Addiction Treatment Clients Research Articles

Atmospheres of craving: a relational understanding of the desire to use drugs

Aims Craving is commonly described as an ‘intense desire’ to use drugs. Due to its relevance for addiction theories and treatment, much effort has been put into understanding how and when craving occurs. An undisputed definition of craving is however still lacking. The aim of this article is to explore how craving is experienced and resisted after cessation of substance use. Methods This article analyses interviews with former addiction treatment clients. By analyzing the described event of craving, the study shows the complexities in such narratives. Findings We found that the interaction between temporal, relational and material forces move people toward or away from craving. Craving thus seemed to be both relational and located in-between forces. Conclusions We conclude that craving appeared in the studied narratives to emanate from different atmospheres, with a concurrent focus on settings rather than on substances. A relational understanding of craving can add to the typical, but limited, account of craving as an individual issue. It also avoids stigmatizing ideas that people who do not resist cravings simply fail to say no. We end by asking if craving is a relevant concept within the addiction field at all.

The Promise of Technology-Based Services for Addiction Treatment Clients Residing in Nonurban Areas.

The Promise of Technology-Based Services for Addiction Treatment Clients Residing in Nonurban Areas.

Barriers and Facilitators to Tobacco Cessation in a Nationwide Sample of Addiction Treatment Programs

IntroductionSmoking rates among addiction treatment clients are 3–4 times higher than those of the general population. Recent studies indicate that ceasing tobacco use during treatment may improve recovery outcomes. Across the United States, publicly funded addiction treatment programs vary widely in terms of their tobacco policies and tobacco cessation services offered to clients. MethodsThe study reported here is the qualitative component of a larger study. Twenty-four programs were recruited from a random sample of publicly funded programs participating in the NIDA Clinical Trials Network. Semi-structured interviews were administered by phone to program directors. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts. FindingsWhile all directors expressed interest in helping clients to quit smoking, they cited numerous barriers to implementing tobacco policies and services. These included smoking culture, client resistance, lack of resources, staff smoking, and environmental barriers. Directors also cited several factors that they believed would support tobacco cessation. These included financial support, enhanced leadership, and state mandates against smoking in addiction treatment programs. ConclusionAddiction treatment programs are beginning to place more emphasis on tobacco cessation during treatment. However, furthering this goal requires substantial infrastructural and cultural change. These qualitative study findings may help to inform Single State Agencies (SSAs) to support publicly funded addiction treatment programs in their tobacco cessation efforts. In order to maximize effectiveness, state-level policies regarding tobacco cessation during treatment should be informed by ongoing dialogue between service providers and SSAs.

'The lesser of two evils': A qualitative study of staff and client experiences and beliefs about addressing tobacco in addiction treatment settings.

The aim of this study was to explore beliefs about tobacco dependence treatment from the perspective of staff and clients in addiction treatment settings. A qualitative study was conducted between August and November 2013 using grounded theory methodology. Participants were recruited from four government-funded drug and alcohol services in a regional centre of New South Wales, Australia. Treatment centre staff (n = 10) were interviewed using a semistructured interview guide and two focus groups (n = 5 and n = 6) were held with clients of the same treatment centres. Both clients and staff wish to do more about tobacco use in addiction treatment services, but a number of barriers were identified. Staff barriers included lack of time, tobacco-permissive organisational culture, lack of enforcement of smoke-free policies, beliefs that tobacco is not a treatment priority for clients and that clients need to smoke as a coping strategy, and perceptions that treatment was either ineffective or not used by clients. Clients reported smoking as a habit and for enjoyment or stress relief, seeing staff smoking, nicotine replacement therapy unaffordability and perceptions that nicotine replacement therapy may be addictive, and inability to relate to telephone cessation counselling as barriers to quitting smoking. Client and staff perceptions and attitudes about the treatment of tobacco, particularly those relating telephone support and nicotine replacement therapy, provided information, which will inform the design of smoking cessation programs for addiction treatment populations. [Wilson AJ, Bonevski B., Dunlop A., Shakeshaft A, Tzelepis F., Walsberger S., Farrell M., Kelly PJ, Guillaumier A. 'The lesser of two evils': A qualitative study of staff and client experiences and beliefs about addressing tobacco in addiction treatment settings. Drug Alcohol Rev 2015].

The influence of music on emotions and cravings in clients in addiction treatment: A study of two clinical samples

Music is commonly associated with substance use yet little is known about the music experiences of adults with substance use disorders. In particular, there has been no detailed analysis of musical influences on emotions and cravings among clients in treatment and how these influences might occur. To explore these questions, surveys of music experiences were collected from 143 clients undergoing treatment (37 private hospital clients and 106 residential rehabilitation clients). Of the hospital sample, 70% listened to music for over an hour each day, typically while alone, and their preferred genres were pop and rock. Clients stated that music listening intensified the emotional experience of drug taking and vice versa. Residential rehabilitation clients reported that their preferred music was gloomier or heavier when using substances than when in recovery. Forty-three percent said that particular music increased their urge to use substances, and there were five common explanations, including: the song was associated with past experiences of substance use; the song evoked emotions related to substance use; and the song contained lyrics about substance use. Nevertheless, most respondents believed that music was important to their recovery. The findings are considered in terms of their clinical implications.

Smoking Behaviors and Attitudes Among Clients and Staff at New York Addiction Treatment Programs Following a Smoking Ban: Findings After 5 Years.

Addiction treatment clients are more likely to die of tobacco-related diseases than of alcohol or illicit drug-related causes. We aimed to assess smoking behavior, and smoking-related attitudes and services, in New York addiction treatment programs before a statewide smoking ban in treatment facilities was implemented (2008), 1 year (2009) and 5 years after implementation (2013). We conducted surveys at each time point with clients (N = 329, 341, and 353, respectively) and staff (N = 202, 203, and 166, respectively) from five residential and two methadone maintenance programs in New York State. At each data collection wave, questionnaires measured smoking behavior as well as smoking-related knowledge, attitudes, and experiences with tobacco cessation services as part of addiction treatment. Staff smoking prevalence decreased from 35.2% in 2008 to 21.8% in 2013 (P = .005) while client smoking prevalence over the same period was unchanged (68.1% vs. 66.0%, P = .564). Among clients who smoked, mean cigarettes per day decreased from 13.7 (SD = 8.38) to 10.2 (SD = 4.44; P < .001). There were significant time-by-treatment-type interactions for client tobacco-related attitudes and cessation services received; and for staff self-efficacy and cessation services provided. In residential programs, scores for most items decreased (became less positive) in 2009 followed by a partial rebound in 2013. Methadone program scores tended to rise (become more positive) throughout the study period. Staff and clients may respond differentially to tobacco-free policies depending on type of treatment program, and this finding may help to inform the implementation of tobacco-free policies in other statewide addiction treatment systems.

Comorbid mental disorders among clients in addiction treatment: The costs of care

Urbanoski, K., Rehm, J., Lange, S., &amp; Popova, S. (2014). Comorbid mental disorders among clients in addiction treatment: The costs of care. The International Journal Of Alcohol And Drug Research, 3(4), 297-304. doi:http://dx.doi.org/10.7895/ijadr.v3i4.183Aims: To compare the volume and costs of services for clients with and without comorbid mental disorders in an addiction treatment system.Design: Secondary data analysis.Setting: Administrative data for the fiscal year 2010–2011 were abstracted from the Drug and Alcohol Treatment Information System (DATIS).Participants: Data represents all clients entering publicly funded services in Ontario in the fiscal year 2010–2011 (N = 41,953).Measures: Service costs were calculated using recent estimates of the cost per outpatient visit and day of residential care. Average numbers of visits/days per client, with and without mental disorders, were compared across gender and age subgroups.Findings: Overall, 22% of clients treated in 2010–2011 reported a past-year mental disorder. The costs of services for these clients were estimated to be between $18.5 and $40.3 million (in Canadian dollars), or 20% of the total service costs for the year. The largest difference in average volume of care was seen for residential treatment, where having a mental disorder was associated with seven fewer days of care. On average, during the period studied, among those without mental disorders, men spent 20 more days in residential care than did women.Conclusions: At the system-level in Ontario, clients with mental disorders did not account for a disproportionate amount of the total costs of care during the year. While these findings may signal a mismatch between the needs of clients with co-occurring disorders and their use of services, it is also possible that such clients receive additional care in other treatment sectors. Further study is warranted to explore potential unmet needs among clients with co-occurring disorders in addiction treatment.

The Clustering of Psychopathology Among Adults Seeking Treatment for Alcohol and Drug Addiction

Beyond the high prevalence of co-occurring mental and substance use disorders, little is known about more complex patterns of psychopathology and multimorbidity, particularly in treatment populations. We sought to identify a parsimonious set of latent classes to describe the structure of mental disorder comorbidity among adults entering outpatient addiction treatment, and explore differences in the structure and prevalence of classes across sociodemographic characteristics. Participants (N=544) completed the Psychiatric Diagnostic Screening Questionnaire at treatment admission. We used latent class analysis to identify classes of clients with specific patterns of co-occurring mental disorders. The best-fitting solution identified 3 classes, characterized by no comorbidity (i.e., substance use disorders only), co-occurring major depression, and multimorbidity or a high degree of psychopathology. Older age was associated with lower probability of being in the class with co-occurring major depression, women were more likely than men to be in the multimorbid class, and being married or partnered was associated with a lower probability of being in either of the comorbid classes. These results are consistent with general population research on the patterning of psychiatric disorders, implying that while clients in addiction treatment may have extraordinarily high levels of psychopathology, the patterns of symptoms and the groups most affected are not markedly different than in other settings. By capturing the complexity of interrelationships among the many factors that are known to influence prognosis and outcomes, latent class analysis offers a useful way to examine and represent case-mix in clinical populations.

Chronic non-cancer pain and six-month follow-up outcomes among community-based opiate addiction treatment clients on methadone

Individuals who seek medication-assisted treatment for opiate addiction are generally prescribed methadone along with behavioral counseling at a licensed opiate treatment program (OTP). For OTP clients who also have chronic non-cancer pain (CNCP), the disease of addiction is treated, but the disease of CNCP may not be addressed. Though connecting opioid dependence and CNCP may seem obvious since opioids produce both analgesia and euphoria, limited data is available on their co-occurrence and the impact on treatment outcomes.

Integration of Parenting Skills Education and Interventions in Addiction Treatment

Children of parents with substance use disorders are at risk for various adverse outcomes, and maladaptive parenting behaviors seem to be an important mediator of this risk. Although numerous research studies have highlighted the promise of parenting interventions in modifying parenting behavior, very little is known about the integration of parenting skills education and interventions into addiction treatment programs. In this study, a convenience sample of 125 addiction treatment programs in the United States was drawn. A key staff member was interviewed to gather basic information about the extent and nature of parenting skills education and interventions offered at their program. In addition, respondents were asked to rate the importance of parenting skills relative to other addiction treatment priorities. Descriptive analyses revealed that 43% reported some form of parenting classes, but few used a structured curriculum. Given the known beneficial influence of effective parenting practices on reducing adverse childhood outcomes, it is surprising that relatively few substance abuse treatment programs have adopted structured parenting skills interventions as part of their standard service offerings. More research is warranted on the extent to which parenting skills interventions are integrated into the continuum of services available to parents with a substance use disorder.

The moderating effects of group cognitive–behavioral therapy for depression among substance users.

This study examined the prospective longitudinal relationship between changes in depressive symptoms on alcohol and/or drug (i.e., substance) use among addiction participants in treatment, and whether group cognitive-behavioral therapy for depression (GCBT-D) moderated the relationship. Using a quasi-experimental intent-to-treat design, 299 residential addiction treatment clients with depressive symptoms (Beck Depression Inventory-II, BDI-II scores > 17; Beck, Steer, & Brown, 1996) were assigned to either usual care (n = 159) or usual care plus a 16-session GCBT-D intervention (n = 140). Two follow-up interviews were conducted, one 3 months after the baseline interview corresponding to the end of the intervention, and then one 3 months later. Parallel-process growth modeling was used to examine changes in depressive symptoms and the associated changes in abstinence and negative consequences from substance use over time. Treatment group was included as a moderator of the association. Participants in the GCBT-D condition showed a greater increase in abstinence and greater decreases in depressive symptoms and negative consequences over time. There were significant interaction effects, such that the associations between depressive symptoms, negative consequences, and abstinence changes were larger in the usual-care condition than in the GCBT-D condition. The results suggest that the intervention may be effective by attenuating the association between depressive symptoms and substance use outcomes. These findings contribute to the emerging literature on the prospective longitudinal associations between depressive symptoms and substance use changes by being the first to examine them among a sample receiving GCBT-D in an addiction treatment setting.

Perceptions of 12-Step Interventions Among UK Substance-Misuse Patients Attending Residential Inpatient Treatment in a UK Treatment Setting

In spite of a considerable evidence base suggesting the benefits of participation in Alcoholics Anonymous and other 12-step fellowships, most studies have been conducted in the United States. Preliminary studies have suggested that clients in addiction treatment in the United Kingdom may be more ambivalent about 12-step groups, and the current article examines barriers and pathways to engagement in 12-step recovery support groups for 125 drug and alcohol users (84.5% of the total sample) attending an inpatient detoxification unit in Birmingham, England. Two-thirds (69.4%) reported prior attendance at 12-step meetings, but current levels of affiliation were low and significant barriers to 12-step meeting attendance were identified. Barriers to participation include the perceived religious components of 12-step meetings, prior negative experiences in 12-step meetings, failure to identify with group members, and difficulties simultaneously participating in both 12-step meetings and structured treatment.

Measuring smoking knowledge, attitudes and services (S-KAS) among clients in addiction treatment

Background Addiction treatment programs are increasingly working to address prevalent and comorbid tobacco dependence in their service populations. However at present there are few published measurement tools, with known psychometric properties, that can be used to assess client-level constructs related to tobacco dependence in addiction treatment settings. Following on previous work that developed a staff-level survey instrument, this report describes the development and measurement characteristics of the smoking knowledge, attitudes and services (S-KAS) for use with clients in addiction treatment settings. Method 250 clients enrolled in residential drug abuse treatment programs were surveyed. Summary statistics were used to characterize both the participants and their responses, and exploratory factor analysis (EFA) was used to examine the underlying factor structure. Results Examination of the rotated factor pattern indicated that the latent structure was formed by one knowledge factor, one attitude factor, and two “service” factors reflecting program services and clinician services related to tobacco dependence. Standardized Cronbach's alpha coefficients for the four scales were, respectively, .57, .75, .82 and .82. Conclusions The proposed scales have reasonably good psychometric characteristics, although the knowledge scale leaves room for improvement, and will allow researchers to quantify client knowledge, attitudes and services regarding tobacco dependence treatment. Researchers, program administrators, and clinicians may find the S-KAS useful in changing organizational culture and clinical practices related to tobacco addiction, help in program evaluation studies, and in tracking and improving client motivation.

Investigating a four-pathway model of adult attachment orientation and health

We tested a model, derived from attachment theory, linking adult attachment orientation to health through four hypothesized intervening paths: affect, stress, social support, and health-risk behavior. Questionnaires were administered to 623 university students and 219 addiction treatment clients. In both samples, attachment avoidance and attachment anxiety dimensions were indirectly, rather than directly, related to lower subjective ratings of health. In both samples, data were consistent with the affect and stress pathways linking attachment to health. Results for the social support and health-risk behavior pathways were less robust. Results were consistent for male and female respondents. Findings are discussed in terms of attachment theory and the affect regulation processes linking attachment and health. Implications are considered, along with directions for future research.

Cognitive impairment influences drinking outcome by altering therapeutic mechanisms of change.

Serious neuropsychological impairments are seen in a minority of addiction treatment clients, and, theoretically, these impairments should undermine behavioral changes targeted by treatment; however, little evidence supports a direct influence of impairment on treatment response. To address this paradox, the authors used structural equation modeling and Project MATCH data (N=1,726) to examine direct, mediated, and moderated paths between cognitive impairment, therapeutic processes, and treatment outcome. Mediated relations were found, wherein impairment led to less treatment compliance, lower self-efficacy, and greater Alcoholics Anonymous Involvement, which, in turn, more proximally predicted drinking. Impairment further moderated the effect of self-efficacy, making it a poor predictor of drinking outcomes in impaired clients, thereby suggesting that impaired and unimpaired clients traverse different pathways to addiction recovery.

Out of touch or on the money: Do the clinical objectives of addiction treatment coincide with economic evaluation results?

Previous economic studies have examined the association between substance abuse treatment and reduced costs to society, but it remains uncertain whether the economic measures used in cost and benefit-cost analyses of treatment programs correspond in direction and magnitude with clinical outcomes. In response to this uncertainty, the present study analyzed a longitudinal data set of addiction treatment clients to determine the statistical agreement between clinical and economic outcomes over time. Data were collected from 1,326 clients in the Chicago cohort of the Persistent Effects of Treatment Study. These individuals were interviewed at baseline as well as at 6-, 24-, 36-, and 48-month followup periods (91.6% followup). Correlations between clinical and economic measures were generally small (ρ of 0.1 to 0.3) and often became non-significant once we controlled for baseline severity. The results demonstrate that although some associations exist, outcomes should be evaluated along both clinical and economic dimensions.

The Effectiveness of Vocational Services for Substance Users in Treatment

Employment appears frequently in the literature as an outcome criterion for substance users in treatment, and most clinicians subscribe to the belief that work plays an important role in recovery from addiction. Despite the importance attached to employment, the major standard treatment modalities have not been shown as effective in increasing client employment after treatment. The article presents a critical review and synthesis of three decades of research on the effectiveness of specialized vocational intervention for addiction treatment clients.

Attitudes and Beliefs About 12-Step Groups Among Addiction Treatment Clients and Clinicians: Toward Identifying Obstacles to Participation

Participation in 12-step groups (12SG) during and after formal treatment has been associated with positive outcome among substance users. However, the effectiveness of 12SG may be limited by high attrition rates and by low participation, areas on which there has been little research. Clinicians play an important role in fostering 12-step participation, and the insights which they develop in their practice can greatly contribute to informing the research process. Yet, little is known about clinicians’ attitudes about 12-step groups or about their experiences in referring clients. This study surveyed clients (N = 101) and clinicians (N = 102) in outpatient treatment programs to examine 12-step-related attitudes and to identify potential obstacles to participation. Data collection was conducted between 05, 2001 and 01, 2002 in New York City. Both client and clinician samples were primarily African-American and Hispanic; 32% of clients reported substance use in the previous month, with crack and marijuana cited most frequently as the primary drug problem. On average, clinicians had worked in the treatment field for 8 years. Both staff and clients viewed 12SG as a helpful recovery resource. Major obstacles to participation centered on motivation and readiness for change and on perceived need for help, rather than on aspects of the 12-step program often cited as points of resistance (e.g., religious aspect and emphasis on powerlessness). Clinicians also frequently cited convenience and scheduling issues as possible obstacles to attending 12SG. Clinical implications of these findings are discussed, including the importance of fostering motivation for change, the need to assess clients’ beliefs about and experiences with 12SG on a case-by-case basis, and to find a good fit between clients’ needs and inclinations on the one hand, and the tools and support available within 12-step groups on the other.

ANTISOCIAL BEHAVIORAL SYNDROMES AND RETURN TO DRUG USE FOLLOWING RESIDENTIAL RELAPSE PREVENTION/HEALTH EDUCATION TREATMENT

This study compared residential addiction treatment clients meeting full DSM-III-R criteria for antisocial personality disorder (ASPD) with those reporting syndromal levels of antisocial behavior only in adulthood (AABS) on time to and severity of first posttreatment drug use. Antisocial syndrome and selected other mental disorders were assessed using the Diagnostic Interview Schedule, Revised for DSM-III-R, and validity of self-reported posttreatment drug behavior was measured against results of hair analysis. Among subjects followed within 180 days after treatment exit, individuals with ASPD were at modestly increased risk of a first lapse episode compared to those with AABS. However, the two groups did not differ in severity of lapse. Participants with ASPD demonstrated poorer agreement between self-reported posttreatment drug behavior and hair data. These results add to the evidence suggesting that the DSM requirement for childhood onset in ASPD may be clinically important among substance abusers in identifying a severely antisocial and chronically addicted group at elevated risk for early posttreatment recidivism. Our findings support the importance of careful classification of antisocial syndromes among substance abusers and the identification of characteristics of these syndromes that underlie clients’ risks for posttreatment return to drug use to provide optimally individualized treatment planning.