Making the hard work of recovery more attractive for those with substance use disorders

Substance use disorder severity is associated with sensitivity to effort-related decision-making constraints

RATIONALE

Several studies have reported associations between substance use and effort-related decision making, or the degree to which effort expenditure impacts the choice between lower and higher value rewards. However, previous research has not explored effort-related decision making in populations with severe substance use disorder.

OBJECTIVES

Investigate the association between effort-related decision-making and substance use disorder severity.

METHODS

Adults with substance use disorders (n = 106) enrolled in intensive outpatient treatment completed clinician administered diagnostic interviews and the effort expenditure for rewards task (EEfRT). General linear mixed methods tested the interactive effect of substance use disorder severity and trial-level probability and value on the likelihood of selecting a high-effort choice.

RESULTS

There was a significant interaction between SUD severity and both reward value and reward probability on high-effort choice. The strength of the association between both reward value and probability on high-effort choice significantly increased with SUD severity.

CONCLUSIONS

These results support theories of reward sensitivity and behavioral economics and highlight an emerging risk factor that may serve as a useful target for treatment.

Daily profiles of nondrug reward and their association with daily outcomes for people in recovery from opioid use disorder: An application of latent profile analysis applied to intensive longitudinal data

INTRODUCTION

Daily rewarding experiences not involving drugs are complex and may differentially support recovery from addiction. Rarely has nondrug reward, and its multiple facets (i.e. anticipation, meaning etc.), been examined in daily life-this could uncover the acute benefits of different components of nondrug reward on daily recovery outcomes.

METHODS

153 adults in recovery from OUD receiving opioid agonist treatment (M age=41.1, SD=9.5; 57 % women; 84 % white) completed daily diaries for three weeks (2067 person-days), answering 7 continuous items about appraisals of nondrug rewards (e.g., meaning, reward, and anticipation). Item responses were used as indicators in a latent profile analysis. Daily latent profiles of nondrug reward were tested for their association with recovery outcomes (quality of life, mood, craving and use) using robust standard errors to adjust for the multilevel data structure.

RESULTS

The selected model had four latent profiles (% of days): Highly Anticipated-Rewarding (35 %), Moderately Rewarding (31 %), Minimally Rewarding-Unplanned (22 %), and Highly Rewarding-Unplanned profile (12 %). Relative to the Moderately Rewarding profile, Highly Anticipated-Rewarding was associated with greater positive mood and quality of life and lower negative mood and low-arousal moods. People with more days in the Highly Anticipated-Rewarding Profile (vs. Moderately Rewarding) were less likely to use or crave opioids.

CONCLUSION

Greater meaning, reward, and anticipation (including planning) across indicators within profiles were associated with the best recovery outcomes. Latent profile analysis applied to intensive longitudinal data offers an innovative methodological approach for simultaneously assessing multiple daily protective factors that together may differentially promote recovery.

Opioid Regulation of Social Homeostasis: Connecting Loneliness to Addiction

Loneliness heightens the risk of substance use disorder, and a desire to escape this negative feeling motivates drug use. Opioid drugs in particular are believed to target neurobiological circuits involved in social bonding, increasing vulnerability to opioid addiction when social connectedness is lacking. In this narrative review, we consider how current understanding of μ opioid modulation of reward and threat processing across domains sheds light on the mechanisms that link loneliness and substance use. We discuss evidence for state- and context-dependent μ opioid modulation of social affect and behaviors, which appears to promote prioritization of high-value reward options also in the context of threat. Tying this literature to the model of social homeostasis, we argue for a role of μ opioids in regulating social homeostasis across species. Finally, we explore how disruption of social homeostasis in chronic opioid use contributes to continued drug use. We highlight how increasing patients' psychosocial resources and opportunities for social bonding can improve recovery from drug addiction. Throughout, we consider the translational robustness and generalizability of the nonhuman animal evidence in light of existing human research.

Substance use negatively impacts change in reinforcement during the year following substance use treatment

OBJECTIVE

Although research supports an association between increased alternative reinforcement and decreased substance use, the impact of substance use on changes in reinforcement during posttreatment recovery remains untested. This study tested the effect of abstinence duration and substance use frequency on the trajectories of four reinforcement mechanisms, behavioral activation, reward probability, reward barriers, and valued living, from pre- to 12-month posttreatment.

METHOD

Adults in intensive outpatient substance use disorder treatment (N = 206) completed self-report measures of the four reinforcement constructs and substance use over six timepoints from pre- to 12-month posttreatment. Latent curve models were used to test the association between reinforcement trajectories and abstinence duration and substance use frequency, respectively.

RESULTS

Lower substance use frequency was associated with significantly improved behavioral activation, reward probability, and reward barriers across the posttreatment period (ps < .05). Higher substance use frequency was associated with significantly lower valued living at each timepoint (ps < .05). Longer abstinence duration was significantly associated with higher behavioral activation and valued living, and lower reward barriers at 12-months (ps < .05).

CONCLUSIONS

Substance-free reinforcement improves during treatment and is negatively impacted by substance use frequency during posttreatment. Abstinence duration is positively associated with substance-free reinforcement at 12-month posttreatment. These findings support the conceptualization of reinforcement as a malleable treatment target that is negatively impacted by substance use. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Changes in the trajectories of drug-free friendships and substance use among a cohort of individuals with multiple substance use disorders

Aims: We used reports (n = 208) of drug-free friendships and alcohol and drug use by people diagnosed with substance use disorder in order to investigate their annual change trajectories across 4 years after treatment and the association between these trajectories and debut age and gender. Methods: The participants were recruited from the Stavanger region, Norway. Using cross-sectional analysis, we first examined the relationship between "alcohol and drug use" and "drug-free friendships" across the five follow-ups. We tested whether these associations were significant using chisquare chi-squared tests. Second, we developed three latent growth curve models examining the association between "alcohol and drug use" and "drug-free friendships". Results: Our analysis displays a stable drug-free friendships pattern across follow-ups. Only in the fourth follow-up was there a significant association between lower "alcohol and drug use" and having "drug-free friendships" (χ2 = 18.27, df = 8, p < .05). In model 1, we found no association between gender, debut age, and alcohol and drug use; model 2 had significant variance on intercept but not on slope; model 3 had good fit (χ2 = 44.33, df = 39, comparative fit index = 0.98, root mean square error of approximation = 0.027). However, we did not find any significant regression path between the "alcohol and drug use" and "drug-free friendships" slopes. Conclusions: Drug-free relationships were in the studied cohort group found to have little influence on reducing alcohol and drug use, while debut age and gender were unrelated to use trajectories across 4 years. We suggest that future research should focus on the frequency and quality of drug-free friendships and participants' friendship assessments because previous research has found such relationships to facilitate recovery.

One or Many Recoveries? Recoveries in the Plural for a Better Understanding of One's Healing Journey

BACKGROUND

Since the 60s, the recovery-oriented approach has greatly influenced mental health policy and practice, and much research has been devoted to exploring it. In the face of a generic definition of the 'recovery' construct, to which many articles refer, a closer examination of the literature reveals a plurality of theories and ways about how changes related to the recovery occur and how to evaluate them.

AIMS

This narrative review explores the different definitions of recovery available in the literature, by investigating the adjectives that qualify it and the theoretical construct the adjective refers to.

METHOD

From the online databases PubMed, Scopus, Google Scholar and PsycINFO, 43 articles were selected for the review.

RESULTS

Seven definitions of recovery emerged, each supported by specific theoretical perspectives: clinical, personal, narrative, social, family, cultural and relational recovery. The adjectives refer to theoretical frameworks often very distant from each other and in epistemological competition; nevertheless, many papers assume a reconcilability and possible integration. The authors critically discuss the advantages and risks of considering such different constructs as complementary.

CONCLUSIONS

Keeping theoretical descriptions and models of healing open and plural means enabling mental health practitioners not to monologise discourses of change by imposing their point of view on users. It means supporting users to authentically seek their healing pathways without conforming to clinicians' expectations. It also means abandoning misleading and naive simplifications and strictly using the appropriate terms relevant to the specific healing construct that researchers refer to from time to time. This is particularly important when it comes to the relational component, which seems to be receiving more and more attention in the literature, and about which there is more confusion.

PATIENT OR PUBLIC INVOLVEMENT

The study involved two experts by experience, or peer support specialists, in a more than active role as components of the research team. They participated equally with the other team members in all phases of the work: the design and conduct of the study, the discussion of findings and advice about implications and dissemination.

The repeatable battery for the assessment of neuropsychological status (RBANS) and substance use disorders: a systematic review

BACKGROUND

Cognitive deficits are prevalent among substance use disorder (SUD) patients and affect treatment retention and outcome. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a well-researched instrument in diverse patient groups and has the potential to serve as an effective and accurate method for identifying cognitive impairment in SUD patients. This systematic review examines the RBANS' ability to detect cognitive impairment in SUD patients. Limitations of knowledge and the need for further research are discussed.

METHODS

We conducted a systematic search using PsycINFO, Medline, and Cochrane databases to identify relevant studies and articles on applying RBANS in SUD. No time limits were imposed on the search. Search words were RBANS, substance use disorder, drug use disorder, and alcohol use disorder, and the most common specific types of drugs (e.g., opiates, cannabis, and methamphetamine).

RESULTS

A systematic search identified 232 articles, of which 17 were found eligible and included in the review. Most studies examined patient groups using either alcohol, methamphetamine, or opioids. The results are presented in the form of a narrative review. We identified some evidence that the RBANS can detect group differences between SUD patients and healthy controls, but the findings were somewhat inconsistent. The literature search revealed little information about cognitive profiles, reliability, factor structure, and construct and criterion validity.

CONCLUSIONS

The evidence concerning the validity and usefulness of the RBANS in SUD populations is scarce. Future research should investigate cognitive profiles, reliability, factor structure, and construct and criterion validity.

Recovery Horizons: Nature-Based Activities as Adjunctive Treatments for Co-Occurring Post-Traumatic Stress Disorder and Substance Use Disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) frequently co-occur, and individuals with co-occurring PTSD and SUD often experience more complex treatment challenges and poorer outcomes compared to those with either condition alone. Integrative treatment approaches that simultaneously address both PTSD and SUD are considered the most effective and include both pharmacological and non-pharmacological strategies. In recent years, complementary interventions have garnered increased attention due to their broad appeal and potential therapeutic benefits in enhancing existing treatments for PTSD and SUD. This review explores the existing literature on the use of nature-based activities, such as hiking, camping, sailing, and surfing in treating individuals with co-occurring PTSD and SUD. Nature-based activities offer promising adjunctive benefits, including the reduction of PTSD symptoms and craving levels. While evidence supports the therapeutic value of nature-based activities, current research remains limited. Further research is needed to better understand their therapeutic role and to refine their implementation in clinical practice.

Behavioral activation for veterans with co-occurring alcohol use disorder and posttraumatic stress disorder: Basis and methodology for a pilot randomized controlled trial

BACKGROUND

Nearly 2 million U.S. veterans live with co-occurring alcohol use disorder and posttraumatic stress disorder (AUD/PTSD). Extant AUD/PTSD treatments emphasize symptom reduction, sometimes overlooking psychosocial functioning improvements, and have dropout rates as high as 50 %. Additionally, current approaches to measuring psychosocial functioning are limited to self-report. This study protocol describes a 1:1 parallel, two-arm, pilot randomized controlled trial comparing Behavioral Activation (BA) psychotherapy to Relapse Prevention (RP) psychotherapy for veterans with AUD/PTSD.

METHODS

Forty-six veterans with AUD/PTSD will be block-randomized to eight weekly, virtual, hour-long individual sessions of BA or RP. Clinical interview, self-report, and geospatial assessments will be administered at pre- and post-treatment. Select outcome and exploratory measures will be administered during treatment. Analyses will focus on trial feasibility, BA acceptability, and preliminary efficacy. Geospatial analyses will explore whether pre- to post-treatment changes in geospatial movement can be used to objectively measure treatment response. The study site and an independent Data and Safety Monitoring Board will monitor trial progress, safety, and quality. De-identified data from consenting participants will be submitted to a sponsor-designated data repository.

CONCLUSION

If successful, this trial could help to provide veterans with AUD/PTSD with a more acceptable treatment option. Positive findings would also lay groundwork for testing BA in civilians with AUD/PTSD. Finally, by incorporating novel geospatial methods and technologies, this study could potentially yield a new approach to objectively measuring AUD/PTSD recovery that could be used in other clinical trials. This study was registered in ClinicalTrials.gov (NCT06249386).

The Role of Savoring in Young Adult Cannabis Use and Associated Consequences: A Replication Study

Young adults exhibit high rates of cannabis use and are at heightened risk of experiencing negative cannabis-associated consequences. The purpose of the present study was to replicate and extend to prior work on savoring, the ability to experience positive experiences/emotions, and cannabis use frequency on cannabis-associated consequences. Young adults (18-25 years old, N = 122, 36.1% women) who reported weekly cannabis use completed self-report surveys. Savoring was significantly associated with cannabis use frequency (r = .28, p < .01) and cannabis-associated consequences (r = -.20, p < .05). Cannabis use frequency was significantly and negatively associated with cannabis-associated consequences (r = -.24, p < .01). However, the interaction between cannabis use frequency and savoring on cannabis-associated consequences was not significant (b = 0.0004, p = .91, 95% CI [-0.007, 0.008]). When the interaction was removed, neither cannabis use frequency (b = -0.14, p = .08, CI [-0.29, -0.02]) nor savoring (b = -0.05, p = .16, CI [-0.13, 0.02]) were associated with cannabis-associated consequences. Results did not replicate previous findings regarding the moderating role of savoring in the relationship between cannabis use frequency and cannabis-associated consequences. Future research may explore why findings did not replicate by using more fine-grained assessment methods and comprehensive measures of cannabis use.

Recovery from alcohol use disorder: Reinforcer pathology theory, measurement, and methods

Recovery from alcohol use disorder (AUD) is a dynamic process that often entails periods of drinking but has been defined primarily by abstinence. Recently, a broader interpretation of recovery was developed, including meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM) remission criteria and improved psychosocial functioning. This new understanding of recovery has facilitated the development of novel theories and methodologies. This paper reviews a new theoretical perspective of recovery, Reinforcer Pathology, and two novel methodological approaches in light of this broader view of recovery. Using this theoretical framework as a foundation, we propose an alternative perspective to explain the recovery process as it relates to environmental factors and valuation of the future; we suggest that changing the environment in which substances are available (e.g., increasing non-alcohol-related activities) and extending one's temporal window are associated with improved recovery outcomes (e.g., remission and quality of life). In this review, we discuss two novel methodological approaches. The first uses latent profile analysis to show that using a measure of Relative Reinforcement Value of Alcohol-Free Activities is associated with a greater likelihood of belonging to a high functioning/infrequent heavy drinking recovery profile. The second developed an online national sample and used an accelerated longitudinal design to study longer-term recovery of up to 12 years over a 5-year study period. Reinforcer Pathology theory, novel methods, and measures may further our understanding of recovery and begin to address critical questions for future studies. Subsequent randomized clinical trials should examine whether the suggested targets and interventions based on the theoretical model improve recovery outcomes prospectively. Measuring and promoting alcohol-free activity engagement may facilitate improved recovery outcomes, while novel methodologies permit an understanding of returning to use or remission across different recovery durations.

A randomized feasibility study of a positive psychology journaling intervention to support recovery from substance-use disorders

BACKGROUND

Individuals in early recovery face significant biopsychosocial stressors causing a preponderance of negative affect. Novel interventions are needed to improve mood and well-being to support recovery. Positive Recovery Journaling (PRJ) combines elements of positive psychology, behavioral activation, and journaling to emphasize what is going right and to encourage small, positive steps that align with an individual's values to make life in recovery more rewarding and therefore more reinforcing. Our objective was to determine PRJ's feasibility, acceptability, and impact on a set of strengths-based, multidimensional aspects of recovery, including satisfaction with life, happiness with recovery, and commitment to sobriety.

METHODS

The study randomized adults in substance-use disorder treatment (N = 81) to PRJ or control. Those in PRJ were asked to practice PRJ daily and complete online surveys for four weeks; those in the control group completed online surveys for four weeks. We used multi-level modelling to determine intercept and slope for feasibility and acceptability outcomes as well as to compare differences in recovery indicators between treatment and control at baseline and Weeks 2, 4, and 8. We conducted intention-to-treat and per-protocol analyses for each recovery indicator.

RESULTS

Participants were 53 % female, and 26 % Black, Indigenous, People of Color (BIPOC) and mean age of 39 years. PRJ participants attended 71 % of groups and completed 56 % of the daily PRJ entries. Treatment and control groups rated their study tasks (PRJ for the treatment group, surveys for the control group) as equally easy; however, the PRJ group rated PRJ as significantly more satisfying, helpful, and pleasant. Treatment and control were not significantly different on any recovery indicator. In post hoc analyses, we found that for those with <90 days sobriety at baseline (51 %), PRJ had a statistically significant beneficial effect for satisfaction with life, happiness with recovery, and numerous secondary recovery indicators.

DISCUSSION

Results suggest a positive impact of PRJ on numerous recovery indices for those in earliest recovery. Integrating PRJ into support services among those with <90 days sobriety could reinforce what is going well in recovery to encourage its continued maintenance and thereby improve treatment outcomes.

Examining cocaine use reductions and long-term outcomes in two clinical trials of continuing care for cocaine dependence

BACKGROUND

There is a need to identify clinically meaningful non-abstinent endpoints for cocaine use disorder (CUD) clinical trials. In this study, we sought to replicate and extend prior work validating reductions in cocaine use frequency levels as an endpoint by examining associations between reductions in cocaine use frequency and long-term functioning outcomes.

METHODS

We conducted a secondary analysis of two randomized clinical trials (N = 445; 77.5 % male; mean age = 42.18 years; 86.5 % Black, 10.8 % non-Hispanic white) that evaluated telephone-based continuing care for a 12- and 24-month period. Cocaine use frequency levels, measured with the Timeline Followback, were (1) abstinence (no past-month cocaine use), (2) low-frequency use (1-4 days of use/month), and (3) high-frequency use (5+ days of use/month).

RESULTS

Among those who completed the 12-month follow-up (n = 392), most reduced from high-frequency use at baseline to abstinence at the 12-month follow-up (n = 243; 62.0 %). An additional 21.2 % (n = 83) reported either high-to-low-frequency use (n = 35; 8.9 %) or low use-to-abstinence (n = 48; 12.2 %); 16.8 % of participants (n = 66) did not change or increased their cocaine frequency level. Compared to those who had no change/increases in frequency levels, at least a one-level reduction from baseline to 12-month follow-up (i.e., high-to-low-frequency use, high-to-abstinence, low-to-abstinence) was concurrently associated with lower levels of negative consequences at the 12-month follow-up and prospectively with lower levels of cocaine use and consequences at 24-month follow-up, with effect sizes in the medium-to-large range. Those who reduced to abstinence generally had fewer drug use consequences at the 12-month follow-up than those who reduced to a low-frequency level; however, these groups did not significantly differ on any outcomes at the 24-month follow-up.

CONCLUSIONS

Categorical reductions in cocaine use frequency levels, including those short of abstinence, are associated with less cocaine use and lower problem severity up to two years following treatment entry. Low-frequency cocaine use following the initial treatment phase does not appear to forebode worsening functioning, such as escalations in cocaine use.

Role of relative-reinforcement value of alcohol-free activities during recovery from alcohol use disorder in an adult clinical sample

Behavioral economic theory has been extensively applied to understand alcohol use disorder (AUD). Applications of behavioral economic theory conceptualize AUD as a pattern of harmful alcohol use over extended periods of time in which choices between drinking or engaging in alcohol-free activities favor drinking. Recovery, in contrast, entails a sustained shift toward a pattern of selecting rewarding alcohol-free activities. The present study examined whether alcohol-free activity engagement and the relative-reinforcement value (RRV) of engaging in those activities predicted AUD treatment outcomes via secondary analysis of data from Project MATCH, a multisite randomized clinical trial examining behavioral treatments for AUD (N = 1,279, 75.8% male, 81.0% non-Hispanic White, 9.5% Black, 7.7% Hispanic/Latino, 1.5% American Indian/Alaska Native, < 1% Asian American, and other race/ethnicity). Regression analyses indicated that every additional alcohol-free activity reported at 6 months posttreatment was associated with 7% fewer drinking days, 5% fewer heavy drinking days, and approximately one less drink per drinking day, as well as with significant improvements in depression, purpose in life, and psychosocial functioning at 12 months following treatment. Consistent with behavioral economic theory, higher RRV of alcohol-free activities also predicted significant reductions in drinking and improvements in functioning, and these associations were stronger compared to results for alcohol-free activity frequency only. The findings highlight the importance of understanding environmental contexts conducive to recovery and support the value of increasing alcohol-free activity engagement and the RRV of engaging in such activities to facilitate reductions in drinking and improved functioning among individuals with AUD. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Longitudinal examination of alcohol demand and alcohol-related reinforcement as predictors of heavy drinking and adverse alcohol consequences in emerging adults

BACKGROUND AND AIMS

Behavioral economic theory predicts that high alcohol demand and high proportionate alcohol-related reinforcement are important determinants of risky alcohol use in emerging adults, but the majority of research to date has been cross-sectional in nature. The present study investigated prospective and dynamic relationships between alcohol demand and proportionate alcohol-related reinforcement in relation to heavy drinking days and alcohol problems.

DESIGN

Longitudinal cohort with assessments every 4 months for 20 months.

SETTING

Ontario, Canada.

PARTICIPANTS

Emerging adults reporting regular heavy episodic drinking (n = 636, Mage = 21.44; 55.8% female).

MEASUREMENTS

Heavy drinking days (HDD; Daily Drinking Questionnaire), alcohol problems (Brief Young Adult Alcohol Consequences Questionnaire), alcohol demand (Alcohol Purchase Task) and proportionate alcohol-related reinforcement (Activity Level Questionnaire).

FINDINGS

Linear mixed effects models revealed that behavioral economic indicators and alcohol-related outcomes significantly decreased over the study, consistent with 'aging out' of risky alcohol use. Random intercept cross-lagged panel models revealed significant between-person relationships, such that higher alcohol demand and alcohol-related reinforcement were positively associated with HDD and alcohol problems (random intercepts = 0.187-0.534, Ps < 0.01). Moreover, alcohol demand indicators (particularly the rate of change in elasticity of the demand curve, as measured by α, and the maximum expenditure, Omax) and proportionate alcohol-related reinforcement significantly forecasted changes in HDD at all time points (|βs| = 0.063-0.103, Ps < 0.05) in cross-lagged relationships, with bidirectional associations noted for the rate of change in elasticity (βs = -0.085 to -0.104, Ps < 0.01). Proportionate alcohol-related reinforcement also significantly forecasted changes in alcohol problems at all time points (βs = 0.072-0.112, Ps < 0.01).

CONCLUSIONS

Multiple behavioral economic indicators (demand elasticity, maximum expenditure and reinforcement ratio) forecast changes in heavy episodic drinking and alcohol problems over the course of emerging adulthood. These results further implicate alcohol demand and proportionate alcohol-related reinforcement as etiologically and developmentally important mechanisms in alcohol use trajectories.

Attention-deficit/hyperactivity disorder is associated with more alcohol problems and less substance-free reinforcement: A behavioral economics daily diary study of college student drinkers

OBJECTIVE

Behavioral economic theory suggests that alcohol risk is related to elevated alcohol reinforcing efficacy (demand) combined with diminished availability of reinforcing substance-free activities, but little research has examined these reward-related processes at the daily level in association with comorbid conditions that might influence behavioral patterns and reward. Young people with attention-deficit/hyperactivity disorder (ADHD) report high levels of risky drinking, and this risk may be due in part to elevated demand for alcohol and diminished engagement in enjoyable and valued substance-free activities.

METHOD

College student drinkers (N = 101; 48.5% female; 68.3% White; 18-22 years old) with (n = 51) and without (n = 50) ADHD completed 14 consecutive daily diaries (diary entry n = 1,414). We conducted a series of multilevel path models to examine (a) the associations among ADHD and average daily alcohol demand, substance-free enjoyment, and response contingent positive reinforcement (RCPR) for goal-directed behaviors; (b) the associations among concurrent daily alcohol demand, substance-free reinforcement, and RCPR for goal-directed behaviors and daily alcohol use and alcohol-related negative consequences; and (c) the moderating effect of ADHD on these within-day associations.

RESULTS

ADHD was significantly associated with more daily alcohol-related negative consequences and less daily substance-free enjoyment and RCPR. Regardless of ADHD status, there were significant associations among behavioral economic risk factors and alcohol use and negative consequences, though effects differed within and between persons. There were no moderating effects of ADHD on within-person associations.

CONCLUSIONS

Results expose areas of impairment specific to drinkers with ADHD and advance theory on ADHD and hazardous drinking. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Not Two Sides of the Same Coin: A Qualitative Comparative Analysis of Post-Treatment Abstinence and Relapse

Purpose

Substance use disorder (SUD) can be a chronic relapsing condition with poor treatment outcomes. Studies exploring factors associated with abstinence or relapse after treatment are often quantitative in nature, applying linear statistical approaches, while abstinence and relapse result from non-linear, complex, dynamic and synergistic processes. This study aims to explore these underlying dynamics using qualitative comparative analysis (QCA) as a mixed methods approach to further our understanding of factors contributing to post-treatment abstinence and relapse.

Patients and Methods

In a prospective study, we gathered both qualitative and quantitative data pertaining to post-treatment substance use and the factors linked to substance use outcomes. These factors encompassed psychiatric comorbidity, intellectual disability, social disintegration, post-treatment support, and engagement in activities among patients who had undergone inpatient treatment for severe SUD (n = 58). QCA, a set-theoretic approach that considers the complex interplay of multiple conditions, was applied to discern which factors were necessary or sufficient for the occurrence of either abstinence or relapse.

Results

We found two solutions predicting abstinence, and five for relapse. Post-treatment conditions (support and engagement in activities) were important for retaining abstinence. For relapse, individual baseline characteristics (intellectual disability, social disintegration, psychiatric comorbidity) combined with (post-)treatment factors (post-treatment support, activities) were important.

Conclusion

Although abstinence and relapse represent opposing outcomes, they each exhibit distinct dynamics. To gain a comprehensive understanding of these dynamics, it is advisable to examine them as separate outcomes. For clinical practice, it can be worthwhile to recognize that fostering the conditions conducive to abstinence may differ from preventing the factors that trigger relapse.

The impact of spiritual well-being and social support on substance use treatment outcomes within a sample of predominantly Black/African American adults

INTRO

Substance use and associated problems often return following treatment for substance use disorder (SUD), which disproportionally impact Black/African American (AA) individuals. Social support and spiritual well-being are sources of recovery capital identified as particularly important among Black/AA adults. Social support and spiritual well-being are also posited mechanisms in 12-step; thus, this study tested the effects of social support and spiritual well-being on substance use outcomes over time, distinct from 12-step involvement, among Black/AA adults post-SUD treatment. The study hypothesized that social support and spiritual well-being would demonstrate significant interactions with time, respectively, on substance use frequency and substance use consequences, above the effect of 12-step involvement.

METHOD

The study drew data from a study of 262 adults (95.4 % Black/AA) entering residential SUD treatment (NCT#01189552). Assessments were completed at pretreatment and at 3-, 6-, and 12-months posttreatment. Two generalized linear mixed models (GLMM) tested the effects of social support and spiritual well-being, above the effect of 12-step involvement, on substance use frequency and substance use consequences over the course of 12-months posttreatment.

RESULTS

Higher spiritual well-being predicted significantly less frequent substance use during recovery (β = 0.00, p = .03). Greater 12-step involvement predicted significantly fewer substance use consequences during recovery (β = 0.00, p = .02). In post hoc analyses the effect of spiritual well-being and 12-step involvement dissipated by 3.5- and 6.6-months posttreatment, respectively. The study found no significant effects of social support over time.

DISCUSSION

Spiritual well-being and 12-step involvement are associated with lower substance use and substance use consequences, respectively, in the early months of posttreatment recovery among Black/AA adults. These findings contribute to the growing recovery capital literature informing paths to recovery and sources of support outside of 12-step affiliation. However, these effects diminish over time.

Positive psychological interventions on alcohol use and consequences: Pilot randomized trial in a young adult cannabis-using sample

INTRODUCTION

Young adults exhibit high rates of concurrent alcohol and cannabis use, which is associated with more negative alcohol-related consequences. Positive psychological interventions have successfully been leveraged to target alcohol, cannabis, and nicotine use, as well as substance use disorders, and may be a useful harm reduction approach to reduce alcohol-related consequences. This pilot study sought to generate effect sizes for two positive psychological interventions, Savoring and Three Good Things, on frequency of alcohol use, quantity of alcohol use, and alcohol-related consequences.

METHODS

The current study used data from a pilot study testing positive psychological interventions to reduce cannabis use and cannabis-related consequences in young adults (ages 18 to 25) who used cannabis at least once per week within the prior month (N = 50, Mage = 22.72, 72 % men, 40 % White). Participants reported baseline alcohol and cannabis use and alcohol-related consequences, then the study randomized them to complete a daily Savoring intervention, Three Good Things, or a control exercise, and completed daily text message surveys for two weeks (i.e., the intervention period) and a follow-up survey.

RESULTS

Analyses revealed no significant differences across experimental conditions on alcohol use frequency, alcohol use quantity, or alcohol-related consequences at baseline or follow-up. Paired samples t-tests demonstrated that participants in the Savoring group showed large, significant decreases in alcohol-related consequences (t[16] = 2.28, p = .04, gav = 0.54); no decreases occurred in frequency or quantity of alcohol use. The Three Good Things group showed no significant decreases in alcohol-related consequences, frequency of alcohol use, or quantity of alcohol use.

CONCLUSIONS

Results suggest that a larger scale clinical trial is warranted to determine whether Savoring and Three Good Things might function as harm reduction interventions to reduce alcohol-related consequences in young adults who concurrently use alcohol and cannabis. Future research should use a larger sample, a longer intervention administration period, and a longer follow-up period to examine these positive psychological interventions more rigorously.

What makes a peer? Characteristics of certified peer recovery support specialists in an emergency department-based intervention

Providing brief interventions by certified peer recovery support specialists (CPRSS) in the emergency department (ED) following a drug related visit is a promising method of service engagement and has garnered national attention. This study examines CPRSS's perceptions of the qualities that enable them to deliver interventions in the ED. We conducted qualitative interviews with 14 CPRSSs working in EDs. Interview topics included how the participants became involved with CPRSS work, experiences working in the ED, how the ED differs from other settings, and what interactions with patients look like. Interviews were digitally recorded, transcribed, and analyzed for emerging categories. Three categories were identified relating to CPRSS work: (1) how they approach peer work, (2) inherent qualities required to do the work, regardless of the setting, and (3) context-specific skills required to do the work in the ED. When describing their approach to this work, participants talked about CPRSS work as their life calling and their passion. Participants also identified certain qualities that all CPRSS workers possess, regardless of the setting, including the ability to build rapport, strong listening skills, and a shared lived experience. Lastly, participants identified how specific hard and soft skills help them to navigate organizational and structural challenges in the ED. The unique conditions of the ED and the required qualities of a CPRSS should be considered when implementing an ED-based intervention.

Results of a pilot study examining the effect of positive psychology interventions on cannabis use and related consequences

BACKGROUND

Young adults experience high rates of cannabis use and consequences. Cross-sectional work has linked positive psychological constructs (e.g., savoring) to less cannabis use and consequences, and positive psychological interventions (PPIs) have shown promise in targeting other substance use behaviors. This pilot study sought to provide an initial test of PPIs to reduce young adult cannabis use and consequences.

METHODS

Adults (18-25 years old) who endorsed at least weekly past-month cannabis use (N = 59, 69.6% men, 41.1% White) reported their baseline cannabis use and consequences. Participants were randomized to complete one of three daily exercises (Savoring, Three Good Things, or a control) along with daily text message surveys for two weeks, then completed a follow-up survey at the end of the two weeks.

RESULTS

Paired samples t-tests indicated that participants in the Three Good Things group showed medium to large reductions in frequency of weekly cannabis use (p = .08, gav = -0.57) and cannabis-associated consequences (p = .08, gav = -0.57) from baseline to follow-up. In the Savoring and control groups, there were not significant changes in frequency of weekly cannabis use (Savoring: p = .39, gav = 0.20; Control: p = .96, gav = 0.01) nor cannabis-associated consequences (Savoring: p = .84, gav = 0.05; Control: p = .45, gav = -0.18). Participants in both positive psychology conditions reported the exercises were easy to complete, providing evidence for acceptability.

DISCUSSION

Results provide initial support for the feasibility and potential promise of a text-message based PPI as a harm reduction approach for cannabis users. A larger clinical trial is warranted to test the effects of such interventions with adequate statistical power.

Patient Perspective on the Role of Substance-Free Activities During Alcohol Use Disorder Treatment: A Mixed-Method Study

Behavioral economic theory of addiction proposes that substance use often takes place in environments with limited substance-free reinforcement. While increasing substance-free reinforcement is known to reduce substance use, systematic efforts to boost substance-free reinforcement is not often a focus of most alcohol treatment programs. Participants (N=21) with alcohol use disorder participated in virtual focus group sessions. Qualitative content analysis was conducted on participants' verbatim responses. Substance-free activities were also assessed with a 66-item modified pleasant activity list specifying activity engagement frequency and enjoyment. All participants reported introduction to substance-free activity engagement as part of their treatment, although those in group therapy (relative to individual) reported less consistent support. While motives for initial activity engagement were reported as stemming from external sources (i.e., therapist), activity maintenance was linked to intrinsic motives (i.e., personal interest). All participants identified substance-free activities as a key aid to successful recovery. Types of most helpful activities were ones related to self-care, social connections, acts of service, and creative outlets. Findings are consistent with theories of behavior change and suggest participants believe substance-free activity engagement is an important component of their recovery, however they are not receiving consistent support during the pivotal early recovery period.

Community reinforcement approach (CRA) supported with structured recreation therapy: Experiences of people living with HIV in a pilot substance use treatment program at a specialty hospital

INTRODUCTION

Community reinforcement approach (CRA) is a behavioral intervention that has demonstrated favorable treatment outcomes for individuals with substance use disorders across studies. CRA focuses on abstinence; however, abstinence is not a desired goal among all people who use substances. Previous research has called for harm reduction-oriented treatment programs, especially within hospital settings. We examined the feasibility of a pilot CRA program, "Exploring My Substance Use" (EMSU), that integrates a harm-reduction perspective with structured recreation therapy at a specialty HIV hospital in Toronto, Canada.

METHODS

The 12-week EMSU program was delivered alongside a feasibility study that ran for 24 weeks (including an additional 12 weeks after program completion). We recruited hospital in/outpatients with moderate to severe substance use disorder to participate in the program and study. The EMSU program combined weekly substance use groups with weekly recreation therapy sessions. We collected data at five timepoints throughout the study; this article focuses on qualitative data from the final (24-week) interviews, which examine participants' experiences of the program-an under-researched element in CRA literature. We conducted thematic analysis in NVivo12 and descriptive statistics in SPSSv28.

RESULTS

Of the n = 12 participants enrolled in the EMSU program, six completed the 12-week intervention. All participants completed the 24-week study interview. The average age of participants was 41.5 years; eight identified as cis-male; most identified as white, experienced food insecurity, and were unstably housed. All participants valued the program, including opportunities to learn new skills and examine function(s) of their substance use, and would enroll if it were offered again. Participants discussed the benefits of leisure activities introduced through recreation therapy, which fostered social connections and provided inspiration/confidence to try new activities. Participants cited a lack of support for those experiencing health/personal challenges and overly strict program attendance rules. To improve the program, participants suggested more tactile activities and incorporating incentives.

CONCLUSIONS

Our findings support the feasibility of a CRA-based program with an integrated harm reduction and a recreation therapy component within an outpatient setting. Future programs should consider building in more flexibility and increased supports for clients dealing with complexities as well as consider COVID-19 related contingencies.

Prior Periods of Abstinence Among Adults With an Alcohol Use Disorder: A Qualitative Template Analysis

Abstaining from substance use is a goal of many people with alcohol use disorder (AUD). Understanding patient perspectives of a period of abstinence may assist persons with AUD in achieving this goal. We accessed the electronic health records of adults with AUD entering an emergency department in Baltimore, Maryland, who received a brief peer support intervention for substance use. Data contained open-ended text entered by staff after a patient indicated ever having a sustained period of substance abstinence. Using qualitative template analysis methodology, we identified codes and themes from these open-ended responses from N = 153 adults with AUD. The sample was primarily male (n = 109, 71.2%) and White (n = 98, 64.1%) with an average age of 43.8 years (SD = 11.2). Themes identified included the abstinence length, abstinence reason, relapse, triggers, time of relapse, and treatment. The most common code for abstinence length was “between 1 and 5 years” (n = 55, 35.9%). Other abstinence length codes included “less than 1 year” and “more than 5 years.” Relapse triggers included “family (non-death),” “death of a loved one,” “social,” “economic,” and “treatment-related” reasons. Findings from this study could be used to inform strategies for peer support interventions to assist patients with substance abstinence.

A contextualized reinforcer pathology approach to addiction

Behavioural economic accounts of addiction conceptualize harmful drug use as an operant reinforcer pathology, emphasizing that a drug is consumed because of overvaluation of smaller immediate rewards relative to larger delayed rewards (delay discounting) and high drug reinforcing value (drug demand). These motivational processes are within-individual determinants of behaviour. A third element of learning theory posits that harmful drug use depends on the relative constraints on access to other available activities and commodities in the choice context (alternative reinforcers), reflecting the substantial influence of environmental factors. In this Perspective, we integrate alternative reinforcers into the contemporary behavioural economic account of harmful drug use - the contextualized reinforcer pathology model - and review empirical literature across the translational spectrum in support of this model. Furthermore, we consider how increases in drug-related mortality and health disparities in addiction can be understood and potentially ameliorated via a contextualized reinforcer pathology model in which lack of alternative reinforcement is a major risk factor for addiction.

The values in action character strengths model: a resource for people in addiction recovery

Purpose

The purpose of this study is to examine the Values in Action (VIA) character strengths profile of people in addiction recovery, to identify which strengths are meaningfully represented in this population. This was compared with the generalised profile of a normative population to identify the differentiating features. Reasons for the profile variance and the significance this has for addiction recovery have also been explored.

Design/methodology/approach

An independent group design was adopted using purposive sampling. This saw participants (n = 100) complete the VIA Inventory of Strengths-P assessment to establish a character strengths profile for people in addiction recovery. To identify the differences in this profile, a mean score and rank order comparison was conducted, using data taken from a normative population. Additional exploratory analysis was conducted to establish if there were any significant differences in the character strength profile of males and females.

Findings

In descending order, the top five ranked strengths were kindness, humour, honesty, fairness and teamwork. The lesser five strengths in the profile were spirituality, zest, perseverance, prudence and self-regulation. A distinguishing feature was the presence of humour as a top five strength for people in addiction recovery. The existence of teamwork also deviated from the generalised normative population. There were two strengths shown to have a meaningfully higher score for females, teamwork and love. This did not change the strengths present in the overall top five for males or females, however.

Originality/value

This study contributes useful knowledge to the understanding of character strengths in addiction recovery. To the best of the authors’ knowledge, this is the first time character strengths have been examined in a sample of people in addiction recovery.

Identifying Substitute Activities for Alcohol Consumption: A Preliminary Analysis

Individuals with alcohol use disorder may excessively value alcohol reinforcement over other types of rewards and may seek out environments supportive of alcohol consumption despite negative consequences. Therefore, examining ways to increase engagement in substance-free activities may be useful in treating alcohol use disorder. Past research has focused on preference and frequency of engagement in alcohol-related versus alcohol-free activities. However, no study to-date has examine the incompatibility of such activities with alcohol consumption, an important step in preventing possible adverse consequences during treatment for alcohol use disorder and for ensuring that activities do not function in a complementary fashion with alcohol consumption. The present study was a preliminary analysis comparing a modified activity reinforcement survey with the inclusion of a suitability question to determine the incompatibility of common survey activities with alcohol consumption. Participants recruited from Amazon's Mechanical Turk (N=146) were administered an established activity reinforcement survey, questions regarding the incompatibility of the activities with alcohol consumption, and measures of alcohol-related problems. We found that activity surveys may identify activities that are enjoyable without alcohol, but that some of these activities were still compatible with alcohol. For many of the activities examined, participants who rated those activities as suitable with alcohol also reported higher alcohol severity, with the largest effect size differences for physical activity, school or work, and religious activities. The results of this study are an important preliminary analysis for determining how activities may function as substitutes, and may hold implications for harm reduction interventions and public policy.

Assessing the reliability and validity of the Risk-Need-Responsivity (RNR) program tool

BACKGROUND

Fidelity assessment tools can assess whether a program embraces a core set of principles and performs well. A quality fidelity tool with valid scales can be a feedback loop to identify areas that need further work to improve the program. Using data collected from 1816 correctional and reentry programs in the United States in the construction sample and 761 programs in the confirmation sample, this study examined the internal consistency of the Risk-Need-Responsivity (RNR) Program Tool, an online resource to capture information about structural features of a program.

RESULTS

The study reports on reliability statistics and factor analyses to highlight individual subscales. Six scales emerged and had acceptable to excellent levels of internal consistency. These scales are staffing, reward-and-sanction, clinical standards for programs, coaching, program duration, and risk-need assessment.

CONCLUSIONS

This article discusses fidelity scales from the RNR Program Tool and provides guidance on the importance of tool development processes to ensure accurate, valid, and reliable scales. The purpose of the RNR Program Tool is to create a modern, online tool integrating both the empirical (research) literature on effective practices and clinical standards on quality programming. This process minimizes the need for consultants by giving program administrators the ability to gather information on their programs, score them, and receive instant and targeted feedback with recommendations for improvement to assess their programs against empirical standards in the field. Furthermore, it provides a standardized tool that administrators can use to examine what type of individuals fare better in their programs. The provided targeted feedback can give the programs the ability to seek technical assistance or guidance in specific areas that can strategically strengthen their program.

Social recovery in substance use disorder: A metasynthesis of qualitative studies

ISSUES

In substance use disorder, connection to social communities plays a significant role in the recovery process. The aim here has been to identify and synthesise the qualitative research examining the process of social recovery from a first-person perspective and how social communities assist in this process.

APPROACH

Metasynthesis using the following databases: CINAHL, Embase, MEDLINE, PsycINFO, Scopus, SocIndex and Web of Science. The search returned 6913 original articles, of which 18 met the following criteria: examining the experience of social recovery from a first-person perspective and how social communities support this process, age of 18+, recovery of at least 12 months, in an English-language peer-reviewed journal. Review protocol registration: PROSPERO (CRD42020190159).

KEY FINDINGS

The persons in recovery emphasised communities that they perceived as being safe and non-stigmatising. These are qualities that contributed to positive self-change, and these communities were perceived as suitable arenas in which to confront responsibility and trust. Additionally, participants found that their relationship skills were improving due to the new social bonds forged in these communities. A sense of citizenship was gained along with a regaining of social dignity through voluntary work and giving back to society.

IMPLICATIONS

The pivotal role of the social community identified in this review underscores the importance of recognising and supporting persons in recovery's needs when connecting with such communities CONCLUSION: We propose a four-stage model to guide research into social recovery from a first-person perspective and how social communities support this process.

Computational models of exploration and exploitation characterise onset and efficacy of treatment in methamphetamine use disorder

People with Methamphetamine Use Disorder (PwMUD) spend substantial time and resources on substance use, which hinders their ability to explore alternate reinforcers. Gold‐standard behavioural treatments attempt to remedy this by encouraging action towards non‐drug reinforcers, but substance use often persists. We aimed to unravel the mechanistic drivers of this behaviour by applying a computational model of explore/exploit behaviour to decision‐making data (Iowa Gambling Task) from 106 PwMUD and 48 controls. We then examined the longitudinal link between explore/exploit mechanisms and changes in methamphetamine use 6 weeks later. Exploitation parameters included reinforcement sensitivity and inverse decay (i.e., number of past outcomes used to guide choices). Exploration parameters included maximum directed exploration value (i.e., value of trying novel actions). The Timeline Follow Back measured changes in methamphetamine use. Compared to controls, PwMUD showed deficits in exploitative decision‐making, characterised by reduced reinforcement sensitivity, U = 3065, p = 0.009, and less use of previous choice outcomes, U = 3062, p = 0.010. This was accompanied by a behavioural pattern of frequent shifting between choices, which appeared consistent with random exploration. Furthermore, PwMUD with greater reductions of methamphetamine use at 6 weeks had increased directed exploration (β = 0.22, p = 0.045); greater use of past choice outcomes (β = −0.39, p = 0.002) and greater choice consistency (β = −0.39, p = 0.002). Therefore, limited computational exploitation and increased behavioural exploration characterise PwMUD's presentation to treatment, while increased directed exploration, use of past choice outcomes and choice consistency predict greater reductions of methamphetamine use.

Trust and collaboration between patients and staff in SUD treatment: A qualitative study of patients’ reflections on inpatient SUD treatment four years after discharge

Background and aim: Substance use disorder (SUD) is multifactorial, complex, and involves the severe problematic use of alcohol, prescription drugs, and other substances. People with SUD have long histories of perceived stigma, marginalisation, exclusion, social isolation, and shame. Moreover, patients with SUD are often treated as untrustworthy and incapable of actively participating in their treatment planning, even by healthcare and social services workers. Methods: Through in-depth interviews with former patients who have undergone SUD treatment, we explored their reflections on the treatment content. Interpretative phenomenological analysis revealed that some informants experienced aspects of the treatment as valuable, whereas others considered the same treatment useless or harmful. Results: Essential aspects of treatment were developing self-esteem and optimism about the future, developing strategies for coping with stress and challenging emotions and situations, developing relationships with family and friends, and preparing for life after inpatient treatment. Relationships with staff were described as crucial in all parts of the treatment. Conclusion: In conclusion, we suggest that a transition to a more collaborative treatment philosophy would be ethically and professionally valuable for providing support and treatment and enhancing patients’ perceptions of empowerment, inclusion, participation, and well-being on their terms, in cooperation with supportive others.

Innovating for real-world care: A systematic review of interventions to improve post-detoxification outcomes for opioid use disorder

BACKGROUND

Inpatient detoxification is a common health care entry point for people with Opioid Use Disorder (OUD). However, many patients return to opioid use after discharge and also do not access OUD treatment. This systematic review reports on the features and findings of research on interventions developed specifically to improve substance use outcomes and treatment linkage after inpatient detoxification for OUD.

METHODS

Of 6419 articles, 64 met inclusion criteria for the current review. Articles were coded on key domains including sample characteristics, study methods and outcome measures, bias indicators, intervention type, and findings.

RESULTS

Many studies did not report sample characteristics, including demographics and co-occurring psychiatric and substance use disorders, which may impact postdetoxification OUD treatment outcomes and the generalizability of interventions. Slightly more than half of studies examined interventions that were primarily medical in nature, though only a third focused on initiating medication treatment beyond detoxification. Medical and combination interventions that focused on initiating medications for OUD generally performed well, as did psychological interventions with one or more reinforcement-based components.

CONCLUSIONS

Research efforts to improve post-detoxification outcomes would benefit from clearer reporting of sample characteristics that are associated with treatment and recovery outcomes, including diagnostic comorbidities. Findings also support the need to identify ways to introduce medication for opioid use disorder (MOUD) and other effective treatments including reinforcement-based interventions during detoxification or soon after.

The science of recovery capital: where do we go from here?

BACKGROUND

The concept of recovery capital (RC) has emerged in studies and discussions of the addiction recovery process and as a potential metric and marker for recovery gains. Although conceptual and applied development of the concept in the 20 years since the term was coined has increased, there remains insufficient clarity of key domains, factors and best practice research and applications for populations experiencing addiction. We aimed to review progress around the conceptualisation and operationalisation of RC and to consider future directions for a science of recovery capital.

METHOD

We provided a brief overview of theoretical foundations and advances, empirical measurement and application in treatment and continuing care settings. We next introduced four primary areas for addiction science to address, namely: (i) conceptual development (e.g. how RC domains are unique, but interrelated entities, valence of RC), (ii) empirical testing, adequacy of measurement and analysis, (iii) directions for novel application in treatment and recovery settings and (iv) dissemination and communication to policy, practice and lived experience groups. In this review, we also focussed on some of the challenges that must be addressed for a science of RC, which could produce long-term impact in treatment and policy.

RESULTS

Despite burgeoning empirical work on RC, its application and translation has been unsystematic. The field currently relies on self-report questionnaires for the development of the theory and quantification of RC. Therefore, there is an urgent need for rigorous and systematic conceptual and empirical development of RC.

CONCLUSIONS

A formal collaboration between scholars, practitioners and experts by experience worldwide would move recovery capital forward in an empirically driven and culturally appropriate manner, as would testing its applicability at individual, organisational and societal levels.

Al-Anon Intensive Referral to facilitate concerned others' participation in Al-Anon Family Groups: a randomized controlled trial

AIMS

To test the effectiveness of an intervention, Al-Anon Intensive Referral (AIR), to facilitate participation in Al-Anon Family Groups (Al-Anon).

DESIGN, SETTING AND PARTICIPANTS

Multi-site, randomized controlled trial of AIR versus usual care (UC), with follow-up assessments at 3, 6 and 12 months. The 12-month follow-up rate was 74%. Residential alcohol use disorder (AUD) treatment programs in three US locations. Concerned others (COs) of patients in treatment for AUD. COs were mainly women (77%) who were patients' spouses (33%) or parents (25%).

INTERVENTION AND COMPARATOR

AIR (n = 128) consisted of four sessions over 3 months with an Al-Anon coach. UC (n = 151) was the treatment program's offer of educational sessions for COs.

MEASUREMENTS

Primary outcome: COs' self-reports of any Al-Anon attendance (yes or no) at 3 months.

SECONDARY OUTCOMES

number of Al-Anon meetings and the CO-patient relationship (stressors, resources). Potential predictors of outcomes examined in generalized linear mixed models were their baseline value, time, CO-patient relationship type (marital or non-marital), treatment program and condition.

FINDINGS

There was no effect of condition for the primary outcome (28% in AIR, 21% in UC; Bayes factor = 1.86). Relationship stressors at follow-ups were more severe for COs in a marital relationship with the patient than for COs in a non-marital relationship [β = 2.19, 95% confidence interval (CI) = 1.07, 3.32]. For CO-patient relationship resources at follow-ups, the main effect for condition was significant (β = 1.33, 95% CI = 0.04, 2.61). COs assigned to the AIR condition had more resources than COs who were in the UC condition.

CONCLUSIONS

Relative to usual care, Al-Anon Intensive Referral was not associated with increases in participation of concerned others in Al-Anon, but was associated with more resources in the concerned other-patient relationship.

Mapping, assessing and promoting multiple psychological senses of community (MPSOC) through clinical pathways for treating substance use problems

Aim

The recent nationally implemented clinical pathways for the treatment of substance use problems in Norway require mapping and assessing of patients' needs, challenges, and resources. However, there is a lack of tools for systematically mapping and assessing patients' social situations and social networks as part of the national guidelines. The aim of this article is to present a tool developed to map and assess the patient's social situation, and to propose approaches for promoting multiple psychological senses of community (MPSOC) through clinical pathways for treating substance use problems.

Methods

The proposed tool and approaches are developed based on findings in a previous in-depth collaborative study of MPSOC and recovery among people with substance use problems who received help and services from Norwegian municipalities.

Findings

The findings suggest that multiple communities (geographical, relational and ideal) and senses of communities (within and outside treatment) simultaneously can influence individual recovery processes from problematic substance use in both positive as well as negative ways. As such, these community dimensions are of central importance to include in mapping and assessing of patients' social situations, as well as in the promotion of MPSOC through clinical pathways.

Conclusions

The suggested tool and approaches can increase the likelihood of achieving key aims of the national clinical pathways. Most important, mapping, assessing and promoting MPSOC through clinical pathways may promote long-term recovery processes and positive recovery capital for persons with substance use problems.

Phenomenological insight into the motivation to quit smoking

INTRODUCTION

Quitting tobacco is often viewed as a difficult experience as the dependence includes sets of behavioral, cognitive, social, and physiologic phenomena that prevent most smokers from having a successful first attempt of quitting. The aim of this qualitative study was to gain insight into and understand the motivation for attempts to quit smoking in relation to the stages of the behavior change model.

METHOD

The study team based this qualitative study on Alfred Schütz's social phenomenology framework. The study team planned for fourteen in-depth interviews with patients registered at a Quit Smoking Clinic. Each in-depth session lasted 45-60 min and we audio recorded them with consent. Following full verbatim transcription, the study team carried out detailed thematic analysis using Nvivo software.

RESULTS

Out of a total of 14 patients, 10 agreed to participate (response rate 71.4%). Seven participants (70%) had successfully quit smoking, while the remaining 30% relapsed after the first quit attempt. The study team extracted from the data three key themes with eight child nodes: barriers to quitting smoking, reasons for quit attempt, and how to quit. Unsuccessful attempts were related to tobacco addiction and successful attempts were based on the need to improve one's health and family. The study explored two intrinsic (self-realization and healthy lifestyle) and two extrinsic motivations (family's health and role model for children) for attempting to quit.

CONCLUSION

The study highlights the importance of psychological support in successful quit attempts. Treatment providers should encourage behavior change through intrinsic goals, as such goals, compared to extrinsic goals, have a long-term and positive impact because they can activate autonomous motivation.

"And then the rest happened"- A qualitative exploration of the role that meaningful activities play in recovery processes for people with a diagnosis of substance use disorder

Background: In this qualitative exploration, we report on a thematic analysis of the key role that engaging in meaningful activities may play in recovery processes for people with a diagnosis of substance use disorder (SUD). Methods: We conducted semi-structured, individual interviews with 30 participants and analyzed the parts of this material that were related to meaningful activities. Results: The findings are summarized through the development of three broad themes: (a) the central role of work-"The wages suck, but the job is gold"; (b) mastery and commitment-"I had to get up early, find my spot, I had to be present and fully functioning all day"; and (c) repairing the bridge to community life-"It's my job and working out that has made this possible, really, I see that now." Conclusion: We discuss these findings in relation to a recovery perspective and relevant empirical studies, highlight some important implications for research and practice, and consider the strengths and limitations of the present study.

Psychometric evaluation of the Reward Probability Index in emerging adult drinkers

OBJECTIVE

Diminished access to environmental rewards is an established risk factor for addiction and a focus of many effective treatment approaches. Nevertheless, there is inconsistency in measurement approaches and a need for a psychometrically sound measure. The Reward Probability Index (RPI; Carvalho, Behavior Therapy, 42, 2011, pp. 249-262) is a 20-item self-report rating scale that measures access to and ability to experience psychosocial reward.

METHOD

The current studies sought to evaluate the psychometric properties of the RPI in 2 samples of emerging adult heavy drinkers.

RESULTS

In Study 1, exploratory factor analysis in a sample of 393 college student drinkers supported a 2-factor model of the RPI (Reward Probability and Environmental Suppressors) after removal of redundant items, and corresponding subscales demonstrated good internal consistency. In Study 2, confirmatory factor analysis with 602 emerging adult drinkers recruited from the community supported the 2-factor model as best fitting after removal of one poor indicator, although absolute fit was only adequate. This 2-factor model demonstrated configural, metric, and scalar invariance across non-college and college subgroups as well as Black and White subgroups. Study 2 also demonstrated that the revised RPI subscales showed significant associations with measures of substance-free activity participation and enjoyment, anhedonia, and depressive symptoms. Furthermore, the study revealed the RPI Environmental Suppressors subscale predicted alcohol-related problems (β = .25, p < .001) beyond demographic covariates, weekly drinking, and depressive symptoms.

CONCLUSIONS

These studies provide evidence for the validity of the RPI as an efficient measure of access to reward among emerging adult heavy drinkers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mindfulness-based Therapeutic Sailing for Veterans With Psychiatric and Substance Use Disorders

INTRODUCTION

Complementary interventions have the potential to enhance treatment engagement and/or response among veterans with psychiatric disorders and/or substance use disorders (SUDs). Mindfulness-based therapeutic sailing (MBTS) is a novel three-session, complementary intervention, which combines nature exposure via recreational sailing and mindfulness training. It was developed specifically to augment both treatment response and engagement among veterans with psychiatric disorders or SUDs. The study reports a follow-up investigation of a version of MBTS modified based upon a previous initial pilot study.

MATERIALS AND METHODS

This is an institutional review board-approved study of 25 veterans, 23 males and 2 females, who participated in MBTS along with a diagnosis-, gender-, and age-matched control group. All participants had at least one psychiatric disorder or SUD and most (92%) had two or more conditions, with the most common being any SUD (76%) and PTSD (72%). Instruments used to evaluate within-subjects pre- to post-intervention psychological changes were the Acceptance and Action Questionnaire II (AAQII), the Toronto Mindfulness Scale (TMS), and the Five Facet Mindfulness Questionnaire (FFMQ). The Physical Activity Enjoyment Scale (PACES) was administered to evaluate how much the participants enjoyed the intervention. Outcome measures were collected for 1-year pre-intervention and 1-year post-intervention for between-subject analyses. These were numbers of medical and psychiatric hospitalizations, emergency department visits, mental health (MH) and substance abuse treatment visits, and MH and substance abuse treatment failed appointments. Data analysis consisted of using paired, two-tailed t-tests on psychological instrument results, Poisson regression on discrete outcome measures, and chi-square test of independence on demographic factors.

RESULTS

Within-subjects comparisons revealed significant mean pre- to post-intervention increases in AAQII (P = .04) and TMS scores (P = .009). The FFMQ scores increased but the change was nonsignificant (P = .12). The PACES scores were high for all sessions, indicating enjoyment of the intervention by participants. Although the coefficient was nonsignificant, Poisson regression uncovered reduction in substance abuse treatment visits post-intervention. There were no significant differences for the other variables. For demographic factors, the differences between intervention and control groups were not statistically significant.

CONCLUSIONS

The MBTS is associated with increases in psychological flexibility (AAQII) and state mindfulness (TMS). The intervention was perceived as pleasurable by participants (PACES) and is potentially associated with decreased utilization of substance use treatment services. These results must be considered as preliminary; however, these finding corroborate results from a previous pilot study and indicate that MBTS holds promise as a complementary intervention that could result in enhanced treatment engagement and/or outcomes for the population studied. A randomized controlled trial of MBTS is warranted. Further, the model of a three-session intervention combining mindfulness training with nature exposure could be adapted for other types of nature exposure, such as hiking or snowshoeing or other complementary interventions including equine-assisted activities and therapies.

Independent effects of entering recovery as a young versus older adult on long-term functioning and quality of life: Results from a U.S. national study of recovering persons

BACKGROUND

For physical health conditions, earlier intervention typically results in better prognoses and improved quality of life (QoL). Despite some evidence that early intervention yields better subsequent functioning too for behavioral health conditions like alcohol and other drug (AOD) disorders, less is known. This study examined the relationship between the life-stage at which individuals entered AOD recovery, demographic and clinical correlates, and its relationship to a variety of indices of current functioning, QoL and well-being.

METHOD

Nationally representative sample of U.S. adults who resolved an AOD problem (Weighted N = 1844). Structured regression analyses tested whether life-stage at which individuals entered recovery (i.e., as a young [18-30yrs,n = 746] vs. older [>30yrs,n = 1098] adult), was associated with current QoL, happiness, self-esteem, distress, and recovery capital, independent of confounders. Sensitivity analyses investigated effects during the first 5-years of recovery.

RESULTS

Young adult recovery entry was independently associated with current employment, younger age of onset for primary substance, primary substance other than alcohol, and less lifetime psychiatric comorbidity. In fully-adjusted models examining indices of functioning, no association was found between life-stage at recovery entry and current self-esteem, happiness, or distress, but an association was found between young adult recovery entry and better current functioning and QoL. This effect was even more pronounced during the first 5-years of recovery.

CONCLUSION

Irrespective of current age, duration of recovery, and clinical markers of impairment, entering recovery as a young, versus older, adult, is associated with better subsequent QoL - an advantage that appears even more discernable early in recovery.

Integration of motivational interviewing and behavioral economic theories to enhance brief alcohol interventions: Rationale and preliminary examination of client language

Motivational interviewing (MI) is a widely disseminated evidence-based therapeutic approach for engaging clients and motivating health behavior change, especially risky substance use. Refinement of MI theory over the past few decades has provided empirical evidence that the technical component of MI (in-session client language) is a promising mechanism of behavior change (MOBC). However, heterogeneous and small to moderate effect sizes suggest the need for refinement of MOBC measurement and consideration of other types of client language. The current article presents a complementary integration of current MI theory and behavioral economic (BE) mechanisms to further understanding of in-session factors associated with subsequent behavior change. In this paper, we define some of the key MOBCs from MI and BE theories, describe our integrated framework, and present preliminary findings from a pilot study of the effectiveness and MOBCs of a novel BE-informed application of MI in risky college student drinkers. Results from preliminary coding development suggest that BE-informed measures of client language better predict response to a brief intervention in risky college students than traditional change talk measures. We posit that BE theory can offer insight into meaningful session content beyond the current MI constructs of change talk and sustain talk, which in turn may serve to enhance development of clinical practice and inform scientific investigations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Impact of Continuing Care on Recovery From Substance Use Disorder

Continuing care is widely believed to be an important component of effective treatment for substance use disorder, particularly for those individuals with greater problem severity. The purpose of this review was to examine the research literature on continuing care for alcohol and drug use disorders, including studies that addressed efficacy, moderators, mechanisms of action, and economic impact. This narrative review first considered findings from prior reviews (published through 2014), followed by a more detailed examination of studies published more recently. The review found that research has generally supported the efficacy of continuing care for both adolescents and adults, but the picture is complex. Reviews find relatively small effects when results from individual studies are combined. However, continuing care of longer duration that includes more active efforts to keep patients engaged may produce more consistently positive results. Moreover, patients at higher risk for relapse may benefit to a greater degree from continuing care. Several newer approaches for the provision of continuing care show promise. These include incentives for abstinence and automated mobile health interventions to augment more conventional counselor-delivered interventions. Primary care can be used to provide medications for opioid and alcohol use disorders over extended periods, although more research is needed to determine the optimal mix of behavioral treatments and other psychosocial services in this setting. Regardless of the intervention selected for use, the status of most patients will change and evolve over time, and interventions need to include provisions to assess patients on a regular basis and to change or adapt treatment when warranted.

Envisioning a future: Values clarification in early recovery from opioid use disorder

High rates of relapse and overdose during early recovery from opioid use disorder (OUD) highlight the importance of providing effective treatment during this crucial phase. While early treatment often focuses on managing urges and withdrawal symptoms, eliciting personally salient motivators may help to target predictors of treatment outcomes such as motivation and self-efficacy. This experimental study examined the effect of a brief values clarification exercise on motivation and self-efficacy for abstinence in a sample of n = 93 individuals in brief residential treatment for OUD. Participants were randomly assigned to values clarification or a time management control condition exercise. Self-efficacy for abstinence as measured by a validated single-item measure was higher for participants in the values condition (M = 8.7) compared to control (M = 7.8, p = .013), while motivation for abstinence as measured by the commitment to sobriety scale was similarly high for both the values clarification (M = 28.0) and control (M = 27.8, p = .642) groups. There were no group differences in delay discounting, the theorized mediator of these relationships. Taken together, these results suggest that even a brief values clarification exercise may increase self-efficacy for abstinence when added to early residential treatment for OUD.

The Association between Reward Sensitivity and Activity Engagement: the Influence of Delay Discounting and Anhedonia

Aim

Reward sensitivity affects individuals’ motivation to engage in goal-directed behavior. Other concepts, critical for reward appraisal, that potentially influence activity participation encompass delay discounting and anhedonia. The aim of this study was to test the hypothesis that anhedonia and delay discounting influence the relationship between reward sensitivity and activity engagement.

Methods

In total, 37 inpatient patients with an alcohol use disorder (AUD) and 37 matched healthy controls completed the behavioral activation system scale (BAS scale), the Pleasant Activities List (PAL), the Snaith–Hamilton Pleasure Scale (SHAPS) and the Delay Discounting Task (DDT).

Results

Patients differed from controls on SHAPS, DDT-k, PAL substance-related activities (SRA), but not BAS and PAL non-substance-related activities (non-SRA). Correlational analyses revealed a strong correlation between BAS and PAL non-SRA in both patients (r = 0.53) and controls (r = 0.47), but also with PAL-SRA in patients (r = 0.40), although not controls (r = 0.09). BAS was negatively correlated with SHAPS in both groups and with DDT in controls. SHAPS was negatively linked to PAL non-SRA in both groups. The BAS-PAL non-SRA relationship was influenced by discount rates in controls.

Conclusion

A strong link exists between reward sensitivity and engagement in non-SRA in both groups. Delay discounting affects the reward sensitivity and non-SRA association in healthy controls, while anhedonia did not impact the association between reward sensitivity and engagement in (non-)SRA in both conditions.