The relationship between legal status, perceived pressure and motivation in treatment for drug dependence: results from a European study of Quasi-Compulsory Treatment

Types of Medication-Assisted Treatment for Opioid Use Disorder in Turkey: The Perceptions of Inpatients about Treatment Success

OBJECTIVE

The aim of this study was the following. When the different dynamics of agonist or antagonist treatments considered it is assumed that the eligible treatment to the individual may be maintained with high efficacy. Thus, we aimed to examine the difference between treatment methods, considering sociodemographics and positive perception for treatment success.

METHODS

The number of 136 individuals which their ages range between 19-50 and have been getting agonist (buprenorphine/naloxone) or antagonist (naltrexone) treatment because of opioid use disorder while resting in clinics have been evaluated to reveal the factors that may alter their perception about treatment and have been compared with sociodemographic variables and characteristics such as sociotropic and autonomic. Therefore, "Sociodemographic Data Evaluation Form," "Predictive Factors for The Addiction Treatment Success Scale," and "Sociotropy-Autonomy Scale" were used to assess the sociodemographic data, the perception towards factors which have been affected to the treatment and characteristics. The data of the individuals have been collected by the researcher via face-to-face interviews while patients were residential in the clinic.

RESULTS

According to results of our study, it has been detected that there are some differences in the perception of treatment success between individuals who have been getting agonist or antagonist treatments such as treatment method (p<0.05), treatment frequency (p<0.01) and parents' vital statuses (p<0.05).

CONCLUSION

At the end of the study it has been understood that medical and social benefits after the selection of eligible treatment methods which is suitable for individual's perception and characteristics have to be considered.

Pregnancy and substance use – the Norwegian z 10–3 solution.1 Ethical and clinical reflections related to incarceration of pregnant women to protect the foetus from harmful substances

Aims

This article highlights ethical and clinical dilemmas of incarceration of pregnant drug addicts mandated by z 10–3 of the Norwegian Municipal Health and Care Services act.

Material

The material consists of two cases, Siri and Anna, and the ethical dilemmas posed by the use of z 10–3 in these cases.

Methods

Semi-structured in-depth individual interviews were conducted, audio-recorded and transcribed word for word. Transcripts were coded according to converging interests and possible ethical dilemmas and described in a case format. The practical and experiential consequences of the law are discussed in relation to the four main bioethical principles: respect for autonomy, non-maleficence, beneficence and social justice. These are supplemented by the principles of relational ethics.

Results

The application of z 10–3 may lead to situations which distort the psychological preparation for parenthood and strains the helping relationship. The four principles approach seems to be an insufficient tool in grasping the complexity of the situation.

Conclusions

Interventions to protect the foetus from the pregnant woman's use of substances demand elevated professional awareness of ethical and relational challenges and dilemmas. Relational ethics provides a framework to enhance reflexivity and a trusting therapeutic alliance. The potential for psychological change during pregnancy should be invested in. Hence, we suggest that during incarceration according to z 10–3, foetal protection and the promotion of parental competences should be given equal priority.

Improved drug-use patterns at 6 months post-discharge from inpatient substance use disorder treatment: results from compulsorily and voluntarily admitted patients

Background

Treatment services to patients with substance use disorders (SUDs), including those mandated to treatment, needs to be evaluated and evidence based. The Norwegian Municipal Health Care Act calls for mandated treatment for persons with “severe and life-threatening substance use disorder” if these individuals are not otherwise willing to be voluntarily treated and consequently risk their lives over drug use. This study aims to examine substance use–related outcomes at 6 months following inpatient treatment and to analyse factors associated with improved outcomes and abstinence.

Method

This prospective study followed 202 hospitalized patients with SUD who were admitted voluntarily (VA; n = 137) or compulsorily (CA; n = 65). The European Addiction Severity Index was used at baseline and at follow-up to assess socio-demographic and substance use variables. Regression analysis was conducted to investigate factors associated with abstinence at 6 months of follow-up.

Results

The frequency of use of a preferred substance showed marked improvement for both VA and CA patients (61 and 37 %, respectively) at follow-up. Seventy-five percent of VA patients using amphetamine reported improvement compared to 53 % of CA patients. At follow-up, the CA group continued to have a higher rate of injection use. The CA group had experienced higher rates of overdose in the past 6 months and lower abstinence rates (24 % versus 50 %) at follow-up. A lower severity of drug use at intake (non–injection drug use), voluntary treatment modality, and higher treatment involvement during follow-up all were significant factors associated with abstinence at 6 months after treatment.

Conclusion

Voluntary treatment for SUD generally yielded better outcomes; nevertheless, we also found improved outcomes for CA patients. It is important to keep in mind that in reality, the alternative to CA treatment is no treatment at all and instead a continuation of life-threatening drug use behaviours. Our observed outcomes for CA patients support the continuation of CA treatment.

Does Mandated Treatment Benefit Youth? A Prospective Investigation of Adolescent Justice System Involvement, Treatment Motivation, and Substance Use Outcomes

BACKGROUND

The majority of adolescents treated for substance use disorder (SUD) in the United States are now referred by the criminal justice system. Little is known, however, regarding how justice-system involvement relates to adolescent community treatment outcomes. Controversy exists, also, over the extent to which justice system involvement reflects a lack of intrinsic motivation for treatment. This study examined the relation between justice system referral and reported reason for treatment entry and tested the extent to which each predicted treatment response and outcome.

METHOD

Adolescent outpatients (N = 127; M age = 16.7, 24% female) with varying levels of justice-system involvement (i.e., no justice system involvement [No-JSI; n = 63], justice-system involved [JSI; n = 40], justice system involved-mandated [JSI-M; n = 24]) and motivation levels (i.e., self-motivated [n = 40], externally-motivated [n = 87]) were compared at treatment intake. Multilevel mixed models tested these groups' effects on percent days abstinent (PDA) and odds of heavy drinking (HD) over 12 months.

RESULTS

JSI-M were less likely to be self-motivated compared to No-JSI or JSI (p = 0.009). JSI-M had higher PDA overall, but with significant declines over time, relative to no-JSI. Self-motivated patients did not differ from externally-motivated patients on PDA or HD.

CONCLUSIONS

Mandated adolescent outpatients were substantially less likely to report self-motivated treatment entry. Despite the notion that self-motivated treatment entry would be likely to produce better outcomes, a judicial mandate appears to predict an initially stronger treatment response, although this diminishes over time. Ongoing monitoring and/or treatment may be necessary to help maintain treatment gains for justice system-involved adolescents.

Clinical characteristics as a function of referral status among substance users in residential treatment

In the United States, substance users who voluntarily (VO) elect to receive treatment and substance users who are court-mandated (CM) to receive treatment typically obtain care within the same facilities. Little is known about the clinical characteristics that differentiate these individuals. The current study provides rates of specific DSM-IV Axis I and Axis II psychiatric and substance use disorders, comorbidities, childhood trauma, motivation, and other clinical and demographic characteristics as a function of referral status, among individuals in residential substance use treatment (463 participants, M age=43.3; 69.7% male; 88.4% African American). Participants were interviewed and diagnosed using the Structure Clinical Interview for DSM-IV and the Diagnostic Interview for Personality Disorders. Within our sample, VO individuals, as compared to CM individuals had significantly higher rates of psychiatric disorders (68.7% versus 55.2%, respectively), including mood disorders, major depressive disorder, generalized anxiety disorder, and borderline personality disorder. Additionally, they were significantly more likely to have alcohol dependence (43.0% versus 20.8%) and cocaine dependence (66.5% versus 48.9%). Elevated rates of comorbidities and childhood abuse were also observed among VO individuals, while motivation did not differ as a function of referral status. Overall, VO individuals appeared to have more severe problems than their CM counterparts which may suggest that they require more intensive or different types of treatment.

Predictors of retention in the 'voluntary' and 'quasi-compulsory' treatment of substance dependence in europe

BACKGROUND

Policies and practices related to the quasi-compulsory treatment (QCT) of substance-dependent offenders are currently implemented in many countries, despite the absence of reliable knowledge about significant predictors of treatment retention. This study aimed to identify such predictors in QCT and voluntary treatment.

METHODS

Participants were treated in one of 65 institutions in 5 European countries. They were interviewed at intake on substance use, crimes committed, perceived pressure for treatment, self-efficacy, stage of change, employment, and health-related variables. Binary logistic regression models were computed to identify predictors of treatment retention at an 18-month follow-up. Moderator analyses were computed to investigate whether these predictors vary by treatment condition (QCT vs. voluntary).

RESULTS

A higher number of working days in the previous month was positively associated with treatment retention, while use of heroin, crack, and multiple drugs, psychiatric problems in the previous month, and lifetime depression were negatively associated with treatment retention. Higher perceived medical pressure resulted in higher treatment retention rates only for participants in QCT.

CONCLUSION

Predictors of substance abuse treatment retention are quite similar across both QCT and voluntary treatments. Perceived medical pressure is of higher relevance than the often-believed legal pressure for treatment retention in QCT.

Coerced addiction treatment: Client perspectives and the implications of their neglect

Recent work has criticized the evidence base for the effectiveness of addiction treatment under social controls and coercion, suggesting that the development of sound policies and treatment practices has been hampered by numerous limitations of the research conducted to date. Implicit assumptions of the effectiveness of coerced treatment are evident in the organization and evolution of treatment, legal, and social service systems, as well as in related legislative practices. This review builds upon previous work by focusing in greater detail on the potential value of incorporating client perspectives on coercion and the implications for interpreting and applying existing research findings. Reviewing the existing empirical and theoretical literature, a case is made for greater accuracy in representing coercive experiences and events in research, so as to better align the measured concepts with actual processes of treatment entry and admission. Attention is given to studies of the effectiveness of treatment under social controls or pressures, the connections to coercion and decision-making, and theoretical perspectives on motivation and behaviour change, including Self-Determination Theory in particular. This synthesis of the available research on coerced addiction treatment suggests that it remains largely unclear to what extent many of the commonly employed methods for getting people into treatment may be detrimental to the treatment process and longer-term outcomes. The impact of coercion upon individual clients, treatment systems, and population health has not been adequately dealt with by addiction researchers to date.

Early exit: estimating and explaining early exit from drug treatment

Background

Early exit (drop-out) from drug treatment can mean that drug users do not derive the full benefits that treatment potentially offers. Additionally, it may mean that scarce treatment resources are used inefficiently. Understanding the factors that lead to early exit from treatment should enable services to operate more effectively and better reduce drug related harm. To date, few studies have focused on drop-out during the initial, engagement phase of treatment. This paper describes a mixed method study of early exit from English drug treatment services.

Methods

Quantitative data (n = 2,624) was derived from three English drug action team areas; two metropolitan and one provincial. Hierarchical linear modelling (HLM) was used to investigate predictors of early-exit while controlling for differences between agencies. Qualitative interviews were conducted with 53 ex-clients and 16 members of staff from 10 agencies in these areas to explore their perspectives on early exit, its determinants and, how services could be improved.

Results

Almost a quarter of the quantitative sample (24.5%) dropped out between assessment and 30 days in treatment. Predictors of early exit were: being younger; being homeless; and not being a current injector. Age and injection status were both consistently associated with exit between assessment and treatment entry. Those who were not in substitution treatment were significantly more likely to leave treatment at this stage. There were substantial variations between agencies, which point to the importance of system factors. Qualitative analysis identified several potential ways to improve services. Perceived problems included: opening hours; the service setting; under-utilisation of motivational enhancement techniques; lack of clarity about expectations; lengthy, repetitive assessment procedures; constrained treatment choices; low initial dosing of opioid substitution treatment; and the routine requirement of supervised consumption of methadone.

Conclusion

Early exit diminishes the contribution that treatment may make to the reduction of drug related harm. This paper identifies characteristics of people most likely to drop out of treatment prematurely in English drug treatment services and highlights a range of possibilities for improving services.