment engagement, completion, and abstinence at treatment exit.

RESULTS

Overall, 59% of patients completed treatment (48% of patients from outpatient services). Treatment completion was associated with greater likelihood of abstinence at treatment exit. Patients were more likely to complete treatment if they engaged in treatment, were older, and had more severe drug problems (characterized by daily drug use and heroin problems) and attended programs of shorter duration. Residential treatment was associated with greater likelihood of treatment engagement, completion, and abstinence at treatment exit.

CONCLUSION

Improving rates of outpatient treatment completion will enhance the effectiveness of South Africa's SUD treatment system. Interventions that promote engagement in treatment, particularly among younger patients; reduce program length through referral to step-down continuing care; and ensure better matching of drug problem to treatment level and type could improve rates of treatment completion.

Evidence of validity and reliability of the Opiate Dosage Adequacy Scale (ODAS) in a sample of heroin addicted patients in buprenorphine/naloxone maintenance treatment

OBJECTIVE

The Opiate Dosage Adequacy Scale (ODAS) is a clinical tool to individually measure the "adequacy" of opioid doses in patients on maintenance treatment. The aim of this paper is to provide evidence for the validity and reliability of the ODAS in a sample of patients in buprenorphine/naloxone (B/N) maintenance treatment.

METHOD

Cross-sectional study of a convenience sample of B/N-treated patients (n = 316) from four Autonomous Communities in Spain. Participants completed a battery of instruments to assess the following: buprenorphine dose adequacy; heroin dependence severity; psychological adjustment; and patient-desired adjustment of buprenorphine dose.

RESULTS

Exploratory Factor Analysis identified four factors from the ODAS that together account for 85.4% of the total variance: "Heroin craving and use"; "Overmedication"; "Objective opiate withdrawal symptoms (OWS)" and 'Subjective OWS'. Compared to patients with an "inadequate" B/N dose (ODAS), patients with "adequate" doses had less heroin use in the last week (0.01 vs. 0.40; t = -2.73; p < 0.01, 95% CI: -0.67, -0.10), less severe heroin dependence (2.20 vs. 5.26, t = -5.14, p < 0.001; 95% CI: -4.23, -1.88), less psychological distress (3.00 vs. 6.31, t = -4.37, p < 0.001; 95% CI: -4.80, -1.81), and greater satisfaction with their doses (42.1% vs. 13.6%, χ² = 14.44, p < 0.01). Cronbach's alpha coefficient was 0.76 (0.81, 0.92, 0.94, and 0.93, respectively, for the four factor dimensions).

CONCLUSION

These findings support the validity and reliability of the ODAS as a tool to measure and assess buprenorphine dose adequacy in the context of an opioid dependency treatment program.