Engagement In Substance Abuse Treatment Research Articles

Substance Abuse Treatment, Critical Race Theory, and Counter-Storytelling, for the Black Emerging Adult Male.

Black-emerging adult males face many barriers to the effective engagement in substance abuse treatment including stigma, lack of access to resources, and engagement with the criminal justice system. This case study introduces a group therapy and counter-storytelling intervention to understand and effectively mitigate some of these barriers. Counter-storytelling, derived from critical race theory (CRT) framework, focuses on marginalized individuals sharing how various aspects of society impact them, which is often different from the majority narrative. Through this intervention, Black-emerging adult males discussed the challenges they face when engaging in treatment, coping skills for barriers they face, and overcoming stigma of substance abuse recovery. Using a group therapy and counter-storytelling intervention, clinicians can begin to suspend how they traditionally think about treatment for Black-emerging adult males and engage in more effective practices to support this population.

The Moderating Effect of Substance Abuse Treatment Engagement on the Connection Between Support From Program Participants and Substance-Related Recidivism for Justice-Involved Women.

This study examines the prediction of substance-related technical violations and arrests from (a) a three-dimensional measure of substance abuse treatment engagement-treatment satisfaction, treatment participation, and counselor rapport-and (b) support from peers in the treatment program. The study focuses on 204 women on probation or parole who attended a substance abuse treatment program in the first 9 months of supervision. Data were collected in face-to-face interviews and from official records of violations and arrests. Generalized linear mixed-effects modeling was used to assess the main effects and the interaction effect of within-program peer support and other indicators of engagement as predictors of substance-related technical violations and arrests. Peer support was positively related to violations/arrests when treatment engagement was low. Findings suggest that for women who do not score high in treatment engagement, support from peers is related to increased recidivism, and group treatment may be contraindicated.

Abstinence-Only: Are You Not Working the Program or Is the Program Not Working for You?

Low retention rates are common in substance use treatment programs. The dominant model of service delivery in the United States is abstinence-only, a high-threshold service delivery model requiring abstinence. What “doesn’t work” for the client—from the client point of view—is an overlooked source of insight about client engagement and disengagement. We report client counter-narratives about the choice to disengage from abstinence-based services, shifting from a story of “dropouts” to one of self-respect. Understanding why clients choose to disengage from treatment can help us as practitioners to “meet clients where they are” and enhance engagement in substance abuse treatment.

Substance abuse treatment engagement, completion and short-term outcomes in the Western Cape province, South Africa: Findings from the Service Quality Measures Initiative

BackgroundOptimizing the effectiveness of substance use disorder (SUD) treatment is critical in low-and middle-income countries (LMICs) with limited opportunities for SUD treatment. This is the first study to identify targets for interventions to improve the quality of SUD treatment in a LMIC. MethodWe explored correlates of three indicators of treatment quality (treatment engagement, completion and abstinence at treatment exit) using data from a SUD performance measurement system implemented in the Western Cape Province of South Africa. The sample included data from 1094 adult treatment episodes representing 53% of the treatment episodes in 2016. Using multivariate logistic regression analyses, we modeled socio-demographic, substance use and program correlates of treatment engagement, completion, and abstinence at treatment exit. ResultsOverall, 59% of patients completed treatment (48% of patients from outpatient services). Treatment completion was associated with greater likelihood of abstinence at treatment exit. Patients were more likely to complete treatment if they engaged in treatment, were older, and had more severe drug problems (characterized by daily drug use and heroin problems) and attended programs of shorter duration. Residential treatment was associated with greater likelihood of treatment engagement, completion, and abstinence at treatment exit. ConclusionImproving rates of outpatient treatment completion will enhance the effectiveness of South Africa’s SUD treatment system. Interventions that promote engagement in treatment, particularly among younger patients; reduce program length through referral to step-down continuing care; and ensure better matching of drug problem to treatment level and type could improve rates of treatment completion.

Substance abuse treatment engagement among mothers: Perceptions of the parenting role and agency-related motivators and inhibitors

ABSTRACTThis qualitative study explored (1) the parenting role as a motivator and inhibitor to engaging in substance abuse treatment and (2) parenting-related, agency-imposed barriers and facilitators to substance abuse treatment engagement. Nine focus groups (N = 45) were conducted with current and former male and female recipients of treatment services in one Southeastern state. Using inductive thematic analysis, transcripts were analyzed to identify key themes related to parenting. Females were over-represented in our groups and were more vocal than males regarding issues of parenting as these related to treatment. Among mothers, motivations for treatment related to parenting included involvement with child protective services and the desire to be a better parent. Inhibitors for treatment included anxiety over separation from child, debilitating guilt, and parenting demands. Facilitators for participation included mother–child residential programs, services for children, concrete support, and advocacy and emotional support. Barriers for participation included decreased access to the child and barriers specific to mother–child residential programs. To enhance treatment engagement among parents, providers can address agency-level barriers and draw upon the parenting role as intrinsic motivation for change. Policies and services are needed that promote flexibility, choice, and support parents to engage in treatment services.

Effects of Peer Recovery Coaches on Substance Abuse Treatment Engagement Among Child Welfare-Involved Parents

Effects of Peer Recovery Coaches on Substance Abuse Treatment Engagement Among Child Welfare-Involved Parents

Spanish language proficiency among providers and Latino clients' engagement in substance abuse treatment

Quality of care, such as provision of services in Spanish, is a common factor believed to improve treatment engagement among Spanish-speaking Latinos in health care. However, there is little evidence that Spanish language proficiency among providers increases treatment access and retention in publicly funded substance abuse treatment. We analyzed client and program data collected in 2010–2011 from publicly funded treatment programs in Los Angeles County, California. An analytic sample of 1903 Latino clients nested within 40 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on days to initiate and spent in treatment. As hypothesized, Spanish language proficiency was negatively associated with client wait time and positively associated with retention in treatment, after controlling for individual and program characteristics. The path analysis models showed that Spanish language proficiency played a mediating role between professional accreditation and client wait time and retention. These preliminary findings provide an evidentiary base for the role of providers' Spanish language proficiency and Latino engagement in treatment for a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to enhance linguistically competent care, are discussed.

A Web-Based Behavior Therapy Program Influences the Association Between Cognitive Functioning and Retention and Abstinence in Clients Receiving Methadone Maintenance Treatment

Objective: Deficits in cognitive functioning have been well-documented in persons with substance use disorders. In addition, some evidence suggests that poorer cognitive functioning predicts poorer engagement in substance abuse treatment and worse treatment outcomes. This trial is a non-blind, randomized clinical trial with parallel design. Methods: Clients were recruited from a local methadone maintenance clinic within the first 30 days of treatment. All participants completed a comprehensive, computerized neuropsychological assessment (MicroCog) at the time they entered the clinical trial. Participants were randomized to receive 12 months of either standard methadone maintenance treatment or methadone maintenance treatment with an integrated web-based intervention as part of treatment. The aims of the current study were to (a) characterize the cognitive functioning of clients entering methadone maintenance treatment, (b) evaluate the impact of cognitive functioning on the primary outcomes of treatment retention and opioid abstinence, and (c) determine whether cognitive functioning had a differential impact on these outcomes across treatment conditions. Randomization was non-blind and participants were stratified on past-month cocaine use and prior history of methadone, LAAM, or buprenorphine treatment. Results: Eighty participants were randomized to each condition (N = 160). Mean scores on MicroCog scales fell in the average and low average ranges and there were no differences in scores between treatment groups. Lower scores on General Cognitive Proficiency predicted longer study retention (χ 2 = 5.03, p < .05), although this effect was quite small. Generalized linear modeling showed that scores on all MicroCog scales except for Spatial Processing significantly predicted opioid abstinence (defined as percent of total weeks and percent of tested weeks with continuous abstinence), with lower scores predicting smaller percentages of continuous weeks of abstinence. This pattern was not evident in regression analyses in which abstinence was defined as number of total weeks of abstinence. An interaction effect was observed, whereby lower cognitive scores predicted lower levels of abstinence for participants in standard methadone maintenance treatment, but not for those who received the web-based intervention as part of methadone maintenance treatment. Conclusions: Technology-based interventions may hold promise for minimizing the impact of poorer cognitive functioning on treatment outcomes.

Impact of intensive case management on child welfare system involvement for substance-dependent parenting women on public assistance

This study examined the impact of intensive case management (ICM) on decreasing child welfare system involvement in a sample of substance-dependent parenting women who participated in a welfare demonstration study comparing ICM to usual screen-and-refer models employed in welfare settings. Previous research established the effectiveness of ICM in both increasing engagement in substance abuse treatment and in promoting abstinence, and the current study tested whether ICM had downstream impacts on child welfare outcomes not directly targeted by the intervention. The sample included 302 mothers recruited from welfare offices and their 888 minor children. Child welfare outcomes were available from administrative records for four years following study entry and included incident reports and out-of-home child placements. An initial positive effect of ICM was found on child placements, but its impact lessened over time and was likely due to the increased contact with case managers that occurred early in the study. Overall, minimal benefits of ICM were found, suggesting that while ICM was effective in the areas of treatment engagement and abstinence, there were no downstream benefits for child welfare outcomes. Implications of findings in terms of increased need for cross-system collaboration are discussed.

ART adherence changes among patients in community substance use treatment: a preliminary analysis from MACH14

BackgroundOpiate substitution treatment has been associated with better adherence to lifesaving antiretroviral medications, but the impact of other substance abuse treatment on adherence is unknown.FindingsIn this study, 215 patients who had been in adherence-focused research studies provided electronically-measured adherence data and a measure of whether the patient had recently been in substance abuse treatment. Recent engagement in substance abuse treatment was independently associated with significantly higher adherence, after covarying for recent substance use and other factors potentially affecting adherence.ConclusionsThe findings suggest that substance abuse treatment is associated with better adherence. Potential mechanisms by which substance abuse treatment improves adherence, such as more stability or more future-orientation, require further study.

Effect of Insurance Parity on Substance Abuse Treatment

Objective: This study examined the impact of insurance parity on the use, cost, and quality of substance abuse treatment. Methods: The authors compared substance abuse treatment spending and utilization from 1999 to 2002 for continuously enrolled beneficiaries covered by Federal Employees Health Benefit (FEHB) plans, which require parity coverage of mental health and substance use disorders, with spending and utilization among beneficiaries in a matched set of health plans without parity coverage. Logistic regression models estimated the probability of any substance abuse service use. Conditional on use, linear models estimated total and out-of-pocket spending. Logistic regression models for three quality indicators for substance abuse treatment were also estimated: identification of adult enrollees with a new substance abuse diagnosis, treatment initiation, and treatment engagement. Difference-in-difference estimates were computed as (postparity - preparity) differences in outcomes in plans without parity subtracted from those in FEHB plans. Results: There were no significant differences between FEHB and non-FEHB plans in rates of change in average utilization of substance abuse services. Conditional on service utilization, the rate of substance abuse treatment out-of-pocket spending declined significantly in the FEHB plans compared with the non-FEHB plans (mean difference=−$101.09, 95% confidence interval [CI]=−$198.06 to −$4.12), whereas changes in total plan spending per user did not differ significantly. With parity, more patients had new diagnoses of a substance use disorder (difference-in-difference risk=.10%, CI=.02% to .19%). No statistically significant differences were found for rates of initiation and engagement in substance abuse treatment. Conclusions: Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care. (Psychiatric Services 62:129–134, 2011)

Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders

Research has documented the significant challenges of engaging individuals with comorbid serious mental illness (SMI) and substance use disorders (SUDs) in substance abuse treatment. To date it is unclear which factors predict treatment initiation and engagement in this group of individuals with SUDs. In this study we conducted two analyses using data from a randomized trial of substance abuse treatment in outpatients with SMI: the first examining predictors (collected during screening) of completing an initial intake assessment and the second examining predictors (collected during the intake assessment) of becoming engaged in treatment. Results indicated that males and those with schizophrenia spectrum diagnoses were less likely to complete the intake assessment. Participants who reported more positive feelings about their family were more likely to engage in substance abuse treatment. Participants who were recently arrested were less likely to engage in treatment. Those who met criteria for current drug dependence were less likely to engage in treatment. Overall, these findings are a useful step in determining factors that predict substance abuse treatment initiation and engagement in individuals with SMI and SUDs.

Associations of Housing Status With Substance Abuse Treatment and Service Use Outcomes Among Veterans

Associations of Housing Status With Substance Abuse Treatment and Service Use Outcomes Among Veterans

Evaluation of the Washington State Access to Recovery project: Effects on Medicaid costs for working age disabled clients

In 2004, the federal government made a major commitment to support expanded substance abuse (SA) recovery services by initiating the Access to Recovery (ATR) program. The initial ATR I program awarded grants to 14 states, including Washington State. We evaluated Washington's ATR I program to determine its effect on Medicaid costs for working age disabled clients. We compared per member per month (PMPM) Medicaid costs during 1 year follow-up for clients who received ATR services ( N = 1,347) with costs for a matched comparison group of 1,243 clients and used multiple regression techniques to estimate changes in Medicaid costs associated with ATR. ATR was found to be associated with reductions in PMPM Medicaid costs of $66 ( p = .11) to $136 ( p = .05) depending upon months of Medicaid eligibility. Recovery services aimed at facilitating engagement in SA treatment and aftercare appear to foster modest savings in Medicaid costs for working age disabled clients.

Alcohol Treatment Research Assessment Exposure Subject Reactivity Effects: Part II. Treatment Engagement and Involvement

This is the second of two articles in this issue on participant reactivity to alcohol treatment research assessment protocols. In the first article, Clifford et al. presented experimental evidence that the combination of less frequent and less comprehensive assessment results in the least assessment reactivity, as measured by alcohol use and related consequences at 1 year after admission for adult outpatient treatment for alcohol problems. In addition, Part I revealed that the presence of either frequent or comprehensive research assessment tends to result in a greater degree of reactivity. This article extends the analyses by Clifford et al. to treatment for substance use-disorders engagement and involvement across a 1-year follow-up. The design, participants, and procedures were identical to those described in Clifford et al. Treatment data were obtained from hospital records and participants' self-reports as part of the Timeline Followback interview. Analyses revealed several effects of frequency of assessment and comprehensiveness of assessment on treatment engagement or involvement. The reactivity effect observed varied with the dependent variable, which included if a participant presented for outpatient treatment (more likely in the comprehensive groups), the number of days of outpatient substance use-disorders treatment during follow-up (no reactivity effects), if a participant engaged in intensive treatment for substance-use disorders during follow-up (more likely for the frequent groups in Months 1-6, but the reverse in Months 7-12, and overall more likely in the brief conditions), and the number of days of intensive treatment for substance-use disorders during follow-up (more days in the frequent groups in Months 1-6, no frequency differences in Months 7-12, and overall more days in the brief groups), respectively. Additional analyses showed that treatment participation did not mediate the reactivity effects on alcohol use and related consequences reported by Clifford et al. Data provide experimental evidence for a causal relationship between frequency of assessment and comprehensiveness of assessment on substance abuse-treatment engagement and involvement. Future research should be directed at understanding the factors in the assessment process that determine reactivity effects.

Enhancing substance abuse treatment engagement in incarcerated adolescents.

The purpose of this study was to determine whether motivational interviewing (MI), compared with an attention control condition (relaxation training [RT]) enhances substance abuse treatment engagement in incarcerated adolescents. At the start of incarceration, adolescents were randomly assigned to individually administered MI or RT. Subsequently, therapists and adolescents (N = 130) rated degree of adolescent participation in the facility's standard care group-based treatments targeting crime and substance use. All adolescents received the facility standard care treatment after their individual MI or RT session. MI statistically significantly mitigated negative substance abuse treatment engagement. Other indicators of treatment engagement were in the expected direction; however, effect sizes were small and nonsignificant. These findings are significant, given concerns regarding the deleterious effects of treating delinquent adolescents in groups and the potential for adolescents to reinforce each other's negative behavior, which in turn may lead to escalated substance use and other delinquent behaviors after release.

Informed consent to undergo treatment for substance abuse: a recommended approach

With more than 3 million persons receiving substance abuse treatment per year in the United States and with increasing interest in treatment outcomes, there is a need for closer attention to all aspects of the treatment process. However, minimal attention has been given to informed consent as a way of enlisting client engagement and active participation in treatment. Although there is some literature on informed consent in substance abuse research, the literature on informed consent to undergo substance abuse treatment is very limited. Incorporating informed consent into substance abuse treatment is recommended as part of motivational interviewing. Standard treatment consent issues include (1) the clinical characteristics of the problem, including diagnosis; (2) treatment recommendations; (3) the risks and benefits of treatment; (4) the financial costs of the intervention; (5) alternative services or interventions should a client refuse the recommended form of care; and (6) freedom to choose or refuse treatment. This article provides a background for informed consent procedures to facilitate client engagement in substance abuse treatment and suggests needs for future research on informed consent to undergo substance abuse treatment.

Substance Abuse Treatment and Hospitalization among a Cohort of HIV‐Infected Individuals with Alcohol Problems

We examined the association of substance abuse treatment services on hospitalization among participants in the HIV-Alcohol Longitudinal Cohort (HIV-ALC) study of HIV-infected individuals with a history of alcohol problems. A standardized questionnaire that inquired about demographics, substance use, use of substance abuse treatment services, and hospitalization was administered to 349 HIV-ALC participants. We defined substance abuse treatment services as any of the following in the past 6 months: 12 weeks in a half-way house or residential facility, 12 visits to a substance abuse counselor or mental health professional, or participation in any methadone maintenance program. Almost one third of this cohort were hospitalized in the past 6 months. Substance abuse treatment was not significantly associated with hospitalization [adjusted odds ratio (AOR) 1.0; 95% confidence interval (CI) 0.7-1.5), whereas homelessness (AOR 2.3; 95% CI 1.5-3.6), injection drug use (AOR 1.7; 95% CI 1.0-2.7), severity of alcohol dependence (AOR 1.02; 95% CI 1.00-1.05), CD4 cell count (AOR 0.999; 95% CI 0.998-1.00), and HIV RNA (AOR 1.1; 95% CI 1.0-1.2) were independently associated with increased odds of hospitalization over time. Engagement in substance abuse treatment was not associated with a decrease in hospital use by HIV-infected individuals with a history of alcohol problems. The period of substance abuse treatment may present an opportunity to address health care utilization patterns of HIV-infected individuals.

Psychometric properties of the Toronto Alexithymia Scale (TAS-20) for substance users

To determine the psychometric properties of the Toronto Alexithymia Scale (TAS-20), an established self-report measure of alexithymia, for a substance user sample participating in a clinical trial of outpatient cognitive-behavioral therapies (N=230). Confirmatory and exploratory factor analyses were used to determine the number and nature of the factors underlying the TAS-20 in a sample of substance users. Structural equation modeling was used to determine the predictive validity of the TAS-20. A factor structure comparable, but not identical, with TAS-20 psychometric results with other populations was found; alpha coefficients were .88 for the feelings factor, .62 for the external thinking factor, and .87 for the total score. Although, on average, the substance users did not appear to have elevated alexithymia scores compared with the undergraduate students, alexithymia predicted less treatment engagement, i.e., fewer sessions attended and weaker helping alliance. Alexithymia also predicted alcohol use outcomes but not drug use outcomes. The relation between alexithymia and drinking outcome was conditional on whether the patient was using solely alcohol at baseline. The TAS-20 has reasonably good psychometric properties in this sample, which might be improved by dropping several marginal questionnaire items. Alexithymia appears to attenuate substance abuse treatment engagement. More clinical and research experience with this construct and specific instrument in substance user samples is needed.

Substance abuse treatment and risk behaviors among HIV-infected persons with alcohol problems

We examined the association of substance abuse treatment with sexual and drug use risk behaviors among 349 HIV-infected persons with a history of alcohol problems using a standardized questionnaire regarding sexual and drug use risk behaviors, demographics, substance use, and use of substance abuse treatment.We defined substance abuse treatment services as any of the following in the past 6 months: 12 weeks in a half-way house or residential facility; 12 visits to a substance abuse counselor or mental health professional; day treatment for at least 30 days; or participation in any methadone maintenance program. Our three outcome variables of high-risk behavior were the Risk Assessment Battery sex-risk and drug-risk scores and high-risk sex behavior which included any of the following: inconsistent condom use; having more than one sexual partner; and exchanging sex for money or drugs. Although sexual risk was high (51%) in our HIV-infected cohort, engagement in substance abuse treatment was not independently associated with lower frequency of any of our measures of high- risk behaviors. Although the opportunity exists to address HIV risk behaviors in the setting of substance abuse treatment, effective institutionalization of this challenging behavior change effort has not yet been realized.