Implementing opioid overdose education and naloxone distribution in an outpatient community treatment program

Substance use disorders (SUDs) are a major epidemic in the USA. Patients who lack transportation may have limited access to outpatient SUD treatment programs and are less likely to remain in care. Encouraging the use of free, reliable transportation during enrollment is an untested mechanism for greater retention. A pragmatic pilot study was conducted in Southwest Ohio between November 2020 and July 2022, among people with SUDs like opioid and alcohol use disorders who enrolled in an outpatient treatment program and screened positive for transportation barriers. Eligible patients were offered free, unlimited transportation for the first 12 weeks of treatment and randomized 1:1 to receive weekly text message reminders to schedule their ride (intervention) versus none (control). The primary outcome was retention in care at 12 weeks. Secondary outcomes included retention at 24 weeks and retention at weeks 12 and 24 when stratifying by those dispensed SUD medications (e.g., buprenorphine/naloxone, buprenorphine, methadone) at the treatment site versus not, and SUD type. The intervention arm included 171 patients and 190 patients were in the control arm. For retention in care at 12 weeks, there was not a statistically significant difference between intervention (77/171 = 45.0%) and control (81/190 = 42.6%) arms (odds ratio (OR) 1.10; 95% confidence interval (CI) 0.57 to 2.00, p=0.69). At 24 weeks, retention was lower for both the intervention (44/171 = 25.7%) and control (54/190 = 28.4%) arms but not statistically significantly different (p=0.54). Greater retention at 12 weeks was observed for the intervention versus the control arm among patients dispensed SUD medications but at week 24 there was no statistically significant difference. No differences were observed by SUD types at any time point. Weekly reminders did not affect overall care retention but did at week 12 among patients dispensed SUD medications.

This study examined the potential differential benefits for patients with co-occurring psychiatric and substance use disorders (SUDs) entering treatment at one of three types of treatment programs: dual-diagnosis, SUD, and psychiatric treatment programs. This quasiexperimental study compared 6-month substance use and psychiatric symptom outcomes of 257 adults with co-occurring substance use and psychiatric disorders who had sought treatment at one of four outpatient treatment programs that used group treatment as the main treatment modality: a dual diagnosis, a psychiatric, or one of two SUD treatment programs. At treatment initiation, patients received a structured diagnostic interview and a survey assessing SUD and psychiatric symptoms; the survey was readministered 6 months later. Multiple and logistic regression analyses examined patient SUD and psychiatric outcome indicators to compare potential benefits of initiating treatment at a dual-diagnosis treatment program. At treatment entry, patients who e...

Background Benzodiazepines are widely prescribed, yet their long-term use among patients with substance-use disorders (SUDs) remains poorly understood. This study examined benzodiazepines in a substance use treatment program. Objectives This study aims to describe prescribing patterns, tapering and discontinuation characteristics, and return to use rates in SUD patients receiving benzodiazepines in a community-based outpatient substance use treatment program. Methods In this single-site, retrospective chart review study, electronic health records of 51 patients, prescribed benzodiazepines between FY 2014–2024, in a community-based outpatient substance use treatment program were analyzed. Demographics, psychiatric and SUD diagnoses, benzodiazepine half-life, dose, taper duration, discontinuation status, and return to use were examined descriptively. Results Intermediate-acting BZDs were the most commonly prescribed (68.6%), with limited attempts to switch to longer-acting agents. BZD prescriptions were discontinued in only 25.4% of cases, and 38.4% of those who discontinued returned to use. Patients who successfully tapered had longer down-titration durations compared to those who returned to use. (5.4 months vs. 2.2 months in return to use cases). Among patients with benzodiazepine use disorder, return to use occurred in 50.0% of those who discontinued. The patient population demonstrated notably high rates of psychiatric comorbidities and previous psychiatric hospitalizations. Conclusions In patients with SUDs, benzodiazepine discontinuation is uncommon and frequently followed by return to use. Brief tapers show little benefit. Our data support that successful BZD tapering may require prolonged, structured tapering within integrated mental-health and substance use care to minimize return to use.

Spatial accessibility of substance use disorder (SUD) treatment is a crucial component of access and a comprehensive analysis can help to identify if and where a lack of spatial accessibility is a barrier to treatment. We conducted a cross-sectional analysis of spatial accessibility of SUD treatment (outpatient, opioid treatment program, and residential) in New York State (NYS). We estimated two measures of spatial accessibility: one-way travel time (i.e., drive time for NYS outside of New York City [NYC] and public transit time for NYC) and robustness (i.e., the difference in travel time between the closest and fifth closest facility). Comparison facilities included Federally Qualified Health Centers, dialysis facilities, and hospitals. We compared travel time and robustness by urbanicity (NYC, urban non-NYC, rural) and NYS economic development region using population-weighted paired t-tests. The percentage of NYS residents within 30min travel time was 97.2% for outpatient SUD treatment programs and 82.3% for opioid treatment programs. Mean statewide travel time to outpatient SUD treatment programs was comparable to travel time to Federally Qualified Health Centers (difference: 1.0min [95%CI 0.9 to 1.1; P < 0.001]) and dialysis facilities (difference: 0.1min [95%CI 0.03 to 0.2; P = 0.01]), and significantly shorter than to hospitals (difference: 5.6min [95%CI 5.4 to 5.7; P < 0.001]). Travel time to opioid treatment programs was significantly longer than to Federally Qualified Health Centers (difference: -7.4min [95%CI -7.6 to -7.2; P < 0.001]), dialysis facilities (difference: -8.2min [95%CI -8.4 to -8.1; P < 0.001]), and hospitals (difference: -2.8min [95%CI -3.0 to -2.6; P < 0.001]). Compared with NYC, mean travel time to each type of SUD treatment program was significantly shorter in urban non-NYC areas and longer in rural areas. For robustness, compared with NYC, there was no significant difference in urban non-NYC areas for outpatient and residential SUD treatment programs, but more limited robustness for opioid treatment programs in urban non-NYC areas and all types of SUD treatment programs in rural areas. We identified widespread spatial accessibility of SUD treatment facilities across NYS. Recent opportunities such as revised federal regulations on opioid treatment program mobile medication units, increased flexibility in using telehealth in opioid treatment programs and other settings, and opioid settlement funding can be leveraged to increase access in rural areas.

Objective A history of childhood abuse and neglect (CAN) is significantly associated with psychopathologies in adulthood, including comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Difficulties in emotion regulation (ER) might influence the association between CAN and PTSD. The aim of this study was to examine the relationship between CAN and PTSD symptom severity in women with SUD and to investigate the mediating role of general difficulties in ER and its specific dimensions. Method: We examined 320 women, with a current diagnosis of at least subsyndromal PTSD and SUD, using self-report measures of CAN, PTSD symptom severity, and ER difficulties. We conducted both simple and multiple bootstrapping-enhanced mediation analysis to investigate whether general difficulties in ER and its specific dimensions mediate the relationship between CAN and PTSD symptom severity. Results: General difficulties in ER mediated the association between CAN and PTSD symptom severity. CAN significantly predicted adult PTSD symptom severity, directly and indirectly, through ER difficulties. Difficulties engaging in goal directed behavior when distressed was the only ER dimension, which mediated the effect of CAN on PTSD symptoms. Conclusions: Our results suggest that difficulties in ER and specifically difficulties engaging in goal directed behavior when distressed might constitute an influential factor in the relationship between CAN and PTSD symptom severity in a sample of SUD patients, and highlight the importance of targeting ER as a potential treatment focus for patients with comorbid PTSD and SUD.

Background: Psychotherapeutic interventions aimed at treating posttraumatic stress disorder (PTSD) in adolescents and young adults are hampered by high dropout rates. Looking at the results from adult treatments, short, intensive, outpatient treatment programmes may offer a promising alternative, but it has yet to be tested in this young population. Objective: To assess the results of a six-day intensive outpatient trauma-focused treatment programme for young individuals (12-25 years) with PTSD. The treatment combined prolonged exposure and EMDR therapy, supplemented with physical activity and the participation of relatives and/or friends. Treatment was performed by a rotating team of therapists. Methods: Seventy-four adolescents and young adults (89% women, mean age = 18.6 years, 36 patients aged 12–17 and 38 patients aged 18-25; SD = 3.1) with PTSD and a minimum of four memories of A-criterion traumatic events participated in the programme. PTSD symptoms, depressive symptoms, and the perceived burden of trauma symptoms were assessed before treatment, at the start and one month after treatment. Results: Patients showed a significant reduction in PTSD symptoms from pre-treatment to one month after treatment (Cohen’s d = 1.66). Of all patients, 52 (70%) showed a clinically meaningful response, and 48 (65%) no longer met the diagnostic criteria for PTSD one month after treatment. Depressive symptoms also decreased significantly (Cohen’s d = 1.02). The dropout rate was 4% (N = 3). None of the patients experienced an adverse event or worsening of symptoms. Conclusions: Results suggest that a short, intensive, outpatient therapy programme combining prolonged exposure, EMDR therapy, physical activity, and participation of relatives and friends, is well-tolerated, and an effective and safe treatment alternative for adolescents and young adults with PTSD due to multiple traumatization.

Hurt people who hurt people: Violence amongst individuals with comorbid substance use disorder and post traumatic stress disorder

Background: Research has demonstrated a strong link between trauma, posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) in general and cannabis use disorders in particular. Yet, few studies have examined the impact of cannabis use on treatment outcomes for individuals with co-occurring PTSD and SUDs. Methods: Participants were 136 individuals who received cognitive-behavioral therapies for co-occurring PTSD and SUD. Multivariate regressions were utilized to examine the associations between baseline cannabis use and end-of-treatment outcomes. Multilevel linear growth models were fit to the data to examine the cross-lagged associations between weekly cannabis use and weekly PTSD symptom severity and primary substance use during treatment. Results: There were no significant positive nor negative associations between baseline cannabis use and end-of-treatment PTSD symptom severity and days of primary substance use. Cross-lagged models revealed that as cannabis use increased, subsequent primary substance use decreased and vice versa. Moreover, results revealed a crossover lagged effect, whereby higher cannabis use was associated with greater PTSD symptom severity early in treatment, but lower weekly PTSD symptom severity later in treatment. Conclusion: Cannabis use was not associated with adverse outcomes in end-of-treatment PTSD and primary substance use, suggesting independent pathways of change. The theoretical and clinical implications of the reciprocal associations between weekly cannabis use and subsequent PTSD and primary substance use symptoms during treatment are discussed.

The purpose of this study was to examine the availability of outpatient substance use disorder (SUD) treatment programs in the United States. A geographic information system (GIS) was used to spatially locate outpatient SUD treatment programs, calculate areas, and determine population density within specific areas. Urban areas were mapped using data from the US Census (2000). Addresses of outpatient SUD treatment programs were obtained from the Facility Locator Web site of the Substance Abuse and Mental Health Services Administration. A 15-mile service catchment around each outpatient SUD treatment program was drawn. The amount of urban area not covered by the service catchment represents the underserved. Total underserved urban area and population without access was computed for each state. Significant variability of underserved urban area and population was observed across the states. Moderate correlations among area and population suggest that some states are more effective in locating SUD treatment programs than other states.

This paper examines factors associated with change in PTSD symptom severity among individuals randomised to receive an integrated exposure-based psychotherapy for PTSD and substance dependence–Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Outcomes examined include change in PTSD symptom severity as measured by the Clinician Administered PTSD Scale (CAPS), and the reliability and clinical significance of change in PTSD symptom severity. Factors examined include patient baseline characteristics, treatment characteristics, and events over follow-up. The mean difference in CAPS score was 38.24 (SE 4.81). Approximately half (49.1%) demonstrated a reliable and clinically significant improvement in PTSD symptom severity. No one was classified as having demonstrated clinically significant worsening of symptoms. Three independent predictors of reductions in PTSD symptom severity were identified: baseline PTSD symptom severity (β 0.77, SE 0.23, p = 0.001), number of traumas experienced prior to baseline (β −0.30, SE 0.15, p = 0.049), and number of sessions attended (β 2.05, SE 0.87, p = 0.024). The present study provides further evidence regarding the safety of the COPE treatment and factors associated with improvement in PTSD symptom severity. The identification of only a small number of predictors of the outcome points to the broad applicability of the COPE treatment to PTSD and substance use disorder (SUD) patients.

Dissociation and under-regulation of affect in patients with posttraumatic stress disorder with and without a co-morbid substance use disorder

The study compared services received in substance abuse treatment programs by women who reported involvement in prostitution and by those who did not. Women (N=1,604) in a national study of substance abuse programs completed a structured interview assessing substance abuse, demographic characteristics, and past-year prostitution at program entry. At discharge, information was gathered on treatment modality (residential including inpatient, or outpatient), duration, and amounts of medical, mental health, and psychosocial services received during treatment. Analyses compared women involved in prostitution and those not involved. Women involved in prostitution were more likely to enter residential treatment. No differences between involvement groups were found in residential treatment duration, services received in residential treatment, or length of outpatient enrollment. In outpatient programs, women involved in prostitution received more psychosocial services. Substance abuse treatment programs appear responsive to the greater needs of women involved in prostitution. However, more research is needed on outcomes.

To advance understanding of the effectiveness of evidence-based treatments for comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD), research must provide a more nuanced picture of how substance use affects change in PTSD symptoms over the course of treatments and whether prolonged exposure techniques can be efficacious during active substance use. A data set that included patients with PTSD/subthreshold-PTSD and SUD treated with an exposure-based intervention provided an opportunity to conduct a secondary analysis to test how patients' substance use impacted PTSD change over treatment. We applied growth models to week-to-week PTSD symptom and substance use changes during treatment and follow-up of a randomized controlled trial of two cognitive-behavioral treatments for PTSD and SUD: Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE) and Relapse Prevention Therapy (RPT). Cross-lagged analyses were used to determine whether prior week substance use impacted subsequent PTSD symptom severity. Both treatments evidenced significant reductions in PTSD symptom severity. In the context of continued substance use, results suggest that individuals still benefit from exposure-based treatment. Results provide evidence that RPT and COPE both led to significant reductions in PTSD, providing further support that exposure-based techniques tailored for SUD can be conducted without jeopardizing PTSD or SUD outcomes. Implications for clinical decision making around treatment selection are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) commonly cooccur following trauma, and their co-occurrence is associated with substantial costs; however, our understanding of the timing and sequencing of these posttrauma mental health conditions is limited. This study examined the trajectories of PTSD symptom severity and substance use among individuals recently exposed to a traumatic event, with a focus on the potential moderating roles of PTSD and SUD diagnoses at the final assessment. Additionally, in attempt to better understand the functional relationship between PTSD symptoms and substance use posttrauma, this study compared models reflecting the theories of self-medication, susceptibility, and mutual maintenance. Participants included 137 individuals who had experienced a traumatic event within 6 months prior to study enrollment. Participants completed four assessments over an approximate 1-year period that included clinician-administered measures for DSM-5 PTSD symptoms and SUD diagnosis and self-report measures of alcohol and drug use. Change over time in PTSD symptoms and substance use by diagnostic status were investigated using growth curve models. Temporal sequencing between PTSD symptom severity and substance use was investigated with bivariate latent difference score structural equation modeling. In line with the conceptualization of PTSD as a disorder of impeded recovery, having a diagnosis of PTSD at the final assessment moderated the trajectory of PTSD symptom severity such that symptom severity declined only among those without PTSD. In contrast, the influence of SUD appeared to be negligible. Both PTSD and SUD diagnoses were associated with initial drug use frequency. However, the relationship between alcohol use and diagnostic status did not reach statistical significance. Regarding temporal relationships between PTSD symptoms and substance use, significant and negative PTSD to change in substance use cross-lagged paths were found across most of the models, while only one significant substance use to change in PTSD severity crosslagged path emerged in the PTSD intrusion with alcohol use model. These results add to a growing body of research suggesting trauma-focused intervention is viable for individuals with PTSD/SUD. Further, examination of potential mediators and moderators of the relation between PTSD and SUD is recommended as a critical focus for future research.

To determine the relations between obstructive sleep apnea (OSA) diagnosis, the likelihood of being diagnosed with a psychological condition, among obese veterans, after accounting for severity of obesity and the correlated nature of patients within facility. We hypothesized that (1) individuals with a diagnosis of OSA would be more likely to receive a diagnosis of a (a) mood disorder and (b) anxiety disorder, but not (c) substance use disorder. Cross-sectional retrospective database review of outpatient medical records between October 2009 and September 2010, conducted across all 140 Veterans Health Administration (VHA) facilities. The entire VA Health Care System. Population-based sample of veterans with obesity (N = 2,485,658). Physician- or psychologist-determined diagnosis of psychological conditions including mood, anxiety, and substance use disorders. Using generalized linear mixed modeling, after accounting for the correlated nature of patients within facility and the severity of obesity, individuals with a diagnosis of sleep apnea had increased odds of receiving a mood disorder diagnosis (OR = 1.85; CI = 1.71-1.72; p < 0.001), anxiety disorder diagnosis (OR = 1.82; CI = 1.77-1.84; p < 0.001), but not a diagnosis of substance use disorder. Among obese veterans within VA, OSA is associated with increased risk for having a mood and anxiety disorder, but not substance use disorder, with the strongest associations observed for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). In addition, this relation remained after accounting for severity of BMI.