Gender differences in treatment retention among individuals with co-occurring substance abuse and mental health disorders

Explanatory models and coping with alcohol misuse among conflict-affected men in Ukraine

Affecting nearly 10% of men globally, alcohol use disorders (AUDs) represent a significant public health burden. Existing work, including from Ukraine, suggests that living in conflict settings may exacerbate the risk of AUDs. However, there is a dearth of evidence regarding alcohol misuse, as well as knowledge of factors associated with alcohol misuse patterns, in conflict settings. The aim of this qualitative study was to investigate explanatory models of alcohol misuse among conflict-affected men in Ukraine. Purposive and snowball sampling were used to recruit 66 conflict-affected men with alcohol misuse, family members of men who misuse alcohol, community health workers, and mental health and psychosocial support providers from locations across Ukraine. In the group of men who misuse alcohol (n=25), we recruited individuals with diverse experiences of adversity: 1) internally displaced persons from eastern Ukraine and Crimea displaced after 2014; 2) Ukrainian military veterans or territorial defense volunteers from various regions; and 3) men living 5-15 kilometers from the frontline. Semi-structured interviews were conducted in Ukrainian or Russian, and analysed using deductive and inductive analysis. Qualitative data received from each subgroup were analysed separately. The resulting explanatory model represents how Ukrainian conflict-affected men describe causes of alcohol misuse. Participants identified that alcohol misuse among Ukrainian men is often used as "self-treatment" to address mental health symptoms and feelings of demoralization that are exacerbated by a lack of supportive social environments and socio-economic problems; these behaviours also occur in an environment that deems alcohol misuse to be culturally appropriate. Family members and service providers offered a similar understanding of alcohol misuse as the men themselves. Strategies suggested by conflict-affected men to protect against alcohol misuse included engaging in alternative activities, finding supportive social environments, fear of negative consequences from alcohol misuse and increasing self-awareness and self-control. These findings indicate possible implications for interventions that target alcohol misuse among conflict-affected men, as well as demonstrate a need for developing culturally sensitive interventions that can address this unaddressed public health need.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative outpatient clinic data

QUESTION

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders (OUD), from large samples in the community.

GOAL

To determine sex disparities in non-medical opioid use (NMOU) at the end of treatment with medications for opioid use disorder (MOUD), using national data.

DESIGN

Observational study of outpatient MOUD programs in the "Treatment episode data set-discharges" (TEDS-D) for 2019.

PARTICIPANTS

Persons aged ≥ 18 in their first treatment episode, in outpatient MOUD-based therapy for heroin or other opioids (N = 10,065). The binary outcome was presence/absence of NMOU in the month prior to discharge.

RESULTS

In univariate analyses, males had higher odds of NMOU compared to females (odds ratio=1.22; p = 6.84 ×10-5 after Bonferroni correction). A multivariable logistic regression detected a relatively small male>female odds ratio of 1.14 (p = 0.0039), surviving adjustment for demographic variables and social determinants of health. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., if they were in the white racial category, and were not of hispanic ethnicity). Also, using by smoking, inhalation or injection routes (versus oral) was associated with greater odds of NMOU, irrespective of sex.

CONCLUSIONS

This national community sample shows that males overall have greater odds of NMOU in their first treatment episode with MOUD, a potential indicator of more unfavorable outcomes. Further analyses should examine the underpinnings of this disparity, including clinical severity features.

Client preferences for the design and delivery of injectable opioid agonist treatment services: Results from a best-worst scaling task

BACKGROUND AND AIMS

Clinical trials support injectable opioid agonist treatment (iOAT) for individuals with opioid use disorder (OUD) for whom other pharmacological management approaches are not well-suited. However, despite substantial research indicating that person-centered care improves engagement, retention and health outcomes for individuals with OUD, structural requirements (e.g. drug policies) often dictate how iOAT must be delivered, regardless of client preferences. This study aimed to quantify clients' iOAT delivery preferences to improve client engagement and retention.

DESIGN

Cross-sectional preference elicitation survey.

SETTING

Metro Vancouver, British Columbia, Canada.

PARTICIPANTS

124 current and former iOAT clients.

MEASUREMENTS

Participants completed a demographic questionnaire package and an interviewer-led preference elicitation survey (case 2 best-worst scaling task). Latent class analysis was used to identify distinct preference groups and explore demographic differences between preference groups.

FINDINGS

Most participants (n = 100; 81%) were current iOAT clients. Latent class analysis identified two distinct groups of client preferences: (1) autonomous decision-makers (n = 73; 59%) and (2) shared decision-makers (n = 51; 41%). These groups had different preferences for how medication type and dosage were selected. Both groups prioritized access to take-home medication (i.e. carries), the ability to set their own schedule, receiving iOAT in a space they like and having other services available at iOAT clinics. Compared with shared decision-makers, fewer autonomous decision-makers identified as a cis-male/man and reported flexible preferences.

CONCLUSIONS

Injectable opioid agonist treatment (iOAT) clients surveyed in Vancouver, Canada, appear to prefer greater autonomy than they currently have in choosing OAT medication type, dosage and treatment schedule.

A systematic review of interventions to enhance initiation of and adherence to treatment for alcohol use disorders

BACKGROUND

Alcohol use disorders (AUDs) contribute significantly to the global disease burden in terms of morbidity and mortality. While effective treatment options exist, engagement with care remains a challenge, impacting treatment outcomes and resource allocation, particularly in resource-constrained settings. In this review, we aim to systematically examine and synthesize the evidence on interventions targeting initiation of and adherence to treatment for AUDs.

METHODS

A search was conducted on six electronic databases (MEDLINE, PsycINFO, Embase, Global Health, CINAHL and CENTRAL) using search terms under the following concepts: alcohol use disorders, initiation/adherence, treatments, and controlled trial study design. Due to the heterogeneity in intervention content and outcomes among the included studies, a narrative synthesis was conducted. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools.

RESULTS

The search yielded 32 distinct studies testing eleven categories of interventions. 23 out of 32 studies reported effectiveness of interventions in improving at least one initiation or adherence outcome, with 11 studies reporting an improvement in at least one outcome related to drinking, and four studies reporting improvements in at least one measure of well-being or disability. Community Reinforcement Approach and Family Training (CRAFT) emerged as a prominent approach for treatment initiation, contingency management for adherence, and motivational interviewing (MI) for both treatment initiation and adherence.

CONCLUSION

Integrating initiation and adherence interventions into AUD treatment services holds immense potential for optimizing client outcomes and fostering overall well-being. However, generalizability of these strategies remains uncertain owing to the lack of studies conducted in low- and middle-income countries. Addressing this gap is crucial for enhancing global access to effective treatments for AUDs.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative study

Question

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders, in "real world" settings.

Goal

To determine sex disparities in non-medical opioid use (NMOU) at the end of outpatient medication-assisted treatment (MAT), using nationally representative data.

Design

Observational epidemiological study of publicly funded outpatient MAT programs in the national "Treatment episode data set-discharges" (TEDS-D) for 2019.

Participants

Persons aged ≥18 in their first treatment episode, in outpatient MAT for use of heroin or other opioids (N=11,549). The binary outcome was presence/absence of NMOU.

Results

In univariate analyses, males had significantly higher odds of NMOU, compared to females (odds ratio=1.27; Chi2 [df:1]=39.08; uncorrected p<0.0001; p=0.0041 after Bonferroni correction). A multivariable logistic regression detected a male>female odds ratio of 1.19 (95%CI=1.09-1.29; p<0.0001), adjusting for socio-demographic/clinical variables. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., at ages 18-29 and 30-39; corrected p=0.012, or if they used opioids by inhalation; corrected p=0.0041).

Conclusions

This nationally representative study indicates that males have greater odds of NMOU in their first episode of MAT, indicating more unfavorable outcomes. The study reveals specific socio-demographic and clinical variables under which this sex disparity is most prominent.

Telehealth and delivery of alcohol use disorder treatment in the Veterans Health Administration

BACKGROUND

The use of telehealth treatment of alcohol use disorder (AUD) has increased since the start of the COVID-19 pandemic. However, it is unclear which patients are using telehealth and how telehealth visits are associated with treatment duration. This study examined characteristics associated with telehealth use among Veterans Health Administration patients receiving AUD treatment.

METHODS

Using a national retrospective cohort study, we examined data from March 01, 2020 to February 28, 2021 to: First, identify patient characteristics associated with (a) any telehealth versus only in-person care for AUD treatment, and (b) video (≥1 video visit) versus only telephone visits for AUD treatment (≥1 telephone visit, no video) among any telehealth users. This analysis used mixed-effects logistic regression models to adjust for potential correlation across patients treated at the same facility. Second, we assessed whether visit modality was associated with the amount of AUD treatment received (number of AUD psychotherapy visits or medication coverage days). This analysis used mixed-effects negative binomial regression models.

RESULTS

Among 138,619 patients who received AUD treatment, 52.8% had ≥1 video visit, 38.1% had ≥1 telephone but no video visits, and 9.1% had only in-person visits. In the regression analyses, patients who were male or had an opioid or stimulant use disorder (compared to having no non-AUD substance use disorder) were less likely to receive any telehealth-delivered AUD treatment compared to only in-person AUD treatment. Among patients who received any telehealth-delivered AUD treatment, those who were ≥45 years old (compared to 18-29 years old), Black (compared to White), diagnosed with a cannabis or stimulant use disorder, or diagnosed with a serious mental illness were less likely to receive a video visit than only telephone visits. Receiving any AUD telehealth was associated with receiving more psychotherapy visits and medication coverage days than only in-person care.

CONCLUSIONS

Telehealth, a common modality for AUD treatment, supported a greater number of psychotherapy visits and a longer duration of medication treatment for AUD. However, some groups were less likely to receive any video telehealth than telephone visits, suggesting that multiple treatment modalities should remain available to ensure treatment access.

Substance Use Disorders in Women

Substance use disorder (SUD) is among the leading causes of premature morbidity and mortality and imposes significant health, economic, and social burdens. Gender differences have been found in the development, course, and treatment of SUD, with women at increased risk for physiologic and psychosocial consequences compared with men. Reasons for these differences are multifold and include biological, genetic, environmental, and behavioral factors. This article discusses SUD among women, emphasizing clinical considerations for care. Specific topics include epidemiology, sex and gender differences, common comorbidities, screening, diagnosis, treatment, pregnancy, and sociocultural factors.

The Incidence and Disparities in Use of Stigmatizing Language in Clinical Notes for Patients With Substance Use Disorder

OBJECTIVE

The language used to describe people with substance use disorder impacts stigma and influences clinical decision making. This study evaluates the presence of stigmatizing language (SL) in clinical notes and detects patient- and provider-level differences.

METHODS

All free-text notes generated in a large health system for patients with substance-related diagnoses between December 2020 and November 2021 were included. A natural language processing algorithm using the National Institute on Drug Abuse's "Words Matter" list was developed to identify use of SL in context.

RESULTS

There were 546,309 notes for 30,391 patients, of which 100,792 (18.4%) contained SL. A total of 18,727 patients (61.6%) had at least one note with SL. The most common SLs used were "abuse" and "substance abuse." Nurses were least likely to use SL (4.1%) while physician assistants were most likely (46.9%). Male patients were more likely than female patients to have SL in their notes (adjusted odds ratio [aOR], 1.17; 95% confidence internal [CI], 1.11-1.23), younger patients aged 18 to 24 were less likely to have SL than patients 45 to 54 years (aOR, 0.55; 95% CI, 0.50-0.61), Asian patients were less likely to have SL than White patients (aOR, 0.45; 95% CI, 0.36-0.56), and Hispanic patients were less likely to have SL than non-Hispanic patients (aOR, 0.88; 95% CI, 0.80-0.98).

CONCLUSIONS

The majority of patients with substance-related diagnoses had at least one note containing SL. There were also several patient characteristic disparities associated with patients having SL in their notes. The work suggests that more clinician interventions about use of SL are needed.

Therapeutics for Substance-Using Women: The Need to Elucidate Sex-Specific Targets for Better-Tailored Treatments

In the last decade, alcohol consumption in the US has risen by 84% in women compared with 35% in men. Furthermore, research has shown that sex- and gender-related differences may disadvantage women in terms of developing a range of psychological, cognitive, and medical problems considerably earlier in their drinking history than men, and despite consuming a similar quantity of substances. While this "telescoping" process has been acknowledged in the literature, a concomitant understanding of the underlying biobehavioral mechanisms, and an increase in the development of specific treatments tailored to women, has not occurred. In the current chapter we focus on understanding why the need for personalized, sex-specific medications is imperative, and highlight some of the potential sex-specific gonadal and stress-related adaptations underpinning the accelerated progress from controlled to compulsive drug and alcohol seeking in women. We additionally discuss the efficacy of these mechanisms as novel targets for medications development, using exogenous progesterone and guanfacine as examples. Finally, we assess some of the challenges faced and progress made in terms of developing innovative medications in women. We suggest that agents such as exogenous progesterone and adrenergic medications, such as guanfacine, may provide some efficacy in terms of attenuating stress-induced craving for several substances, as well as improving the ability to emotionally regulate in the face of stress, preferentially in women. However, to fully leverage the potential of these therapeutics in substance-using women, greater focus needs to the placed on reducing barriers to treatment and research by encouraging women into clinical trials.

Social Factors Predict Treatment Engagement in Veterans with PTSD or SUD

Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.

Women-Reported Barriers and Facilitators of Continued Engagement with Medications for Opioid Use Disorder

Opioid-related fatalities increased exponentially during the COVID-19 pandemic and show little sign of abating. Despite decades of scientific evidence that sustained engagement with medications for opioid use disorders (MOUD) yields positive psychosocial outcomes, less than 30% of people with OUD engage in MOUD. Treatment rates are lowest for women. The aim of this project was to identify women-specific barriers and facilitators to treatment engagement, drawing from the lived experience of women in treatment. Data are provided from a parent study that used a community-partnered participatory research approach to adapt an evidence-based digital storytelling intervention for supporting continued MOUD treatment engagement. The parent study collected qualitative data between August and December 2018 from 20 women in Western Massachusetts who had received MOUD for at least 90 days. Using constructivist grounded theory, we identified major themes and selected illustrative quotations. Key barriers identified in this project include: (1) MOUD-specific discrimination encountered via social media, and in workplace and treatment/recovery settings; and (2) fear, perceptions, and experiences with MOUD, including mental health medication synergies, internalization of MOUD-related stigma, expectations of treatment duration, and opioid-specific mistrust of providers. Women identified two key facilitators to MOUD engagement: (1) feeling "safe" within treatment settings and (2) online communities as a source of positive reinforcement. We conclude with women-specific recommendations for research and interventions to improve MOUD engagement and provide human-centered care for this historically marginalized population.

The role of age and opioid agonist treatment on substance use treatment completion in the United States

BACKGROUND

There is a large body of research indicating that substance use disorder treatment completion leads to higher rates of sustained recovery. However, not much is known about how age and opioid treatment programs (OTPs) OTPinteract to affect treatment completion. The purpose of this article is to better understand the pathway between age, OTP, and treatment completion.

METHODS

Data from the US 2017 Treatment Episodes Data Set was analyzed. Seemingly unrelated bivariate probit regression was used to determine whether OTP access mediates the relationship between age and treatment completion. We used propensity score matching to simulate the effects of a randomized control trial and to attenuate the likelihood of a Type 1 error.

RESULTS

Older adults have a higher likelihood than their younger counterparts of completing treatment regardless of OTP status in inpatient and outpatient settings. Those who received OTP in inpatient treatment had a 45% increased probability of completing treatment in detox settings and a 41% increased probability of completing treatment in inpatient settings. Older adults (age 50+) were more likely to receive OTP than their younger counterparts. There is a small but significant indirect effect of age on treatment completion in inpatient settings.

CONCLUSIONS

Older adults are more likely to receive OTP in both inpatient and outpatient settings. However, age does not appear to affect the probability of treatment completion when individuals receive OTP, except in inpatient settings. Implications are discussed.

Health Care Utilization Patterns for Patients With a History of Substance Use Requiring OPAT

Background

Uninsured people who use drugs (PWUD) require extended parenteral antibiotic therapy when diagnosed with complex infections such as osteomyelitis. They are ineligible to enroll in our self-administered outpatient antimicrobial therapy (S-OPAT) program and instead sent to a skilled nursing facility (SNF). We aim to retrospectively assess clinical outcomes of PWUD discharged from our safety net hospital to complete OPAT in an SNF.

Methods

Using our hospital electronic medical record, PWUD discharged to an SNF for extended antibiotic therapy were identified for the study period, 1/1/17–4/30/18. Demographics, drug use, discharge diagnosis, antibiotic therapy, discharge disposition from SNF (AMA, early non-AMA, completed), 30-day emergency department (ED) utilization, and 30-day readmission were collected for the study cohort. ED utilization and 30-day readmission rates were analyzed by disposition group.

Results

While the majority of patients completed treatment (83), a sizeable number left AMA (26) or early non-AMA (20). Patients who left early, AMA or non-AMA, had increased rates of 30-day readmission or ED utilization (P=.01) and increased rates of 30-day readmission alone (P=.01), but not ED utilization alone (P=.43), compared with patients who completed treatment.

Conclusions

In our cohort, many PWUD discharged to an SNF to receive parenteral antibiotics did not complete treatment. These patients were observed to have increased health care utilization compared with patients completing therapy.

Music therapy for people with substance use disorders

BACKGROUND

Substance use disorder (SUD) is the continued use of one or more psychoactive substances, including alcohol, despite negative effects on health, functioning, and social relations. Problematic drug use has increased by 10% globally since 2013, and harmful use of alcohol is associated with 5.3% of all deaths. Direct effects of music therapy (MT) on problematic substance use are not known, but it may be helpful in alleviating associated psychological symptoms and decreasing substance craving.

OBJECTIVES

To compare the effect of music therapy (MT) in addition to standard care versus standard care alone, or to standard care plus an active control intervention, on psychological symptoms, substance craving, motivation for treatment, and motivation to stay clean/sober.

SEARCH METHODS

We searched the following databases (from inception to 1 February 2021): the Cochrane Drugs and Alcohol Specialised Register; CENTRAL; MEDLINE (PubMed); eight other databases, and two trials registries. We handsearched reference lists of all retrieved studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials comparing MT plus standard care to standard care alone, or MT plus standard care to active intervention plus standard care for people with SUD.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We included 21 trials involving 1984 people. We found moderate-certainty evidence of a medium effect favouring MT plus standard care over standard care alone for substance craving (standardised mean difference (SMD) -0.66, 95% confidence interval (CI) -1.23 to -0.10; 3 studies, 254 participants), with significant subgroup differences indicating greater reduction in craving for MT intervention lasting one to three months; and small-to-medium effect favouring MT for motivation for treatment/change (SMD 0.41, 95% CI 0.21 to 0.61; 5 studies, 408 participants). We found no clear evidence of a beneficial effect on depression (SMD -0.33, 95% CI -0.72 to 0.07; 3 studies, 100 participants), or motivation to stay sober/clean (SMD 0.22, 95% CI -0.02 to 0.47; 3 studies, 269 participants), though effect sizes ranged from large favourable effect to no effect, and we are uncertain about the result. There was no evidence of beneficial effect on anxiety (mean difference (MD) -0.17, 95% CI -4.39 to 4.05; 1 study, 60 participants), though we are uncertain about the result. There was no meaningful effect for retention in treatment for participants receiving MT plus standard care as compared to standard care alone (risk ratio (RR) 0.99, 95% 0.93 to 1.05; 6 studies, 199 participants). There was a moderate effect on motivation for treatment/change when comparing MT plus standard care to another active intervention plus standard care (SMD 0.46, 95% CI -0.00 to 0.93; 5 studies, 411 participants), and certainty in the result was moderate. We found no clear evidence of an effect of MT on motivation to stay sober/clean when compared to active intervention, though effect sizes ranged from large favourable effect to no effect, and we are uncertain about the result (MD 0.34, 95% CI -0.11 to 0.78; 3 studies, 258 participants). There was no clear evidence of effect on substance craving (SMD -0.04, 95% CI -0.56 to 0.48; 3 studies, 232 participants), depression (MD -1.49, 95% CI -4.98 to 2.00; 1 study, 110 participants), or substance use (RR 1.05, 95% CI 0.85 to 1.29; 1 study, 140 participants) at one-month follow-up when comparing MT plus standard care to active intervention plus standard care. There were no data on adverse effects. Unclear risk of selection bias applied to most studies due to incomplete description of processes of randomisation and allocation concealment. All studies were at unclear risk of detection bias due to lack of blinding of outcome assessors for subjective outcomes (mostly self-report). We judged that bias arising from such lack of blinding would not differ between groups. Similarly, it is not possible to blind participants and providers to MT. We consider knowledge of receiving this type of therapy as part of the therapeutic effect itself, and thus all studies were at low risk of performance bias for subjective outcomes.  We downgraded all outcomes one level for imprecision due to optimal information size not being met, and two levels for outcomes with very low sample size.  AUTHORS' CONCLUSIONS: Results from this review suggest that MT as 'add on' treatment to standard care can lead to moderate reductions in substance craving and can increase motivation for treatment/change for people with SUDs receiving treatment in detoxification and short-term rehabilitation settings. Greater reduction in craving is associated with MT lasting longer than a single session. We have moderate-to-low confidence in our findings as the included studies were downgraded in certainty due to imprecision, and most included studies were conducted by the same researcher in the same detoxification unit, which considerably impacts the transferability of findings.

Examining Recovery Status Trends over 7-Years for Men and Women Clients of a Substance Use Disorder Recovery Housing Program

Adults who are homeless and/or involved in the criminal justice system have significantly higher risks of substance use disorders (SUD)s and they may have increased difficulty initiating and maintaining traditional SUD treatments. To address the needs of adults with SUDs who are homeless/criminal justice system involved the Recovery Kentucky programs were established. This study examined outcomes for this recovery housing program among an unduplicated statewide sample of men ( n=672) and women ( n = 732) clients who entered the Recovery Kentucky program and who were followed-up about 12 months after program entry across a 7-year period. Low, but similar rates of problem alcohol or illicit drug use at follow-up were found across the 7-year period. Men had higher rates of return to use than women. Further, about 40% of the clients had at least one recovery status vulnerability factor at follow-up each year of the study with no differences by gender.

Overlapping needs for sexual and reproductive health and HIV prevention in women with substance use disorders

OBJECTIVES

Women with substance use disorders have high unmet needs for HIV prevention and drug treatment and face challenges accessing care for other unique health issues, including their sexual and reproductive health.

METHODS

We did a cross-sectional evaluation of sexual and reproductive health behaviors and outcomes among women with substance use disorders, who were enrolled in one of two concurrent clinical trials of pre-exposure prophylaxis for HIV prevention. Descriptive analyses and bivariate logistic regression were used to assess factors driving contraceptive use, and other essential sexual and reproductive health services utilization and outcomes.

RESULTS

Among 226 women, 173 (76.5%) were of reproductive age. Most women had histories of unintended pregnancy (79.2%) or miscarriage (45.1%) and high HIV risk behaviors (53.5%). Most (61%) participants did not use any form of contraception at the time of assessment, although few (15%) reported pregnancy intentions. In bivariate models, ongoing criminal justice involvement was associated with 2.22 higher odds of not using contraception (95% confidence interval = 1.09-4.53; p = 0.03) and hazardous drinking was protective against not using contraception (odds ratio = 0.33, 95% confidence interval = 0.13-0.81; p = 0.02). Contraception use was not significantly associated with any other individual characteristics or need factors.

CONCLUSIONS

This is the first study that identifies the unmet sexual and reproductive health needs of women with substance use disorders who are engaging with pre-exposure prophylaxis. We found that women accessed some health services but not in a way that holistically addresses the full scope of their needs. Integrated sexual and reproductive care should align women's expressed sexual and reproductive health intentions with their behaviors and outcomes, by addressing social determinants of health.

YESS: A feasibility study of a supported employment program for youths with mental health disorders

OBJECTIVE

In Canada, employment/education support is rarely embedded as a component of mental health service delivery. This study describes a supported education/employment program (SEP) that integrates both clinical and community mental health services. The main objectives were to estimate the feasibility of a 5-week SEP among youths aged 17-24 with mental illness and to estimate the extent to which participation in this program improved employment and mental health outcomes.

METHODS

This was a single cohort study. Feasibility outcomes assessed were demand, acceptability, practicality, integration, adaptation, and effectiveness. These were assessed through recruitment and retention rates, recording patterns of missing data, and examining differences between completers and non-completers. Appropriateness of the outcome measures was assessed through the strength of the association between the outcome measures at baseline. Effectiveness of the program was assessed through employment and as measured using MyLifetracker (MLT), Satisfaction with Life Scale (SWLS), and the Canadian Personal Recovery Outcome Measure (CPROM).

RESULTS

A total of 110 youths with a mean age of 20.6 (SD: 2.2) were recruited. At 5 weeks, 82 (74.5%) of participants remained in the program. Of the people who completed the program, 56.1% were women, 76.6% were in stable housing and 64.1% had depression. Approximately 60% of non-completers used two or more services and were in at-risk housing. More than 25% of participants improved on the patient-reported outcomes. Scores on these measures were moderately to highly correlated with each other. Employment rates varied and corresponded to the waves of the COVID-19 pandemic in Canada.

CONCLUSION

Results showed that this program was feasible and there was high demand for SEP during the COVID-19 pandemic but gaining employment remained difficult. Educational or employment outcomes, measured over a short period, may not be adequate. Instead, individualized and patient-reported outcome measures may be more appropriate for SEP programs.

Investigating interventions that lead to the highest treatment retention for emerging adults with substance use disorder: A systematic review

BACKGROUND AND AIMS

Emerging adults (age 18-25) have the highest rate of substance use disorders (SUD) and often drop out of treatment earlier than those age twenty six or older. In order to increase treatment retention in emerging adults, there needs to be a better understanding of which SUD treatment interventions work best for this population. The purpose of this systematic review was to evaluate treatment interventions for emerging adults with SUD and identify which interventions show promise for retention in treatment.

METHODS

Following the PRISMA guidelines, Medline, PsycInfo, CINAHL (all via EBSCO), and Embase were systematically searched for articles that evaluated treatment interventions for emerging adults with SUD. From here, the authors identified treatment interventions that showed promise for retention in treatment.

RESULTS

Nine studies were included. The main findings indicate (1) behavioral therapy such as cognitive behavioral therapy and contingency management for cannabis and alcohol use disorders, or (2) cognitive behavioral therapy paired with opioid-agonist-therapy for opioid use disorder demonstrate the most promise for retention in treatment.

CONCLUSION

The interventions identified that show promise for emerging adults was similar to studies evaluating interventions for all ages. Given that retention rates are often lower in emerging adults despite the application of the full range of effective adult treatments, this review suggests they may require something different. While further studies are warranted to determine with more certainty what works best to keep emerging adults in treatment, some tentative suggestions are included.

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.

Examination of referral source and retention among women in residential substance use disorder treatment: a prospective follow-up study

Background

Court-mandated substance use disorder (SUD) treatment, as compared to nonmandated treatment, has been associated with increased retention and completion. However, whether child protective services (CPS)-mandated women’s residential SUD treatment leads to improved treatment retention in comparison to criminal justice (CJ)-mandated and nonmandated treatment remains unclear.

Purpose

This study compared the number of days retained in residential SUD treatment among three referral sources (CPS, CJ, and nonmandated), while also examining whether having a co-occurring mental health disorder or increased stress, depression, anxiety, and PTSD symptomology contributed to decreased retention. This study tested the hypothesis that women mandated by the CPS and CJ systems would have improved residential SUD treatment retention compared with nonmandated women.

Methods

Multiple regression analyses were conducted on data for a diverse sample of 245 women (Hispanic: N = 141, Black: N = 50, White: N = 50) mandated or nonmandated (CJ: N = 114, CPS: N = 82, nonmandated: N = 49) into residential SUD treatment to determine each group’s treatment retention outcomes. Results: Women mandated to SUD residential treatment by the CPS system remained in treatment significantly longer (p = .046), compared to women not mandated, representing a 34.4% increase in retention. Findings further revealed a corresponding 2.3% decrease in retention (p = .048) for each one-unit increase in a patient’s stress score, whereas those with a co-occurring mental health diagnosis had a 43.6% decrease in SUD treatment retention (p < .001).

Conclusions

Policy and clinical considerations include (a) increasing case management support and wraparound services that meet the multiple service needs of women who are nonmandated to residential SUD treatment, and (b) incorporating a more nuanced treatment approach that manages mental health disorders and stress symptomology early in treatment when women are most vulnerable to relapse and treatment dropout.

Trial registration

ClinicalTrials.gov Identifier: NCT02977988 (first posted November 30, 2016; last update posted October 7, 2019); U.S. NIH Grant/Contract: 5R01DA038648.

Factors Associated with Substance Use Disorder Treatment Completion, Rhode Island, USA, 2018

INTRODUCTION

The successful retention of individuals with substance use disorders in treatment remains a challenge but is an important indicator of positive post-treatment outcomes. The aim of this study is to advance understanding of pre-admission factors associated with substance use treatment completion in Rhode Island.

METHODS

Data for this longitudinal analysis are from the RI Behavioral Health On-Line Database (RI-BHOLD). The primary outcome of interest was substance use treatment completion defined as any planned discharge from treatment, including transfers to other facilities. Associations were assessed using generalized estimating equations (GEE) to account for the potential of repeated measures for the same individuals.

RESULTS

Among the 7,351 clients discharged from a substance use treatment program in RI in 2018, the treatment completion rate was 58.1%. There was a positive relationship between the frequency of attendance of voluntary self-help groups and odds of treatment completion. Treatment completion rates were lower among those who reported use of opioids (AOR: 0.59; 95% CI: 0.52-0.66) and other drugs (AOR: 0.52; 95% CI: 0.44-0.62), compared to alcohol and for those with co-occurring mental health conditions (AOR: 0.85; 95% CI: 0.76-0.94).

CONCLUSIONS

This study highlights the importance of social connectedness in substance use disorder treatment completion. Future research is needed to identify the characteristics of persons who are most likely to benefit from self-help groups and the optimal combination of treatment participation and attendance of self-help groups across a spectrum of disorder severity and community resources.

Motivations for Treatment Engagement in a Residential Substance Use Disorder Treatment Program: A Qualitative Study

AIMS

The aim of this study was to explore perspectives on motivations for treatment engagement from substance use disorder (SUD) clients in a long-term residential rehabilitation program.

DESIGN AND METHODS

A convenience sample of 30 clients who were enrolled in a year-long SUD treatment program at a residential rehabilitation facility took part in in-depth interviews. Interview transcripts were analyzed using the directed content analysis approach.

RESULTS

Participant accounts indicated that their treatment engagement was motivated by factors that aligned with the six primary constructs of the Health Belief Model: (i) perceived susceptibility (eg, believing that their substance use required intervention and that they were prone to relapse), (ii) perceived severity (eg, substance use negatively impacted their health and harmed their close relationships), (iii) perceived benefits (eg, opportunities for a better life, reconnecting with family members and close friends, & avoiding legal consequences), (iv) perceived barriers (eg, the length of the treatment program), (v) cues to actions (eg, decisive moments, elements of the treatment program, & faith and spirituality), and (vi) self-efficacy in remaining abstinent (eg, treatment program provided them with skills and experiences to maintain long-term sobriety).

DISCUSSION

Our analysis indicates that participants' treatment engagement was linked to their beliefs regarding the severity of their substance use disorder, their treatment program's ability to help them avoid future relapse, and their own capability to act upon the strategies and resources provided by the treatment program. A theoretical understanding of these aspects can contribute to the future planning of precision interventions.

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.

Examining Recovery Program Participants by Gender: Program Completion, Relapse, and Multidimensional Status 12 Months After Program Entry

This study examined individual-level characteristics and factors associated with program completion, relapse, and multidimensional status at follow-up for 213 men and 248 women who entered one of 17 peer-led recovery programs and who completed a follow-up interview 12 months later. Study results found that although there were some significant gender differences at program entry among participants entering Recovery Kentucky, there were few gender differences at follow-up. In addition, although participants had significant psychosocial problems, polysubstance use patterns, and severe substance use disorder (SUD), the majority of both men and women reported completing the program (80.3%), a small minority reported relapse (9.5%), and about one third had worse multidimensional status about 12 months after program entry. Lower quality of life rating at program entry was associated with program completion and with better multidimensional status at follow-up. Study results suggest the recovery program provides an important option for some of the most vulnerable individuals with SUD.

Factors Contributing to Substance Misuse Treatment Completion among Native Hawaiians, Other Pacific Islanders, and Asian Americans

Background: Research on substance abuse treatment completion (SATC) among Asian Americans and Native Hawaiian and Other Pacific Islanders (NHOPIs) is extremely limited despite growing concern of SA among these groups. Objectives: This study examined predictors of SATC among and within Asian, NHOPI, and White racial groups. Methods: 129,939 cases from the SA and Mental Health Services, Treatment Episode Data Set-Discharges-2016 were used in this study. Logistic regressions were employed to examine the differential impact of race on SATC and to investigate the moderating effect of race on the relationship between socioeconomic factors, type of substance used, and type of treatment setting on SATC. Results: NHOPIs were less likely to complete SA treatment than Whites. Within-group analysis indicated that NHOPIs who were in outpatient non-intensive treatment were more likely to complete treatment compared to ones in inpatient (more than 30 days), and outpatient intensive settings. In contrast, Asians and Whites in outpatient non-intensive treatment settings were less likely to complete compared to all other types of treatment settings. Older adults for Whites were more likely to complete treatment compared with younger adults. Age was not a significant predictor of SATC for Asians and NHOPIs. Asian and NHOPI methamphetamine users were less likely to complete treatment compared with White users. Conclusion/Importance: Findings highlight the importance of disaggregating Asians and NHOPIs in future SA studies to better understand how specific factors are relevant to each group, and to guide the development of cultural and race-informed treatments for these groups.

Patient Characteristics Predicting Abstinence in Substance Use Disorder Patients With Comorbid Mental Disorders

Objective: Patients with both a substance use disorder and comorbid mental disorder, or dual diagnosis, form a heterogeneous group with complex treatment needs. Dual diagnosis patients have worse treatment outcomes compared to patients with substance use disorders alone. There is a lack of research focusing on predictors of treatment outcome in dual diagnosis patients. The aim of this study was to identify patient characteristics associated with abstinence in dual diagnosis patients. Methods: In a cohort design, we examined associations between baseline demographic and clinical patient characteristics and abstinence at 14-month follow-up in 102 dual diagnosis patients undergoing treatment in an addiction-psychiatry service in Amsterdam. Immigration, employment, housing, age, emotion regulation, psychiatric symptoms, and frequency and nature of substance abuse were examined as possible predictors of abstinence. Patients were considered abstinent if they had refrained from any substance use in the 30 days prior to the follow-up assessment, as measured with the Timeline Follow Back method. Results: In a multiple logistic regression analysis corrected for treatment utilization, being a first- or second-generation immigrant was associated with lower odds of abstinence (OR = 5.13; 95% CI [1.63, 18.18]), as well as higher levels of depressive and anxiety symptoms at baseline (OR = 0.90; 95% CI [0.81, 0.99]). Gender, age, housing, employment, emotion regulation, frequency and nature of substance abuse, and the psychiatric symptoms positive symptoms, negative symptoms, and manic excitement and disorganization did not show a significant relationship with abstinence. Conclusions: The results indicate that being a first- or second-generation immigrant and experiencing more symptoms of depression and anxiety are predictive of non-abstinence. Attention for linguistic and cultural congruence of dual diagnosis treatments may enhance abstinence in immigrants. Additionally, addressing symptoms of depression and anxiety in dual diagnosis treatment may be beneficial for the maintenance of abstinence. More research is needed on factors influencing treatment success in dual diagnosis patients.

A smartphone app intervention for adult cannabis users wanting to quit or reduce their use: a pilot evaluation

Background

Smartphone applications (apps) offer a promising alternative to face-to-face treatment due to their ease of access and convenience. However, there is a lack of evidence-based apps for cannabis users wishing to reduce their use.

Objectives

The current study evaluated the feasibility and acceptability of a smartphone app intervention (called Assess, Plan, Track, and Tips [APTT]) for cannabis users wanting to reduce their use.

Method

The current study included 111 cannabis users (68% male, aged 18–50 yrs) who had used cannabis in the past month, were not currently in treatment, and who wanted to reduce/quit their use. Participants were given access to APTT for 1 month. Participants reported on their cannabis use and related problems, confidence in resisting use, severity of dependence, and stage of change at baseline, post-intervention (4 weeks), and at 1-month follow-up. At post-intervention, participants also reported on their usage and satisfaction with the app.

Results

The current study found that APTT was acceptable, with over 40% of participants using the app over 20 times over the course of a month. Participants showed a reduction in dependence and cannabis related problems over the course of the study. Further, participants’ stage of change at baseline predicted changes in cannabis use.

Conclusions/importance

These findings support the feasibility and acceptability of APTT as an engaging app for cannabis users wishing to better manage their use and support the need for future RCTs to assess the efficacy of mobile-based interventions for cannabis users.

Electronic supplementary material

The online version of this article (10.1186/s42238-019-0009-6) contains supplementary material, which is available to authorized users.

Patient characteristics associated with treatment initiation and engagement among individuals diagnosed with alcohol and other drug use disorders in emergency department and primary care settings

Background: Treatment initiation and engagement rates for alcohol and other drug (AOD) use disorders differ depending on where the AOD use disorder was identified. Emergency department (ED) and primary care (PC) are 2 common settings where patients are identified; however, it is unknown whether characteristics of patients who initiate and engage in treatment differ between these settings. Methods: Patients identified with an AOD disorder in ED or PC settings were drawn from a larger study that examined Healthcare Effectiveness Data and Information Set (HEDIS) AOD treatment initiation and engagement measures across 7 health systems using electronic health record data (n = 54,321). Multivariable generalized linear models, with a logit link, clustered on health system, were used to model patient factors associated with initiation and engagement in treatment, between and within each setting. Results: Patients identified in the ED had higher odds of initiating treatment than those identified in PC (adjusted odds ratio [aOR] = 1.89, 95% confidence interval [CI] = 1.73-2.07), with no difference in engagement between the settings. Among those identified in the ED, compared with patients aged 18-29, older patients had higher odds of treatment initiation (age 30-49: aOR = 1.25, 95% CI = 1.12-1.40; age 50-64: aOR = 1.42, 95% CI = 1.26-1.60; age 65+: aOR = 1.27, 95% CI = 1.08-1.49). However, among those identified in PC, compared with patients aged 18-29, older patients were less likely to initiate (age 30-49: aOR = 0.81, 95% CI = 0.71-0.94; age 50-64: aOR = 0.68, 95% CI = 0.58-0.78; age 65+: aOR = 0.47, 95% CI = 0.40-0.56). Women identified in ED had lower odds of initiating treatment (aOR = 0.80, 95% CI = 0.72-0.88), whereas sex was not associated with treatment initiation in PC. In both settings, patients aged 65+ had lower odds of engaging compared with patients aged 18-29 (ED: aOR = 0.61, 95% CI = 0.38-0.98; PC: aOR = 0.42, 95% CI = 0.26-0.68). Conclusion: Initiation and engagement in treatment differed by sex and age depending on identification setting. This information could inform tailoring of future AOD interventions.

Psychiatric comorbidity and Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and other drug treatment initiation and engagement across 7 health care systems

Background: Psychiatric comorbidity is common among patients with alcohol and other drug (AOD) use disorders. To better understand how psychiatric comorbidity influences AOD treatment access in health care systems, the present study examined treatment initiation and engagement among a large, diverse sample of patients with comorbid psychiatric and AOD use disorders. Methods: This study utilized data from a multisite observational study examining Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement in treatment (IET) among patients with AOD use disorders from 7 health care systems. Participants were aged 18 or older with at least 1 AOD index diagnosis between October 1, 2014, and August 15, 2015. Data elements extracted from electronic health records and insurance claims data included patient demographic characteristics, ICD-9 (International Classification of Diseases, Ninth Revision) diagnostic codes, and procedure codes. Descriptive analyses and multivariate logistic regression models were used to examine the relationship between patient-level factors and IET measures. Results: Across health care systems, out of a total of 86,565 patients who had at least 1 AOD index diagnosis during the study period, 66.2% (n = 57,335) patients also had a comorbid psychiatric disorder. Among patients with a comorbid psychiatric disorder, 34.9% (n = 19,998) initiated AOD treatment, and of those, 10.3% (n = 2,060) engaged in treatment. After adjusting for age, sex, and race/ethnicity, patients with comorbid psychiatric disorders were more likely to initiate (odds ratio [OR] = 3.20, 95% confidence interval [CI] = 3.08, 3.32) but no more likely to engage (OR = 0.56, 95% CI = 0.51, 0.61) in AOD treatment, compared with those without a comorbid psychiatric disorder. Conclusions: Findings suggest that identification of comorbid psychiatric disorders may increase initiation in AOD treatment. However, innovative efforts are needed to enhance treatment engagement both generally and especially for individuals without diagnosed psychiatric conditions.

Factors associated with Healthcare Effectiveness Data and Information Set (HEDIS) alcohol and other drug measure performance in 2014-2015

Background: Only 10% of patients with alcohol and other drug (AOD) disorders receive treatment. The AOD Initiation and Engagement in Treatment (AOD-IET) measure was added to the national Healthcare Effectiveness Data and Information Set (HEDIS) to improve access to care. This study identifies factors related to improving AOD-IET rates. Methods: We include data from 7 health systems with differing geographic, patient demographic, and organizational characteristics; all used a common Virtual Data Warehouse containing electronic health records and insurance claims data. Multilevel logistic regression models examined AOD-IET among adults (18+). Results: A total of 86,565 patients had an AOD diagnosis qualifying for the HEDIS denominator. The overall initiation rate was 27.9% with wide variation; the overall engagement rate was 11.5% and varied from 4.5% to 17.9%. Women versus men (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.76-0.86); Hispanics (OR = 0.85, 95% CI = 0.79-0.91), black/African Americans (OR = 0.82, 95% CI = 0.75-0.90), and Asian Americans (OR = 0.83, 95% CI = 0.72-0.95) versus whites; and patients aged 65+ versus 18-29 (OR = 0.82, 95% CI = 0.74-0.90) had lower odds of initiation. Patients aged 30-49 versus 18-29 (OR = 1.11, 95% CI = 1.04-1.19) and those with prior psychiatric (OR = 1.26, 95% CI = 1.18-1.35) and medical (OR = 1.18, 95% CI = 1.10-1.26) conditions had higher odds of initiation. Identification in primary care versus other departments was related to lower odds of initiation (emergency department [ED]: OR = 1.55, 95% CI = 1.45-1.66; psychiatry/AOD treatment: OR = 3.58, 95% CI = 3.33-3.84; other outpatient: OR = 1.19, 95% CI = 1.06-1.32). Patients aged 30-49 versus 18-29 had higher odds of engagement (OR = 1.26, 95% CI = 1.10-1.43). Patients aged 65+ versus 18-29 (OR = 0.51, 95% CI = 0.43-0.62) and black/African Americans versus whites (OR = 0.64, 95% CI = 0.53-0.77) had lower odds. Those initiating treatment in psychiatry/AOD treatment versus primary care (OR = 7.02, 95% CI = 5.93-8.31) had higher odds of engagement; those in inpatient (OR = 0.40, 95% CI = 0.32-0.50) or other outpatient (OR = 0.73, 95% CI = 0.59-0.91) settings had lower odds. Discussion: Rates of initiation and engagement varied but were low. Findings identified age, race/ethnicity, co-occurring conditions, and department of identification as key factors associated with AOD-IET. Focusing on these could help programs develop interventions that facilitate AOD-IET for those less likely to receive care.

Women receiving specialized treatment for psychoactive substance use: a cohort study

OBJECTIVE

To verify the association between the profile of women who seek specialized treatment for the use of psychoactive substances, their treatment adherence time and the types of substance used.

METHOD

A retrospective cohort with data from medical records of women who sought care at a referral service for the use of psychoactive substances.

RESULTS

The final sample consisted of 411 medical records. A significant association was observed between unemployment (p<0.000), living in the streets/homeless shelters (p=0.003), having HIV/AIDS (p=0.004) and the type of substance used. The best predictors for the treatment adherence time were being a cocaine and crack user (OR=0.22), having family members who use illegal substances (OR=0.36) and reporting suicidal ideation (OR=2.7).

CONCLUSION

The sociodemographic and epidemiological factors of the women in this study are associated with the use of psychoactive substances. The therapeutic strategies developed for this group should take into account the risk stratification, seeking comprehensive and individualized care. Persistent approaches to include family members in the treatment, especially of those who present problems related to the use of psychoactive substances should be considered.

Can We Predict Which Adolescents Will Engage in Outpatient Substance Abuse Treatment?

Understanding which adolescents remain in substance abuse treatment may facilitate the development of effective strategies for enhancing engagement and retention. Using clinical service data from a large naturalistic sample of adolescents, we examined whether client characteristics predict retention in outpatient alcohol and other drug (AOD) treatment. χ² tests and multinomial logistic regressions were conducted to examine relationships between sociodemographic and substance use variables and clinic attendance. Client characteristics of ethnicity, sex, age, living situation (whether living with or away from family), and substance use severity were associated with retention in community AOD treatment. Pacific Island youth, females, 13- to 15-year olds, clients living with family, and clients with more severe substance use were generally more likely to be “engaged” with the service (ie, attended 4+ sessions) than their European and Maori, male, 16- to 19-year-old, and living away from home counterparts. These findings may inform more targeted engagement strategies in the future.

Legacy Interventions With Patients with Co-Occurring Disorders: Legacy Definitions, Life Satisfaction, and Self-Efficacy

BACKGROUND

Individuals with co-occurring disorders tend to avoid interaction with others. To instill hope, legacy intervention aims to highlight past experiences while managing life stressors for a positive outlook. Participants take part in legacy activities-crafting tangible projects and recording one's life events-in order to actualize a personal sense of legacy.

OBJECTIVES

This pre-posttest research tested whether legacy intervention in a partial hospital program (PHP) on reframing past experiences through creative activities could increase life satisfaction and self-efficacy among adults with co-occurring substance misuse and mental health symptoms.

METHOD

Eighty consented patients with co-occurring disorders were randomly assigned to two groups with 62 participants continuing: 37 in legacy intervention (LI) and 25 in partial hospital program only (PHP-only). LI participants were engaged in both PHP and legacy activities. Ten group sessions were held over the course of five weeks for cohorts of 10-15 adult patients in each intervention. Sense of legacy was measured to ensure that LI patients received the appropriate legacy dosage.

RESULTS

With RANOVA analyses between and among three time points, life satisfaction was significantly higher in the LI group with group interaction effect over time. In terms of self-efficacy, both groups showed positive changes but no significant difference could be found between the two groups over time and the interaction (time X group) effect was not significant.

IMPORTANCE

The legacy definitions gathered from the LI group were consistent with existing literature and showed three additional themes: children's involvement, concreteness, and life continuation after death.

Factors associated with attrition in substance using patients enrolled in an intensive outpatient program

BACKGROUND AND OBJECTIVES

Data suggest individuals with substance use disorders (SUD) have high rates of attrition from treatment and exhibit impairments on measures of executive functioning (EF). The primary aim of this pilot study was to investigate if EF is associated with attrition from a 1 month intensive outpatient program (IOP) for SUD, and examine the feasibility of implementing the project.

METHODS

Baseline neurocognitive functioning was assessed by the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the self-reported Behavior Rating Inventory of Executive Functioning (BRIEF-A) questionnaire.

RESULTS

Thirty subjects enrolled in the pilot study: including 20 "completers" (age 39.5 ± 13.1 years) and 10 "drop-outs" who discontinued the IOP prior to completion (age 32 ± 11.1 years). IOP drop-out was associated with earlier age of substance use onset (all p-values <0.05) and male gender, as well as greater SUD, opiate use, and past week substance use. Overall a high level of executive dysfunction was found on the BRIEF-A and CANTAB assessments, and specific differences emerged between completers and drop outs. However, no statistically significant differences were found between these groups on measures of depression, anxiety, or ADHD.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Overall, findings from this pilot study suggest high levels of self-reported executive dysfunction, but EF's predictive association with drop-out was limited. Measures of addiction severity were more strongly associated with attrition, suggesting potential utility of brief motivational interventions prior to commencing an IOP may improve retention. Further investigations with larger and more diverse samples are warranted. (Am J Addict 2017;26:780-787).

The association of psychiatric comorbidity with treatment completion among clients admitted to substance use treatment programs in a U.S. national sample

BACKGROUND

Psychiatric disorders are highly comorbid with substance use disorders and play an important role in their course and recovery. However, the impact of comorbidity on treatment outcomes has not been examined in a U.S. national sample. This study explores the impact of psychiatric comorbidity on treatment completion among individuals admitted to publicly funded substance use treatment facilities across the United States.

METHODS

Using data on first-time treatment episodes in the U.S. from the Treatment Episode Dataset-Discharges (TEDS-D) for the years 2009-2011, logistic regression was used to assess the association between psychiatric comorbidity and treatment non-completion, and Cox proportional hazards regression was used to assess the association between comorbidity and rate of attrition. Analyses were performed for all substances together and then stratified by primary substance of abuse (alcohol, cannabis, stimulants, or opioids).

RESULTS

Of 856,385 client treatment episodes included in our analysis, 28% had a psychiatric comorbidity and 38% did not complete treatment. After adjusting for socio-demographic and treatment characteristics, clients with psychiatric comorbidity had higher odds of not completing treatment relative to those without comorbidity [OR=1.28 (1.27-1.29)], and had an earlier time to attrition [HR=1.14 (1.13-1.15)]. Psychiatric comorbidity was most strongly associated with treatment non-completion and rate of attrition in those admitted primarily for alcohol [OR=1.37 (1.34-1.39); HR=1.19 (1.17-1.21), respectively].

CONCLUSIONS

Individuals with psychiatric comorbidities receiving treatment for substance use disorders face unique challenges that impact their ability to complete treatment. The findings call for further efforts to integrate treatment for psychiatric comorbidities in substance use treatment settings.

Does change in readiness influence retention among African American women and men in substance abuse treatment?

African Americans are less likely than other racial groups to engage in and complete outpatient substance abuse treatment. The current study, conducted as a secondary analysis of a multisite randomized clinical trial, examined whether readiness to change (RTC) over time influences retention and whether gender moderates the relationship between changes in RTC and retention among 194 African American women and men. Participants completed the University of Rhode Island Change Assessment at baseline and at the end of the 16-week study. Findings revealed a significant relationship between RTC over time and retention. Specifically, the more RTC increased throughout the 16-week study, the longer participants remained in treatment. In addition, gender moderated the relationship between changes in RTC and retention, with a stronger association between changes in RTC and retention among men relative to women. One approach to improving substance abuse treatment retention rates is to focus on increasing RTC during treatment, especially among African American men.

Length of stay as a predictor of reliable change in psychological recovery and well being following residential substance abuse treatment

Purpose

Longer length of stay (LOS) in residential alcohol and other drug treatment has been associated with more favourable outcomes, but the optimal duration has yet to be determined for reliable change indices. Optimal durations are likely to be a function of participant and problem characteristics. The purpose of this paper is to determine whether LOS in a residential therapeutic community for alcohol and other drug treatment community independently predicts reliable change across a range of psychological recovery and well-being measures.

Design/methodology/approach

In total, 380 clients from Australian Salvation Army residential alcohol and other drug treatment facilities were assessed at intake and three months post-discharge using the Addiction Severity Index 5th ed., The Depression, Anxiety and Stress Scale, The Recovery Assessment Scale, the Mental Health Continuum-Short Form and The Life Engagement Test.

Findings

The findings confirm LOS as an independent predictor of reliable change on measures of well-being and client perceived assessment of recovery. The mean LOS that differentiated reliable change from no improvement was 37.37 days.

Originality/value

The finding of LOS as a predictor of reliable change and the identification of an estimated time requirement may be useful for residential drug treatment providers in modifying treatment durations.

Co-Occurring Disorders: A Challenge for Mexican Community-Based Residential Care Facilities for Substance Use

OBJECTIVE

In Mexico, specialized treatment services for people with co-occurring disorders are limited within public health services, while private options are deemed too costly. More than 2,000 community-based residential care facilities have risen as an alternative and are the main source of treatment for individuals with substance use disorders; however, suboptimal practices within such facilities are common. Information on the clinical characteristics of patients receiving care in these facilities is scarce and capacity to provide high-quality care for co-occurring disorders is unknown. The aims of this study were to examine the prevalence of co-occurring disorders in patients receiving treatment for substance use in these community-based residential centers and to assess whether the presence of co-occurring disorders is associated with higher severity of substance use, psychiatric symptomatology, and other health risks.

METHODS

This study was conducted with 601 patients receiving treatment for substance use disorders at 30 facilities located in five Mexican states, recruited in 2013 and 2014. Patients were assessed with self-report measures on substance use, service utilization, suicidality, HIV risk behaviors, psychiatric symptomatology, and psychiatric disorder diagnostic criteria.

RESULTS

The prevalence of any co-occurring disorder in this sample was 62.6%. Antisocial personality disorder was the most prevalent (43.8%), followed by major depressive disorder (30.9%). The presence of a co-occurring disorder was associated with higher severity of psychiatric symptoms (aB = .496, SE = .050, p < .05); more days of substance use (aB = .219, SE = .019, p < .05); current suicidal ideation (aOR = 5.07, 95% CI [2.58, 11.17]; p < .05), plans (aOR = 5.17 95% CI [2.44, 12.73]; p < .05), and attempts (aOR = 6.43 95% CI [1.83, 40.78]; p < .05); more sexual risk behaviors; and more contact with professional services (aOR = 1.77, 95% CI [1.26, 2.49], p < .05).

CONCLUSIONS

Co-occurring disorders are highly prevalent in community-based residential centers in Mexico and are associated with significantly increased probability of other health risks. This highlights the need to develop care standards for this population and the importance of clinical research in these settings.