Examining attrition rates at one specialty addiction treatment provider in the United States: a case study using a retrospective chart review

Brief Report: Effectiveness of two financial incentives on patient follow-up after brief substance use disorder inpatient treatment

BACKGROUND AND OBJECTIVES

Clinical follow-up data after substance use disorder (SUD) treatment provides important information about treatment effectiveness, yet compliance is a challenge. We compared financial incentives for obtaining follow-up data from adults receiving inpatient SUD treatment.

METHODS

Participants (N = 237) were randomized to receive a guaranteed incentive, raffle-based incentive, or no incentive for completing a 1-month follow-up assessment. Logistic regression tested the effect of incentives on follow-up completion.

RESULTS

Those in the raffle condition had >2 times higher odds of completing a follow-up assessment compared to those in the no-incentive or guaranteed-incentive conditions.

DISCUSSION AND CONCLUSIONS

The raffle-based financial incentive was most effective in obtaining follow-up data.

SCIENTIFIC SIGNIFICANCE

Raffle-based incentives may improve follow-up after treatment and help clinicians evaluate SUD treatment outcomes.

A Pilot Randomized Controlled Trial Evaluating Peer Recovery Coaches for Addiction Recovery Among Indigenous Americans

BACKGROUND

Peer recovery coaches (PRCs) have experienced addiction and are trained to help others in recovery. Indigenous American (IA) adult PRCs may fill gaps of culturally specific support in addiction.

AIMS

The aims were to: (1) evaluate the feasibility of implementing a PRC intervention compared to an attention control group recovering from a substance use disorder, (2) compare PRC and attention control groups on relapses and secondary outcomes, and (3) measure PRC strategies.

METHODS

In this feasibility trial, we recruited a total of 120 adult IAs with substance use disorders. Ninety participants were randomized to the PRC group which received support from a PRC and 30 to the attention control group which received support from a research nurse. Both groups received weekly support for 12 weeks. Participants completed surveys weekly during the 12-week intervention and then monthly for 3 months.

RESULTS

The two groups had similar quantities of alcohol consumed, days of alcohol use, and days of drug use except that the PRC group had fewer days of alcohol use in the first 3 weeks of the intervention phase (2.05 vs. 3.5 days, p = .04). "Support and advocacy" was the most common PRC intervention. PRCs were widely accepted by individuals who completed the program, receiving positive feedback from 79% of participants.

CONCLUSION

This pilot demonstrated that racially concordant PRC services likely have high acceptability among IA populations. Future studies may draw on these findings by having trained IA coaches recruit and work with individuals in-person to assist with retention.

It takes a village: Feedback from personnel in addiction treatment programs indicates support for changing the intake process

INTRODUCTION

The initial intake encounter represents a critical point for treatment engagement in outpatient addiction treatment programs. Despite the intake assessment being more comprehensive, personalized, and capable of matching clients to level of treatment, addiction treatment programs continue to have among the highest attrition rates. Thus, it may not be what, but how services are delivered that contributes to attrition. The Consolidated Framework for Implementation Research (CFIR) offers a comprehensive framework to attend to sources of needed innovation for the intake process. The current study used a mixed method design, guided by CFIR, to obtain feedback from personnel in addiction treatment programs on the current intake process, as well as the facilitators and barriers to changing the intake process.

METHODS

Personnel within New Mexico-based addiction treatment programs completed measures of individual and organizational readiness to make changes within their programs (N = 79; 76 % women, 79 % White, 55 % Latino/a). From this sample, 38 participants completed a CFIR-based semi-structured interview to identify potential barriers and facilitators to changing the intake process.

RESULTS

Participants reported moderate-to-high scores on readiness and capability to make organizational changes. For qualitative data, we identified nine broad themes, grouped based on (1) perspectives of current intake process (Intake Process, Organization Culture, Change Perspectives, Internal Communication, Client Needs) and (2) perspectives of changing the intake to an MI session (MI knowledge/attitudes, MI at intake, MI in organization, MI fit with Client Needs).

CONCLUSIONS

Findings highlight that there are specific components of the intake content and process that appear to disengage clients, specific policies and procedures that appear to overburden staff, and key stakeholders and resources needed to improve the intake process. Recommendations are provided for intake-specific and procedural-level changes both in the organization and with outside agencies to improve the intake process.

Identifying components of recovery capital that support substance use disorder treatment completion

Purpose

Individuals who do not complete substance use disorder treatment (SUDT) have similar outcomes to the untreated. Recovery capital (RC) is the collection of one's resources that contribute to the initiation and maintenance of sobriety. The aim of this paper was to identify individual measures of RC that are associated with SUDT completion.

Methods

RC data for 69 residents from a men's recovery center was obtained from questionnaires administered to residents at intake and after SUDT graduation or dismissal. Participant data was divided into two groups, Graduates (n = 39, age 35.87±10.83) and Non-Graduates (n = 30, age 34.35±14.44), and retrospectively analyzed to compare RC between groups at various points during SUDT and which RC measures are associated with SUDT completion.

Results

At baseline all participants reported limited RC and there was no significant difference in RC between groups. At graduation, Graduates reported significantly more RC in all measures when compared to baseline and Non-Graduates at dismissal. Non-Graduates reported a significant increase in Checking and Savings at dismissal but no other measure.

Conclusion

Baseline levels of RC in both groups were limited and not significantly different which limited the capacity of the study to identify measures of RC associated with SUDT completion. A lack of RC at onset of SUDT did not preclude SUDT completion and obtaining RC during SUDT was associated with completion as only Graduates reported increases in RC. Future study designs should include participants with variable amounts of RC when entering SUDT.

Patient Activation of Persons With Opioid Use Disorder in Intensive Outpatient Treatment

BACKGROUND

High patient activation is associated with a variety of positive health outcomes. Although increasing patient activation in persons with opioid use disorder (OUD) in intensive outpatient treatment (IOT) programs may increase engagement and improve outcomes, little is known about how patient activation is manifested in these programs.

AIMS

To describe types of instances in which persons play an active role in their IOT or show self-determination in their recovery generally (patient activation) and types of instances in which they play a passive role in their IOT or have recovery directed by others (patient nonactivation).

METHODS

A qualitative descriptive study using data from a larger grounded theory study was conducted. Interviews were completed with 14 persons with OUD who attended an IOT program within a large health care system in the Midwest. Content analysis was used to create a typology of instances of patient activation or nonactivation in participants' IOT experiences.

RESULTS

Six types of instances were identified: (1) making and enacting one's own treatment decisions, (2) actively collaborating with staff, (3) self-determining one's disclosure in groups, (4) making a commitment to treatment, (5) taking responsibility for one's recovery, and (6) taking actions to avoid return to use.

CONCLUSIONS

Patient activation is multidimensional and plays a salient role in IOT experiences. IOT staff should engage patients as active participants in their treatment and encourage mutual goal-setting and shared-decision but should be aware that some approaches used too early in treatment may impede recovery.

Habit-, reward- and fear-related motivations in alcohol use disorder: A one-year prospective study

OBJECTIVE

Cross-sectional studies show that habitual use of alcohol is associated with severity of alcohol dependence reflected across a range of domains and lower number of detoxifications in multiple settings. In this study, we investigated whether alcohol use disorder (AUD) patients with greater habitual use of alcohol at baseline showed worse outcomes after one year of follow-up.

METHODS

A sample of inpatients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) alcohol use disorder (AUD) was assessed at baseline (n = 50) and after one year (n = 30). The Habit, Reward, and Fear Scale (HRFS) was employed to quantify affective (fear or reward) and non-affective (habitual) drives for alcohol use, the Alcohol Dependence Scale (ADS) was used to assess clinical outcomes, and the Depression, Anxiety and Stress Scale (DASS-21) was used to quantify and control for associated affective symptoms.

RESULTS

There was a significant reduction in the three HRFS scores at the follow-up. Regression analyses demonstrated that greater habit- and fear-related drives at baseline predicted greater decreases in the ADS scores at the endpoint. However, after controlling for age, sex and affective symptoms, only reward and fear were associated with reductions in ADS scores at the end of one year. Prescriptions of naltrexone and antidepressants/benzodiazepines did not predict decreases in reward and fear-related motivations.

CONCLUSION

Although we were unable to confirm that habitual subscores at baseline predict worse long-term outcomes among inpatients with AUD, we found that a greater fear and reward motives for the use of alcohol predicted a greater magnitude of improvement in the AUD symptoms after one year. We hope that these findings will help develop new approaches toward AUD treatment and inform models of addiction research.

A Transdiagnostic group therapy for sleep and anxiety among adults with substance use disorders: Protocol and pilot investigation

Introduction

Treatment of substance use disorders (SUDs) is challenging with high rates of treatment dropout and relapse, particularly among individuals with comorbid psychiatric conditions. Anxiety and insomnia are prevalent among those with SUD and exacerbate poor treatment outcomes. Interventions that concurrently target anxiety and insomnia during the early stages of SUD treatment are lacking. To this end, we investigated the feasibility and preliminary effectiveness in a single-arm pilot trial of an empirically informed group transdiagnostic intervention, Transdiagnostic SUD Therapy, to concurrently reduce anxiety and improve sleep among adults receiving treatment for SUD. Specifically, we hypothesized that participants would evidence declines in anxiety and insomnia and improvements in sleep health, a holistic, multidimensional pattern of sleep-wakefulness that promotes wellbeing. A secondary aim was to describe the protocol for Transdiagnostic SUD Therapy and how it may be implemented into a real-world addiction treatment setting.

Method

Participants were 163 adults (M_age  = 43.23; 95.1% White; 39.93% female) participating in an intensive outpatient program for SUD who attended at least three of four Transdiagnostic SUD Therapy sessions. Participants had diverse SUDs (58.3% alcohol use disorder, 19.0% opioid use disorder) and nearly a third of the sample met criteria for two SUDs and comorbid mental health diagnoses (28.9% anxiety disorder, 24.6% major depressive disorder).

Results

As anticipated, anxiety and insomnia reduced significantly across the 4-week intervention period from clinical to subclinical severity, and sleep health significantly improved (ps < 0.001). These statistically significant improvements following Transdiagnostic SUD Therapy demonstrated medium to large effects (ds > 0.5).

Conclusion

Transdiagnostic SUD Therapy is designed to be flexibly administered in "real-world" clinical settings and, preliminarily, appears to be effective in improving emotional and behavioral factors that increase risk for return to substance use and poor SUD treatment outcomes. Additional work is needed to replicate these findings, determine the feasibility of widespread uptake of Transdiagnostic SUD Therapy, and examine whether the treatment effects translate to improvement in substance use outcomes.

Effects of a brief pre-admission telephone reminder on no-show and dropout rates in substance use disorder treatment: a quasi-experimental study

Background

Appointment no-show and early dropout from treatment represent major challenges in outpatient substance use disorder treatment, adversely affecting clinical outcomes and health care productivity. In this quasi-experimental study, we examined how a brief reminder intervention for new patients before their first appointment affected treatment participation and retention. No-shows (not attending any sessions) and dropouts (discontinuation of initiated treatment because of three consecutively missed appointments) were compared between a period with pre-admission telephone calls (intervention) and a period without such reminders (non-intervention).

Methods

Participants were all eligible patients (N = 262) admitted to a Norwegian specialist clinic for substance use disorder treatment. We used the Chi-square test for the no-show analysis. Of the eligible patients, 147 were included in a subsequent dropout analysis. We used the number of visits up to 10 appointments as a measure for time to event. Group differences were analyzed using a Kaplan–Meier plot and the log-rank test. To control for relevant sociodemographic variables, as well as substance use and mental distress severity, we used Cox regression.

Results

No-show rates did not differ between the two periods (12% for non-intervention vs. 14% for intervention; χ2 = 0.20, p = 0.653). Of those consenting to participate in the dropout analysis (n = 147), 28 (19%) discontinued treatment within the time frame of 10 appointments, with no differences between the two periods (log-rank test = 0.328, p = 0.567). Controlling for baseline characteristics did not alter this finding. In fact, of the registered covariates at baseline, only higher education level was associated with attrition, linked to a reduced risk for dropout (hazard ratio = 0.85, 95% CI = 0.74–0.98, p = 0.025).

Conclusion

These findings do not provide support for the systematic use of a brief pre-admission telephone reminder in the current treatment setting.

Trial registration

The study was retrospectively registered 13 Jan 2021 at ClinicalTrials.gov, NCT04707599.

Does Treatment Readiness Shape Service-Design Preferences of Gay, Bisexual, and Other Men Who Have Sex with Men Who Use Crystal Methamphetamine? A Cross Sectional Study

Crystal methamphetamine (CM) disproportionately impacts gay, bisexual, and other men who have sex with men (gbMSM). However, not all gbMSM are interested in changing their substance use. The present study aimed to examine whether participant-preferred service characteristics were associated with their readiness to change. We surveyed gbMSM who used CM in the past six months, aged 18 plus years, on dating platforms. Participants rated service-design characteristics from “very unimportant” to “very important”. Multivariable regression tested service preference ratings across levels of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES-8D). Among 291 participants, 38.7% reported their CM use was not problematic, 19.5% were not ready to take any action to reduce or stop using CM, and 41.7% were ready to take action. On average, participants rated inclusive, culturally-appropriate, out-patient counselling-based interventions as most important. Participants with greater readiness-to-change scores rated characteristics higher than gbMSM with lesser readiness. Contingency management and non-abstinence programming were identified as characteristics that might engage those with lesser readiness. Services should account for differences in readiness-to-change. Programs that provide incentives and employ harm reduction principles are needed for individuals who may not be seeking to reduce or change their CM use.

Identification of Quantifiable Predictors of Relapse in Patients with Alcohol-Associated Liver Disease

Abstinence in patients with alcohol-associated liver disease (ALD) reduces mortality. Most predictors of relapse are not quantifiable, preventing objective analysis of relapse risk and targeted intervention to improve clinical outcomes. We prospectively enrolled patients with ALD from November 2016 to December 2019 and administered a survey with two previously published scales to assess insight into alcohol-use disorder (Hanil Alcohol Insight Scale [HAIS]) and social support (Community Assessment Inventory Scale [CAIS]). Relapse was assessed using surveys and metabolite testing. Unadjusted and prespecified adjusted regression analyses identified predictors of relapse. We enrolled 81% of eligible patients (n = 136), of whom 58 had follow-up data available at the time of analysis. Over a median follow-up of 1 year (interquartile range: 0.5-1.4), 10 patients relapsed (17%). Patients who relapsed were more likely to continue drinking despite either a diagnosis of liver disease or a decompensating event, and were less likely to have been transplanted (all P < 0.05). In unadjusted regression, the HAIS and the "support inside the home" subcategory of the CAIS were predictive of relapse, with odds ratio (OR) = 0.84 (95% confidence interval 0.72-0.97) and 0.85 (0.74-0.97). In adjusted regression, the HAIS was no longer significant, with adjusted OR = 0.70 (0.49-1.00, P = 0.05), whereas the "support inside the home' subcategory of CAIS remained significant, with adjusted OR = 0.69 (0.51-0.92, P = 0.01). Conclusions: Risk factors for relapse in patients with ALD were identified and quantified prospectively, suggesting opportunities to objectively identify patients at risk for relapse as well as to intervene to prevent relapse.

Targeting the Barriers in the Substance Use Disorder Continuum of Care With Peer Recovery Support

Substance Use Disorder (SUD) has been recognized as a chronic, relapsing disorder. However, much of existing SUD care remains based in an acute care model that focuses on clinical stabilization and discharge, failing to address the longer-term needs of people in recovery from addiction. The high rates of client’s disengagement and attrition across the continuum of care highlight the need to identify and overcome the obstacles that people face at each stage of the treatment and recovery process. Peer recovery support services (PRSS) show promise in helping people initiate, pursue, and sustain long-term recovery from substance-related problems. Based on a comprehensive review of the literature, the goal of this article is to explore the possible roles of peers along the SUD care continuum and their potential to improve engagement in care by targeting specific barriers that prevent people from successfully transitioning from one stage to the next leading eventually to full recovery. A multidimensional framework of SUD care continuum was developed based on the adapted model of opioid use disorder cascade of care and recovery stages, within which the barriers known to be associated with each stage of the continuum were matched with the existing evidence of effectiveness of specific PRSSs. With this conceptual paper, we are hoping to show how PRSSs can become a complementary and integrated part of the system of care, which is an essential step toward improving the continuity of care and health outcomes.

Perception of Substance Use Disorder Training: a Survey of General Psychiatry Residents in Nigeria

OBJECTIVE

Substance use disorder (SUD) is a global concern. Evidence from high-income countries suggests that SUD training for psychiatry residents is less than optimal but it is unknown whether the situation is different in low-/middle-income settings. This study assessed psychiatry residents' perception of their SUD training.

METHODS

A cross-sectional survey was conducted among general psychiatry residents in Nigeria from November 2018 to May 2019. Data were collected through self-completion of an English-language questionnaire with multiple-choice and open-ended questions administered face-to-face and online.

RESULTS

A total of 51 participants completed the questionnaire, mean age 33.6 years and 76.5% men. Most participants (70.6%) expressed interest in addiction psychiatry, and 47.1% perceived their SUD training as inadequate. When asked to rate satisfaction with the SUD training they have received so far, 52.9% were unsatisfied, and the absence of in-house SUD training (29.4%) was the leading cause of dissatisfaction. For those who were satisfied, the most common reasons were availability of SUD training and treatment-related factors (31.4%). The most frequent suggestions for making addiction psychiatry subspecialty attractive to psychiatry residents were provision of SUD treatment units, structured SUD training, and continuity of such training. Equipping existing SUD treatment units and creating more treatment units were the most common suggestions for improving current SUD training.

CONCLUSION

This study demonstrated a high level of interest in addiction psychiatry, but satisfaction with SUD training was mixed. Addressing causes of dissatisfaction and areas suggested for improvement would be necessary to sustain interest.

Examination of referral source and discharge outcomes among women in residential substance use disorder treatment

BACKGROUND

Court-mandated substance use disorder (SUD) treatment, compared to nonmandated treatment, has been associated with increased retention and completion. However, due to limitations of previous studies, whether child protective services (CPS) and criminal justice (CJ) mandated treatment improve treatment completion and retention among women in residential treatment remains unclear.

PURPOSE

This study investigated differences in treatment completion and progress based on three clinical discharge outcomes (i.e., completer, noncompleter with significant progress, and noncompleter without significant progress). We hypothesized that women mandated by (1) CJ will have a better treatment discharge outcome (i.e., treatment completer and noncompleter with satisfactory progress) compared to women who are CPS mandated; (2) CPS will have a better treatment discharge outcome (i.e., treatment completer and noncompleter with satisfactory progress) compared to nonmandated women.

METHODS

Study staff conducted multinomial logistic regression analyses on data for a diverse sample of 161 women mandated or nonmandated (CJ: N = 71, CPS: N = 66, nonmandated: N = 24) into residential SUD treatment to determine each group's clinically defined treatment discharge outcomes while controlling for covariates.

RESULTS

Multinomial logistic regression analyses revealed that being mandated by the CJ system predicted being a treatment completer compared to those who were CPS mandated (RR = 9.88, p = .009). The study found no differences in discharge status of completer without satisfactory progress between those who were CPS mandated and those who were CJ mandated or nonmandated. For women mandated by the CPS system compared to nonmandated women, the risk of being a treatment completer relative to noncompleters with satisfactory progress was not significant (RR = 1.08, p = .897). Analyses showed that being mandated by the CJ system predicted an improved clinically defined discharge outcome of treatment completer compared to women who were nonmandated to treatment (RR = 10.74, p = .016). In several of the models, drug and alcohol craving was associated with increased odds of being a noncompleter of treatment without satisfactory progress.

CONCLUSIONS

This study demonstrates that improved treatment completion and discharge status cannot be assumed based solely on being mandated by the CJ or CPS systems. As evidenced by variability in treatment discharge outcomes within and among referral groups, the paper suggests directions for future research.

Feasibility and Acceptability of Mobile Phone Self-monitoring and Automated Feedback to Enhance Telephone Coaching for People With Risky Substance Use: The QUIT-Mobile Pilot Study

OBJECTIVES

This study evaluates the feasibility, acceptability, and perceived benefits of mobile-phone delivered self-monitoring queries and feedback integrated into the evidence-based Quit Using Drugs Intervention Trial (QUIT) screening and brief telephone health coaching intervention to prevent progression from risky drug use to addiction as the QUIT-Mobile intervention.

METHODS

Participants (n = 20) were primarily Black/African American and Latino men in Los Angeles with risky substance use. Self-monitoring surveys were sent by text-message twice-weekly for 6 weeks and once-weekly from 6 to 12-weeks. Surveys consisted of 10 questions regarding drug and alcohol use (ie, # days of use) and cravings, quality of life, and medication adherence. Feedback messages praised or encouraged drug use reductions. Coaches monitored patient responses and discussed them in QUIT's telephone coaching sessions. Participants' experiences were assessed qualitatively at 3-month follow-up.

RESULTS

Nineteen out of 20 participants that completed the qualitative evaluation from the 12-week follow-up reported: (1) self-monitoring surveys helped them adhere to drug use reduction goals and reflect on associations between self-monitoring domains; (2) preference for higher frequency (twice-weekly) self-monitoring during the 6-week coaching period, and then weekly surveys thereafter but not monthly; and (3) self-monitoring and coaching were mutually reinforcing for their drug use reduction goals.

CONCLUSIONS

Results are consistent with prior similar research suggesting that mobile phone self-monitoring of drug use and related factors is feasible and acceptable among diverse adults with risky drug use. Findings also suggest the potential benefits of integrating electronic self-monitoring and feedback into substance use reduction interventions such as QUIT to enhance patient self-management and coaching or counseling intervention components.

The Impact of Matching to Psychotherapy Preference on Engagement in a Randomized Controlled Trial for Patients With Advanced Cancer

Objective: This study examined whether patients who were randomly assigned to their preferred therapy arm had stronger engagement with their treatment than those who were randomly assigned to a non-preferred therapy arm. Method: Data were drawn from a RCT comparing Individual Meaning-Centered Psychotherapy (IMCP), with Individual Supportive Psychotherapy (ISP), in patients with advanced cancer. Treatment engagement was operationalized as patients' perceptions of the therapeutic alliance with their therapist and therapy sessions attended. Two 2 by 2 Analysis of Variance (ANOVA) models were used, with treatment preference (IMCP vs. ISP) and treatment assignment (IMCP vs. ISP) as the independent variables and working alliance and number of sessions attended as outcome variables. Results: Patients who preferred and were assigned to IMCP reported a significantly stronger alliance than those who preferred IMCP but were assigned to ISP. Conclusions: The findings from this study have broader implications for research on psychotherapy beyond the appeal of IMCP in advanced cancer patients. Patients who prefer a novel psychotherapy that they cannot engage in elsewhere, but receive the standard treatment may experience weaker alliance than patients who prefer the standard but receive the novel therapy. Trial registration: Clinicaltrial.gov ID: NCT01323309.

Pretreatment social network characteristics relate to increased risk of dropout and unfavorable outcomes among women in a residential treatment setting for substance use

Increased retention in residential treatment for substance use disorder (SUD) has been associated with more favorable clinical outcomes for residents. Yet SUD treatment dropout remains high. It is essential to uncover factors contributing to these high rates. Little is known about whether features of an individual's social network prior to treatment entry are related to number of days in treatment or to clinical status at treatment termination. To examine these relationships, we analyzed data from 241 women (58.5% Hispanic) entering an SUD residential treatment facility, who agreed to participate in a parent randomized control trial. We assessed characteristics of these women's social networks prior to treatment entry at baseline. We extracted clinician-determined progress at treatment termination and days in treatment two months after treatment entry from clinical records. Data-driven analyses using purposeful selection of predictors showed that the overall size of the social network was associated with increased likelihood of being classified as having achieved good clinical progress in treatment at termination and that number of drug users in the pretreatment social network was related to staying fewer days in treatment. Contrary to our hypothesis, we found no significant associations between other pretreatment social support network characteristics (i.e., social support) and treatment retention or clinical discharge status. Future research should examine how features of social networks change through treatment and how these changes relate to treatment outcomes.

Reducing drug and alcohol use and improving well-being for Indigenous and non-Indigenous Australians using the Community Reinforcement Approach: A feasibility and acceptability study

There is a lack of evidence of effective and appropriate drug and alcohol treatment for Aboriginal and Torres Strait Islander peoples. This paper contributes to addressing the evidence gap by examining the feasibility and acceptability and conducting a pre/post-evaluation of the Aboriginal-adapted Community Reinforcement Approach (CRA) delivered in New South Wales, Australia. Aboriginal and non-Aboriginal clients (n = 55) received tailored CRA delivery between March and November 2013. Compared to the original US version, tailored CRA had reduced technical language, reduced number of treatment sessions, and the addition of group delivery option. An Australian training manual with local case studies was developed. Alcohol, Smoking and Substance Involvement Test (ASSIST), Kessler-5 (K-5) and the Growth Empowerment Measure were used. 58% of participants were followed-up at 3 months. Tailored CRA was feasible to deliver in a rural, community-based health setting, and rated by clients as highly effective and acceptable. CRA was associated with statistically significant reductions in the use of alcohol, tobacco, cannabis, amphetamine and over the counter medication, and levels of psychological distress, and an increase in levels of empowerment for Aboriginal and non-Aboriginal clients. This study provides evidence for the feasibility and acceptability of an Aboriginal-adapted psychological intervention addressing drug, alcohol and mental health outcomes.

A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health

The opioid crisis has reached epidemic proportions in the United States with rising overdose death rates. Identifying the underlying factors that contribute to addiction vulnerability may lead to more effective prevention strategies. Supply side environmental factors are a major contributing component. Psychosocial factors such as stress, trauma, and adverse childhood experiences have been linked to emotional pain leading to self-medication. Genetic and epigenetic factors associated with brain reward pathways and impulsivity are known predictors of addiction vulnerability. This review attempts to present a biopsychosocial approach that connects various social and biological theories related to the addiction crisis. The emerging role of nutrition therapy with an emphasis on gastrointestinal health in the treatment of opioid use disorder is presented. The biopsychosocial model integrates concepts from several disciplines, emphasizing multicausality rather than a reductionist approach. Potential solutions at multiple levels are presented, considering individual as well as population health. This single cohesive framework is based on the interdependency of the entire system, identifying risk and protective factors that may influence substance-seeking behavior. Nutrition should be included as one facet of a multidisciplinary approach toward improved recovery outcomes. Cross-disciplinary collaborative efforts, new ideas, and fiscal resources will be critical to address the epidemic.

An investigation of an open-access model for scaling up methadone maintenance treatment

AIMS

To examine retrospectively patient and programmatic outcomes following the development and implementation of an 'open-access' model in which prospective patients were enrolled rapidly in methadone maintenance treatment, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options.

DESIGN

Medical and administrative records were abstracted to compare data for 1 year before and 9 years after initiating the implementation of an open-access treatment model in May 2007.

SETTING

Methadone maintenance treatment center in Connecticut, USA.

PARTICIPANTS

Individuals with opioid use disorder entering treatment between July 2006 and June 2015. In June 2015, 64% (n = 2594) of the sample were men and 80% (n = 3133) reported that they were white.

INTERVENTION

The Network for the Improvement of Addiction Treatment-informed open-access treatment model uses process improvement strategies to improve treatment access and capacity.

MEASUREMENTS

Census, waiting time, retention, non-medical opioid use, patient mortality and financial sustainability (net income and state-block grants as proportions of revenue).

FINDINGS

In the 9 years following the initial implementation of the open-access model, patient census increased by 183% from 1431 to 4051, and average waiting-time days decreased from 21 to 0.3 (same day) without apparent deleterious effects on rates of retention, non-medical opioid use or mortality. Between fiscal years (FY) 06 and FY 15, net operating margin rose from 2 to 10%, while state-block grant revenues declined 14% and the proportion of total revenue from state-block grant revenue decreased from 49 to 24%.

CONCLUSIONS

An open-access model for rapid enrolment of people with opioid use disorder in methadone treatment appears to improve treatment access, capacity, and financial sustainability without evidence of deleterious effects on treatment outcomes.

The impact of length of stay on recovery measures in faith-based addiction treatment

OBJECTIVE

To determine the impact of length of stay among homeless men in faith-based residential addictions recovery on physical activity, depression, self-esteem, and nicotine dependence.

DESIGN AND SAMPLE

A time series design was utilized to measure changes in the four quality measures at program entry and at 3, 6, and 9 months following admission. The sample consisted of 175 homeless residents enrolled in a faith-based residential recovery program.

MEASURES

Paired t tests were used to determine the change in average instrument response from admission to each follow-up period. Analysis of variance (ANOVA) and Tukey posthoc tests were used to assess for differences in length of stay between demographic variables.

RESULTS

Statistically significant improvements were noted in self-esteem and depressive symptomatology at 3 and 6 months following admission and in physical activity levels at 3 months following admission. Nicotine dependence scores declined at 3 and 6 months but were not statistically significant.

CONCLUSION

Time spent in this faith-based spiritual recovery program had a significant impact on depression, self-esteem, and physical activity. Recommendations for future study include conducting research to analyze the relationship between distinct program elements and quality indicators and comparing faith-based programs to other similar programs and to publicly funded secular recovery programs.

Initial treatment dropout in patients with substance use disorders attending a tertiary care de-addiction centre in north India

Background & objectives:

Dropout from substance use disorders treatment is associated with poor outcomes. Although many factors have been associated with an early dropout of patients, the reasons for dropping out of treatment prematurely remain poorly understood particularly in the Indian context. This study was aimed to study socio-demographic and clinical variables predicting initial dropout of patients attending a tertiary care de-addiction treatment centre in north India.

Methods:

Information was extracted from the records of consecutive newly registered patients from January 2011 to December 2014. The patients who did not come for follow up within 30 days of the first contact were defined as initial dropouts.

Results:

Data of 7991 patients could be retrieved. Majority of the sample consisted of male, married and employed individuals. Of them, 4907 patients (61.3%) were considered initial dropouts. Multivariate analysis revealed that after controlling for other factors, greater age, being employed, lower educational status, lesser duration of substance use, use of alcohol, opiate, tobacco, cannabis or sedative-hypnotic use but the absence of multi-substance use predicted initial drop out.

Interpretation & conclusions:

This study identified some socio-demographic and clinical variables which might predict treatment attrition in substance use disorders. Clinician's awareness towards these factors and tailor-made intervention might improve initial treatment retention. Future research could be directed to find the validity of this assumption.

The Impact of Early Substance Use Disorder Treatment Response on Treatment Outcomes Among Pregnant Women With Primary Opioid Use

OBJECTIVES

This study examined the impact of early patient response on treatment utilization and substance use among pregnant participants enrolled in substance use disorder (SUD) treatment.

METHODS

Treatment responders (TRs) and treatment nonresponders (TNRs) were compared on pretreatment and treatment measures. Regression models predicted treatment utilization and substance use.

RESULTS

TR participants attended more treatment and had lower rates of substance use relative to TNR participants. Regression models for treatment utilization and substance use were significant. Maternal estimated gestational age (EGA) and baseline cocaine use were negatively associated with treatment attendance. Medication-assisted treatment, early treatment response, and baseline SUD treatment were positively associated with treatment attendance. Maternal EGA was negatively associated with counseling attendance; early treatment response was positively associated with counseling attendance. Predictors of any substance use at 1 month were maternal education, EGA, early treatment nonresponse, and baseline cocaine use. The single predictor of any substance use at 2 months was early treatment nonresponse. Predictors of opioid use at 1 month were maternal education, EGA, early treatment nonresponse, and baseline SUD treatment. Predictors of opioid use at 2 months were early treatment nonresponse, and baseline cocaine and marijuana use. Predictors of cocaine use at 1 month were early treatment nonresponse, baseline cocaine use, and baseline SUD treatment. Predictors of cocaine use at 2 months were early treatment nonresponse and baseline cocaine use.

CONCLUSIONS

Early treatment response predicts more favorable maternal treatment utilization and substance use outcomes. Treatment providers should implement interventions to maximize patient early response to treatment.

Concurrent Treatment with Prolonged Exposure for Co-Occurring Full or Subthreshold Posttraumatic Stress Disorder and Substance Use Disorders: A Randomized Clinical Trial

BACKGROUND

To test whether an integrated prolonged exposure (PE) approach could address posttraumatic stress disorder (PTSD) symptoms effectively in individuals with co-occurring substance use disorders (SUD), we compared concurrent treatment of PTSD and SUD using PE (COPE) to relapse prevention therapy (RPT) for SUD and an active monitoring control group (AMCG).

METHODS

We conducted a randomized 12-week trial with participants (n = 110; 64% males; 59% African Americans) who met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria for full or subthreshold PTSD and SUD. Participants were randomly assigned to COPE (n = 39), RPT (n = 43), or AMCG (n = 28).

RESULTS

At the end-of-treatment, COPE and RPT demonstrated greater reduction in PTSD symptom severity relative to AMCG (COPE-AMCG = -34.06, p < 0.001; RPT-AMCG = -22.58, p = 0.002). Although the difference between COPE and RPT was not significant in the complete sample, the subset of participants with full (vs. subthreshold) PTSD demonstrated significantly greater reduction of PTSD severity in COPE relative to RPT. Both treatments were superior to AMCG in reducing the days of primary substance use (COPE-AMCG = -0.97, p = 0.01; RPT-AMCG = -2.07, p < 0.001). Relative to COPE, RPT showed significantly more improvement in SUD outcome at end-of-treatment (RPT-COPE = -1.10, p = 0.047). At 3-month follow-up, COPE and RPT maintained their treatment gains and were not significantly different in PTSD severity or days of primary substance use.

CONCLUSION

COPE and RPT reduced PTSD and SUD severity in participants with PTSD + SUD. Findings suggest that among those with full PTSD, COPE improves PTSD symptoms more than a SUD-only treatment. The use of PE for PTSD was associated with significant decreases in PTSD symptoms without worsening of substance use.

Stratifying delays for assessment by type of substance to improve the probability of attendance in outpatient services

AIMS

1) To confirm the association between delay for assessment (DFA) and probability of first-time attendance in outpatient substance use disorder (SUD) treatment. 2) To evaluate whether this association varies by the type of primary substance for which the assessment was requested. 3) To assess the possibility of estimating differential DFAs to conform to equal probabilities of attendance across various types of primary substance.

METHODS

A prospective observational cohort of consecutive patients (N=1015) who requested a first-time assessment appointment at a publicly funded outpatient SUD treatment center in France between January 2014 and December 2015 was conducted. Logistic regression analyses were performed to evaluate associations between DFA (after log-transformation) and attendance and to provide estimates of attendance probability over time by the type of primary substance.

FINDINGS

After adjusting for gender, age and referral status, the attendance rate was observed to decrease significantly with longer DFA (OR=0.54; 95%CI: 0.44-0.66). The strength of this association differed across types of primary substance (p for heterogeneity <0.0001), with the strongest association being found for opioids (adjusted OR=0.21; 95%CI: 0.10-0.45). DFA was also associated with attendance for alcohol (OR=0.51; 95%CI: 0.37-0.71) and cannabis (OR=0.60; 95%CI: 0.37-0.96), but not for tobacco (OR=0.95; 95%CI: 0.60-1.50). Differential DFAs reflecting equal probabilities of attendance across types of substance could be estimated.

CONCLUSION

Our study suggests that the approach of stratifying DFAs by the type of primary substance could be helpful to improve the probability of first-time attendance in outpatient SUD treatment services.

Behavioral interventions for Cambodian female entertainment and sex workers who use amphetamine-type stimulants

Conditional cash transfer (CCT) and cognitive-behavioral treatments are evidence-based approaches to reduce stimulant use and sexual risk taking. We describe the adaptation and implementation of sequential behavioral interventions for Cambodian female entertainment and sex workers (FESW) who use amphetamine-type stimulants (ATS): (1) a 12-week CCT intervention; and (2) a 4-week cognitive-behavioral aftercare (AC) group. An ongoing cluster randomized stepped wedge trial in 10 Cambodian provinces is enrolling FESW with confirmed recent ATS use to examine the effectiveness of CCT + AC. In the first six provinces, 138 of the 183 eligible FESW (75 %) enrolled in CCT and completed a median of 25 (interquartile range 9-32) of the 36 urine screening visits. Of the 84 participants who were eligible for AC, 79 completed at least one session (94 %) and 57 completed three or more sessions (68 %). Culturally tailored behavioral interventions to reduce ATS use and optimize HIV prevention are feasible in resource-limited settings.

Validation of the alcohol use item banks from the Patient-Reported Outcomes Measurement Information System (PROMIS)

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) includes five item banks for alcohol use. There are limited data, however, regarding their validity (e.g., convergent validity, responsiveness to change). To provide such data, we conducted a prospective study with 225 outpatients being treated for substance abuse.

METHODS

Assessments were completed shortly after intake and at 1-month and 3-month follow-ups. The alcohol item banks were administered as computerized adaptive tests (CATs). Fourteen CATs and one six-item short form were also administered from eight other PROMIS domains to generate a comprehensive health status profile. After modeling treatment outcome for the sample as a whole, correlates of outcome from the PROMIS health status profile were examined.

RESULTS

For convergent validity, the largest correlation emerged between the PROMIS alcohol use score and the Alcohol Use Disorders Identification Test (r=.79 at intake). Regarding treatment outcome, there were modest changes across the target problem of alcohol use and other domains of the PROMIS health status profile. However, significant heterogeneity was found in initial severity of drinking and in rates of change for both abstinence and severity of drinking during follow-up. This heterogeneity was associated with demographic (e.g., gender) and health-profile (e.g., emotional support, social participation) variables.

CONCLUSIONS

The results demonstrated the validity of PROMIS CATs, which require only 4-6 items in each domain. This efficiency makes it feasible to use a comprehensive health status profile within the substance use treatment setting, providing important prognostic information regarding abstinence and severity of drinking.

Implementation of Cognitive-Behavioral Substance Abuse Treatment in Sub-Saharan Africa: Treatment Engagement and Abstinence at Treatment Exit

AIMS

This study documented the treatment cascade for engagement in care and abstinence at treatment exit as well as examined correlates of these outcomes for the first certified Matrix Model® substance abuse treatment site in Sub-Saharan Africa.

DESIGN

This retrospective chart review conducted at a resource-limited community clinic in Cape Town, South Africa, assessed treatment readiness and substance use severity at treatment entry as correlates of the number of sessions attended and biologically confirmed abstinence at treatment exit among 986 clients who initiated treatment from 2009-2014. Sociodemographic and clinical correlates of treatment outcomes were examined using logistic regression, modeling treatment completion and abstinence at treatment exit separately.

RESULTS

Of the 2,233 clients who completed screening, approximately 44% (n = 986) initiated treatment. Among those who initiated treatment, 45% completed at least four group sessions, 30% completed early recovery skills training (i.e., at least eight group sessions), and 13% completed the full 16-week program. Approximately half (54%) of clients who provided a urine sample had negative urine toxicology results for any substance at treatment exit. Higher motivation at treatment entry was independently associated with greater odds of treatment completion and negative urine toxicology results at treatment exit.

CONCLUSIONS

Findings provide initial support for the successful implementation the Matrix Model in a resource-limited setting. Motivational enhancement interventions could support treatment initiation, promote sustained engagement in treatment, and achieve better treatment outcomes.

Evaluating PROMIS® instruments and methods for patient-centered outcomes research: Patient and provider voices in a substance use treatment setting

PURPOSE

Our work as a primary research site of the Patient-Reported Outcomes Measurement Information System (PROMIS®), combined with support from the Patient-Centered Outcomes Research Institute, allowed us to evaluate the real-world applicability and acceptability of PROMIS measures in an addiction medicine setting.

METHODS

As part of a 3-month prospective observational study, 225 outpatients at a substance abuse treatment clinic completed PROMIS item banks for alcohol use (as well as 15 additional item banks from 8 other PROMIS domains, including emotional distress, sleep, and pain), with assessments at intake, 1-month follow-up, and 3-month follow-up. A subsample of therapists and their patients completed health domain importance ratings and qualitative interviews to elicit feedback regarding the content and format of the patients' assessment results.

RESULTS

The importance ratings revealed that depression, anxiety, and lack of emotional support were rated highest of the non-alcohol-related domains among both patients and clinicians. General alcohol use was considered most important by both patients and clinicians. Based on their suggestions, changes were made to item response feedback to facilitate comprehension and communication.

CONCLUSIONS

Both therapists and patients agreed that their review of the graphical display of scores, as well as individual item responses, helped them to identify areas of greatest concern and was useful for treatment planning. The results of our pilot work demonstrated the value and practicality of incorporating a comprehensive health assessment within a substance abuse treatment setting.

Clinician-delivered contingency management increases engagement and attendance in drug and alcohol treatment

OBJECTIVE

This study examined the impact of a low-cost contingency management (CM) delivered by program clinicians on treatment attendance and utilization for patients enrolled in outpatient psychosocial substance abuse treatment.

METHODS

The study used a pre-posttest design to compare substance abuse patients who received Reinforcement-Based Treatment (RBT) plus low cost CM (n=130; RBT+CM) to patients who received RBT only (n=132, RBT). RBT+CM participants received a $10 incentive for returning to treatment the day following intake assessment (day one), and a $15 incentive for attending treatment on day five following admission. RBT clients received standard care intervention without the addition of the CM procedures. Groups were compared on proportion of participants who returned to treatment on day one, mean days of treatment attendance, individual sessions attended, and treatment utilization during the first week and the first month following treatment admission.

RESULTS

Both the RBT+CM and RBT group participants returned to the clinic on day one at high rates (95% versus 89%, respectively). However, the RBT group participants were more likely to attend the intake assessment only (i.e., never return to treatment) compared to the RBT+CM participants. Additionally, the RBT+CM participants attended significantly more treatment days, attended more individual counseling sessions, and had higher rates of overall treatment utilization compared to the RBT participants during the one week and one month following treatment admission.

CONCLUSIONS

Findings support the feasibility and effectiveness of a CM intervention delivered by clinicians for increasing treatment attendance and utilization in a community substance abuse program.