Addiction Professionals Research Articles

Specific versus relational factors in addiction treatment: the forest and the trees, or just more trees?

Miller & Moyers’ paper, ‘The Forest and the Trees: Relational and Specific Factors in Addiction Treatment’, argues that, currently, a focus on the ‘trees’ (specific factors, i.e. specific treatment content) acts to the detriment of examining the ‘forest’ (relational factors, i.e. the larger interpersonal context in which treatment is delivered) 1. The title chosen by the authors evokes the proverbial challenge of not being able to see the forest for the trees, but the authors suggest some additions to existing methodology that would enable researchers to look at both types of variable. In particular, they make the case for specifying and studying these ‘non-specific’ or relational factors. However, from an alternative perspective, specifying ‘non-specific’ factors in the way that Miller & Moyers suggest may actually be creating more trees, instead of enabling a ‘forest’ view. Factors such as therapist interpersonal skills and treatment fidelity, which the authors highlight as modifiable relational factors, have, to date, been targeted through a mechanism very similar to that used for ‘specific content’, e.g. through therapist training [2-4]. In other words, as soon the non-specific factors are specified and practitioners trained accordingly, they can be treated in the same way as specific factors, hence becoming more ‘trees’. Miller & Moyers conclude: ‘as relational influences on outcome come to be better understood, they can be specified, measured, implemented in treatment, tested, and incorporated into the training of the next generation of addiction professionals’. Would this require a fundamental shift in research methods? Arguably not. Observational analyses in existing clinical trials could be used to generate hypotheses regarding these relational factors. Once identified, presumably the next step would be their implementation in treatment, testing via trials, and then incorporation in meta-analyses. However, Miller & Moyers argue that: ‘aggregation of findings—whether across participants in a study, sites within a multisite trial, or trials within a meta-analysis—masks variability in outcomes that may hold important clues to underlying mechanisms’. Such a statement risks painting a false dichotomy between aggregated findings and the investigation of relational factors. In meta-analyses some variation will always exist, whether due to chance or to differences in trial context or content 5, 6. On its own, variance in a meta-analysis does not de-legitimize that meta-analysis, nor does it necessarily mask key causes of variation. Indeed, once these relational factors are specified, measured and tested in the same way in which specific factors are currently dealt with, meta-analyses of the trials of these new tests would still be subject to variation in outcome due to remaining unspecified factors. Miller & Moyers are right to point out that, in focusing exclusively on specific factors related to treatment content, research into addiction treatments may be overlooking important relational factors and their associated effects. However, in acknowledging genuine and measurable causes of variation—more trees, arguably—it is important that a true forest view is not obscured. Using existing methodology, findings can be aggregated without masking the impact of underlying mechanisms, as long as these potential mechanisms are identified in advance. Relational factors that can be measured empirically and in which therapists can be trained can be tested in randomized controlled trials, as has recently been done with empathy in the context of physician training 7, 8. Such trials could then be aggregated in meta-analyses. Even where not tested directly, the contribution of these relational factors could be examined in systematic reviews through meta-regression, as has already been performed with specific factors 9, 10. The trees and the forest can both be taken into account, but it is important not to lose sight of which is which. None. J.H.-B. receives funding from the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views expressed in this research are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.

Two Addiction Professionals Review of “Molecular Neurobiology of Addiction Recovery: The 12 Steps Program and Fellowship”

Two Addiction Professionals Review of “Molecular Neurobiology of Addiction Recovery: The 12 Steps Program and Fellowship”

Validation of the French Version of the Marijuana Craving Questionnaire (MCQ) Generates a Two-Factor Model

Background: Craving is a major issue in drug addiction, and a target for drug treatment. The Marijuana Craving Questionnaire-Short Form (MCQ-SF) is a useful tool for assessing cannabis craving in clinical and research settings. Objective: To validate the French version of the MCQ-SF (FMCQ-SF). Methods: Young adult cannabis users not seeking treatment (n = 679) completed the FMCQ-SF and questionnaires assessing their frequency of cannabis use and craving, cannabis use disorder criteria, and alcohol use. Results: Confirmatory factor analysis of the four-factor FMCQ-SF model did not fit the data well. Exploratory factor analysis suggested a two-factor solution (“pleasure”, characterized by planning and expectation of positive effects, and “release of tension”, characterized by relief from anxiety, nervousness, or tension) with good psychometric properties. This two-factor model showed good internal and convergent validity and correlated with cannabis abuse and dependence and with frequency of cannabis use and craving. Conclusion: Validation of the FMCQ-SF generated a two-factor model, different from the four-factor solution generated in English language studies. Considering that craving plays an important role in withdrawal and relapse, this questionnaire should be useful for French-language addiction professionals.

SY16-1 * CONSTRAINTS AND RESPONSES IN TREATMENT SERVICES FOR ALCOHOL USE DISORDERS IN THE U.K.

The UK has one of the most serious alcohol and addictions problems in Western Europe, but austerity has relatively curbed resources given to treatment. Media and political criticism, that substitute prescribing is costly, demeaning and asocial has been fuelled by headlines on diverted or leaked opiates and opiate-related deaths. Each region has developed a ‘Recovery’ agenda that emphasises (not always exclusively) abstinence. Recovery is found to be associated with social connectedness (particularly with ‘recovery communities’) and new meaning and purpose in life, where ‘giving’ rather than ‘taking’ is the new way of life. These claims are convincing, though are based on observation rather than experimental studies. Nevertheless, when therapists are trained in facilitating the linking of patients with the 12 step groups (AA and NA), randomised controlled trials have shown its effectiveness. But in the UK, addiction professionals are been found to be ignorant, even prejudiced, about the role of such (cost-free) mutual help groups. Medications (and medical staff) to aid recovery are widely regarded as expensive and, by some, as incompatible with ‘recovery’. The recovery movement implies that nudging patients into greater social activity provides a more lasting solution to the social anxiety and hopelessness so often accompanies addictions.

Barriers to Implementation of Treatment Guidelines for ADHD in Adults With Substance Use Disorder

Objective: Attention deficit hyperactivity disorder (ADHD) is common among adult patients with a substance use disorder, yet often goes undetected. This is a qualitative study to explore implementation barriers to a guideline developed in Belgium for the recognition and treatment of ADHD in adult patients with substance use disorder and to gain a better understanding of the strategies to overcome these barriers.Methods: Focus groups were conducted with caregivers and patients to explore experiences with comorbid substance use disorder and ADHD. The barriers reported in these focus groups became the subject of further study in focus groups with addiction professionals (physicians, psychiatrists, and psychologists) who had tried the guideline and with psychiatrists specializing in addiction but without experience with ADHD.Results: Our analysis revealed a number of barriers to the implementation of this guideline, including lack of information from the family, pressure from patients and caregivers to make an ADHD diagnosis, and the potential for abuse of ADHD medication. Furthermore, diagnostic instruments for ADHD have not been validated in people with substance use disorder. Although patients with ADHD are usually treated in an outpatient setting, patients with ADHD comorbid with substance use disorder are difficult to identify in an outpatient setting for various reasons. Finally, there is a lack of specific ADHD expertise in substance use treatment organizations.Conclusions: Despite the availability of an approved guideline for recognizing and treating adult ADHD in patients with a substance use disorder, underdiagnosis and inadequate treatment still persist. As in general substance use treatment, medication only plays a supportive role in the treatment of substance use disorder with comorbid ADHD. An integrated approach and further improvements in the competence of practitioners may help to reduce the resistance to diagnosing ADHD in substance use treatment centers. Practitioners who specialize in addiction medicine and therapists without medical education view the problem from different perspectives and therefore each group needs specific information and training. Targeted interventions need to be developed to keep these patients in treatment.

Attitudes Toward Health-Seeking Behaviors of College Students in Ukraine

This study elicited multiple perspectives on attitudes towards help-seeking behaviors associated with mental health problems of college students in Ukraine. It employed a sequential mixed method design. First, focus groups were conducted with students and psychologists. These data were analyzed and used to develop a survey. The survey was subsequently administered to psychiatrists, the primary providers of services to people with psychiatric problems in Ukraine. Findings from the focus groups revealed four help-seeking behaviors: 1) friends and partners, (2) alcohol use, (3) family support, and (4) conventional and alternative mental health services. Students and psychiatrists differed in their beliefs about help-seeking behaviors. Although psychiatrists believed students sought help from mental health and/or addictions professionals, students reported using self-medication and social network support. Implications include a troubling gap in perceptions between the students impacted and the professional communities that should be serving them.

Training Addiction Professionals in Empirically Supported Treatments: Perspectives from the Treatment Community

ABSTRACT. Background: Large-scale dissemination efforts seek to expand opportunities for the addiction treatment community to receive training in empirically supported treatments (ESTs). Prospective consumers of such training are valuable sources of input about content of interest, preferences for how training events are structured, and obstacles that deter receipt of training. Methods: In this mixed-method study, data were collected in 64 semistructured individual interviews with personnel during site visits to 16 community opioid treatment programs (OTPs). At each OTP, interviews were completed with the executive director, a clinical supervisor, and 2 direct-service clinicians. Topical interests were analyzed qualitatively in a cultural domain analysis. Likert ratings of training event preferences were analyzed via generalized linear mixed models (GLMMs), and unstructured interviewee comments were analyzed via narrative analysis. Obstacles to training receipt were analyzed qualitatively with both content coding and narrative analysis. Results: Based on topics of reported interest, cultural domain analysis suggests as ESTs of note: Multidimensional Family Therapy, Motivational Enhancement Therapy, Relapse Prevention Therapy, “Seeking Safety,” and broad addiction-focused pharmacotherapy. Regarding training event preferences, GLMMs and narrative analysis revealed clear preferences for time-distributed trainings and use of participatory activities (e.g., trainer demonstrations, role plays, small group exercises). Content coding identified cost as the primary obstacle to receipt of EST trainings, followed by lack of time, logistical challenges, and disinterest, and narrative analysis elaborated on contextual issues underlying these obstacles. Conclusions: As primary consumers of EST technologies, the treatment community has valuable input to offer. Dissemination efforts may be enhanced by greater consideration of their preferences for training content and event structure, as well as practical obstacles that challenge their receipt of training.

A Pilot Study of Addiction Professionals’ Views of Certification

A Pilot Study of Addiction Professionals’ Views of Certification

Addiction science advocacy: Mobilizing political support to influence public policy

This paper proposes a new conceptualization of addiction work that makes public policy advocacy central to prevention, treatment, and recovery. The term “addiction science advocacy” is offered as a way to conceptualize what is needed in the addiction field to translate scientific findings into public policy and thereby reduce the harmful consequences of drug problems. Although there are a plethora of evidence based strategies to reduce and prevent harmful consequences associated with drug problems, interventions and their beneficial effects are often neglected, misunderstood, mischaracterized, and underutilized due to destructive social and political influences. This paper suggests that addiction practitioners, researchers, and educators have historically developed professional identities that are too narrow to effectively counteract forces that are destructive to a science based approach to addiction (e.g., moralization and criminalization). Addiction science advocacy rejects the contention that treatment and prevention should be politically neutral because that neutrality is increasingly used by others to ignore, dilute, and redefine important findings. There is therefore an urgent need for development of broader professional identities that emphasize influence of public policy as an integral component of one's work. This paper proposes strategies for addiction professionals to influence policies at national and local community levels.

Addiction: Why is it a disorder of choice and decision?

The financial and social costs of addiction are staggeringly high; countless clinical reports and memoirs document the personal pain and chaos caused by addicted family members. In response, many addiction professionals and much of the public conclude that addiction is a disease. No one, the argument goes, would cause so much harm to themselves and others voluntarily. Yet research tells a different story. Clinical, historical, and biographical evidence reveals that economic conditions, legal sanctions, and the opinions of others, particularly family members and loved ones, influence the course of drug use in addicts. In contrast these same factors have little influence on the symptoms of the diseases addiction is said to be like, such as Alzheimer's, heart disease, and cancer. In support of these points, NIH epidemiological research shows that addiction has the highest remission rate of any psychiatric disorder, that most of those addicted to illegal drugs quit by age 30, and they typically quit without professional assistance. Of course, not all addicts quit by age 30, and dependence on legal drugs has a longer time course. However, analysis reveals that these are not qualitatively different outcomes, so that the choice framework fits both legal and illegal drugs and those who quit and those who don't quit. Nevertheless addiction is a disorder, which implies that its cost outweigh its benefits, which, in turn, appears to contradict choice accounts. However, research-based choice principles, such as hyperbolic discounting and melioration, predict semi-stable choice sequences that are optimal in the short run but suboptimal in the long run. That is, choice theory predicts a pattern of drug binging, remission, relapse, and eventual resolution. These finding do not make addiction any less of a problem, but they point to the most effective way to deal with addiction. The immediate implication is to reward abstinence and penalize drug use. Although this is a simplistic formula, it has been put to effective use in a wide range of settings.

Caffeine and Substance Use Disorders

Caffeine and Substance Use Disorders

Caffeine Withdrawal and Dependence: A Convenience Survey Among Addiction Professionals.

Caffeine withdrawal was included in the research appendix of the DSM-IV to encourage additional research to assist with determining its status for the next version of the manual. Caffeine dependence was not included because of a lack of empirical research at the time of publication. This study assessed the beliefs of addiction professionals about the clinical importance of caffeine withdrawal and dependence. A 6-item survey was developed and delivered electronically to the members of six professional organizations that focus on addiction. Open-ended comments were also solicited. Five hundred members responded. The majority (95%) thought that cessation of caffeine could produce a withdrawal syndrome, and that caffeine withdrawal can have clinical importance (73%); however, only half (48%) thought that caffeine withdrawal should be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). A majority (58%) believed that some people develop caffeine dependence; however, only 44% indicated that it should be in the DSM. Comments suggested that trepidation about inclusion of caffeine diagnoses was due to the concerns about the field of psychiatry being criticized for including common disorders with a relatively low clinical severity. Others, however, expressed an urgent need to take caffeine-related problems more seriously. The majority of addiction professionals believe that caffeine withdrawal and dependence disorders exist and are clinically important; however, these professionals are divided in whether caffeine withdrawal and dependence should be included in DSM. Wider dissemination of the extant literature on caffeine withdrawal and additional research on caffeine dependence will be needed to provide additional guidance to policymakers and healthcare workers.

Codependence with hypersexual and gambling disorder.

Background The risks of behavioral addictions are well documented. There are biological, medical, social, spiritual, psychological, and safety risks to the individual as well as risks, like ripple effects, to the family and friends with whom the individual with behavioral addictions lives. The phenomenon of collateral damage from addictions, especially alcoholism and substance dependence, is well documented. Aims and methods A selected review of the literature reveals little regarding the risks of collateral damage, in particular codependence, from behavioral addictions on non-addicted family and friends. Results This article theoretically posits the existence of codependence to those with two well documented and researched behavioral addictions, hypersexual and gambling disorder, using the biopsychosocial lens. Conclusions Addictions professionals are encouraged to revisit the literature on codependence and consider its influence on family and friends of those with behavioral addictions when providing services.

Acceptance of non-abstinence goals by addiction professionals in the United States.

Previous research has found relatively limited acceptance of nonabstinence goals in addiction treatment settings in the United States. Because such attitudes may have changed over time, this study was designed to assess the current acceptance of nonabstinence goals by addiction professionals as a function of type of substance (alcohol vs. drug), severity of the disorder (DSM-IV abuse vs. DSM-IV dependence), and finality of the outcome goal (intermediate vs. final). The sample comprised 913 members of a national association of addiction professionals who completed a web-based survey. Over one half of respondents rated nonabstinence as somewhat or completely acceptable as both an intermediate and final outcome goal for clients with alcohol abuse, but considerably smaller proportions rated nonabstinence an acceptable intermediate or final outcome goal for clients with alcohol dependence. Regarding drug-taking clients, one half and one third of respondents rated nonabstinence at least somewhat acceptable as an intermediate goal and final outcome goal, respectively, for clients with drug abuse, but fewer rated nonabstinence an acceptable outcome goal for clients with drug dependence. One implication of the findings is that individuals with alcohol and drug problems who avoid treatment because they are ambivalent about abstinence should know that--depending on the severity of their condition, the finality of their nonabstinence goal, and their drug of choice--their interest in moderating their consumption will be acceptable to many clinicians, especially those working in outpatient and independent practice settings.

Neurogenetics and Nutrigenomics of Neuro-Nutrient Therapy for Reward Deficiency Syndrome (RDS): Clinical Ramifications as a Function of Molecular Neurobiological Mechanisms

In accord with the new definition of addiction published by American Society of Addiction Medicine (ASAM) it is well-known that individuals who present to a treatment center involved in chemical dependency or other documented reward dependence behaviors have impaired brain reward circuitry. They have hypodopaminergic function due to genetic and/or environmental negative pressures upon the reward neuro-circuitry. This impairment leads to aberrant craving behavior and other behaviors such as Substance Use Disorder (SUD). Neurogenetic research in both animal and humans revealed that there is a well-defined cascade in the reward site of the brain that leads to normal dopamine release. This cascade has been termed the "Brain Reward Cascade" (BRC). Any impairment due to either genetics or environmental influences on this cascade will result in a reduced amount of dopamine release in the brain reward site. Manipulation of the BRC has been successfully achieved with neuro-nutrient therapy utilizing nutrigenomic principles. After over four decades of development, neuro-nutrient therapy has provided important clinical benefits when appropriately utilized. This is a review, with some illustrative case histories from a number of addiction professionals, of certain molecular neurobiological mechanisms which if ignored may lead to clinical complications.

The influence of lived experience with addiction and recovery on practice-related decisions among professionals working in addiction agencies serving women

Aims: The study objectives were to: (1) understand the value attributed to the lived experience of addiction and recovery among professionals working in addiction agencies serving women in Canada and (2) describe how lived experience influence practice-related decision-making.Methods: A descriptive qualitative study was conducted with a purposeful sample of 26 addiction professionals from 24 addiction agencies. Subsequently, a secondary analysis was conducted to identify data that would provide greater insight into issues related to the use of lived experience in decision-making.Findings: Participants who either described their personal history of addiction or discussed the influence of others’ lived experience on decisions made within the agency indicated that: (1) some professionals perceive lived experience and research evidence as two dichotomous concepts, viewing lived experience as more credible than research evidence; (2) personal experience with a particular treatment can guide treatment decisions; (3) strong adherence to only one source of evidence leads to intra-organizational conflict and (4) different sources of evidence in decision-making need to be acknowledged to inform practice.Conclusion: The addiction field can benefit from increased understanding of decision-making as a multifaceted process involving different sources of evidence, including addiction professionals’ lived experiences of addiction and recovery.

Guidance for New Motivational Interviewing Trainers When Training Addiction Professionals

Evidence-based practices, such as motivational interviewing (MI), are not widely used in community alcohol and drug treatment settings. Successfully broadening the dissemination of MI will require numerous trainers and supervisors who are equipped to manage common barriers to technology transfer. The aims of the our survey of 36 MI trainers were: 1) to gather opinions about the optimal format, duration, and content for beginning level addiction-focused MI training conducted by novice trainers and 2) to identify the challenges most likely to be encountered during provision of beginning-level MI training and supervision, as well as the most highly recommended strategies for managing those challenges in addiction treatment sites. It is hoped that the findings of this survey will help beginning trainers equip themselves for successful training experiences.

Primary and Behavioral Healthcare Integration: Threat or Opportunity for Addiction Treatment Organizations?

Nationwide, health care systems are experiencing an increasingly rapid pace of health reforms, especially in burgeoning areas such as health homes, accountable care organizations, which emphasize the growing need for bidirectional integration of primary care and behavioral health. Several articles in this issue of the Journal of Behavioral Health Services & Research explore care that requires collaboration between primary and behavioral health: “Predictors of primary care physicians’ self-reported intention to conduct suicide risk assessments” by Lisa M Hooper et al., “Outcomes associated with a cognitive-behavioral chronic pain management program implemented in three public HIV primary care clinics” by Jodie Anne Trafton et al., and the “Relationship between neighborhood characteristics and recruitment into adolescent family-based substance use prevention programs” by Hilary F. Byrnes et al. However, is this emphasis on integration a threat or opportunity for specialty addiction treatment organizations? A recent U.S. Substance Abuse and Mental Health Services Administration–U.S. Health Resources and Services Administration Center for Integrated Health Solutions survey 1 identified a growing number of specialty addictions treatment organizations that partner with community health centers, methadone treatment centers that qualify as Federally Qualified Health Centers, and residential treatment programs that offer primary care services onsite. Even state alcohol and drug authorities are focusing on integration at annual provider meetings and state training academies. In communities, specialty addiction treatment organizations have long held relationships with primary care practices. Historically, these relationships have ensured physicals for individuals entering residential care, interim services for pregnant women and individuals using intravenous drugs, and, more recently, medication interventions as a part of addiction treatment. New integration models serve to enhance providers’ opportunities to reach individuals in earlier stages of addiction, and the earlier treatment that follows could assuage damage to their bodies and improve overall treatment outcomes. Developing recovery plans which incorporate overall health, including exercise, prevention, and specific public health goals for chronic health problems, support recovery. In terms of Screening, Brief Intervention, and Referral to Treatment (SBIRT), specialty addiction professionals fill a gap in primary care settings by supporting “referral to treatment.” Without this involvement of addiction professionals, SBIRT programs often fail when a patient requires a

Integrating Mental Health Services Within Primary Care Settings

For 16 years, the Hamilton Family Health Team Mental Health Program has successfully integrated mental health counselors, addiction specialists, child mental health professionals, and psychiatrists into 81 offices of 150 family physicians in Hamilton, Ontario. Maximising the potential of a "shared care" model requires changes within the primary care setting, to support the addition of mental health and addiction professionals, active involvement of primary care staff in managing mental health problems of patients, and collaborative practice. This coordinated effort allow mental health treatment through onsite support from a mental health team and supplants the need to refer most patients to the mental health setting. This article reviews the evolution of the program and the changes made by practices with key lessons learnt.

Exploring the Perspectives of Substance Abusing Black Men Who Have Sex With Men and Women in Addiction Treatment Programs

This study examined the perspectives of African American male injection drug users who have sex with both men and women (IDU-MSM/W) and who are involved in sex trade regarding the need for a human sexuality educational model (HSEM) for addiction professionals. Focus groups were conducted involving an exploratory sample (N = 105) of men who met the following parameters: aged 18 to 40 years, African American, engage in injection drug using behavior, have sex with male and female partners, and who frequent parks and other sex working areas in Baltimore City and surrounding areas. Data suggest that an HSEM may be useful for addiction professionals who work with substance abusing Black MSM/W. Moreover, the model should include opportunities for addiction professionals to (a) identify their personal biases about homosexuality in general (acknowledging personal biases so not to allow those personal biases to influence service); (b) understand the diversity within the Black MSM/W community (e.g., challenge assumptions that all Black MSM/W self-identify as gay); (c) understand how to, and the need for, assessing sexual trauma in Black MSM/W; and (d) understand the need to incorporate risk factors and safer sex practices that may be of concern to a subpopulation of Black MSM/W, such as "barebacking." These findings suggest the need for, and topics to include in, an HSEM that assists professionals with exploring their biases about sexuality and MSM/W and better prepares counselors to address HIV prevention and risky behavior using language that is appropriate for the Black IDU-MSM/W population.