Outpatient Substance Use Disorder Treatment Research Articles

Hospitalists' Attitudes and Experiences With Posthospitalization Care Transitions for Patients With Substance Use Disorders: A Cross-sectional Analysis.

Medical hospitalizations are relatively common among individuals who have substance use disorders (SUDs) and represent opportunities for patient engagement and treatment. Posthospitalization transitions of care are an important element of providing full-spectrum inpatient SUD care; however, little is known about clinicians' experiences with postdischarge care transitions. We conducted a cross-sectional study surveying hospital-based medical clinicians (ie, "hospitalists") across 2 large health systems in the state of Utah to assess current practices, barriers, facilitators, and perceptions toward posthospitalization care transitions for patients with SUDs. We used Wilcoxon signed-rank tests to identify the most impactful barriers and facilitators among all respondents. We used logistic regression models to explore the influence of hospitalists' attitudes toward providing SUD care on perceived barriers and facilitators. The survey was distributed to 429 individuals across 15 hospitals. Eighty-two hospitalists responded to the survey (response rate, 21.4%). Most respondents frequently cared for hospitalized patients with SUDs (n = 63, 77%) and prescribed medications for SUDs (n = 44, 56%). Four respondents (5%) felt that patients received adequate support during care transitions. Lack of social support (P < 0.001) and social factors such as lack of transportation (P < 0.001) were perceived as the largest barriers to successful care transitions. Conversely, a partnering outpatient clinic/clinician (P < 0.001) and outpatient-based care coordination (P < 0.001) were perceived as the strongest facilitators. Respondents' attitudes toward people with SUDs had a modest effect on perceived barriers and facilitators. Hospitalists perceived increased outpatient SUD treatment infrastructure and transitional care supports as most important in facilitating posthospitalization care transitions for patients with SUDs.

Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims

BackgroundPotential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine.MethodsIn this observational, retrospective cohort study using the Merative MarketScan databases (2006–2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression.ResultsAmong enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.03[1.01–1.06]) and PCPs (aHR = 1.07[1.05–1.10]). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.24[1.20–1.29] and aHR = 1.39[1.34–1.45] respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry).ConclusionBuprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.

Development and initial testing of mindful journey: a digital mindfulness-based intervention for promoting recovery from Substance use disorder

Background/Objectives There is a great unmet need for accessible adjunctive interventions to promote long-term recovery from substance use disorder (SUD). This study aimed to iteratively develop and test the initial feasibility and acceptability of Mindful Journey, a novel digital mindfulness-based intervention for promoting recovery among individuals with SUD. Patients/Materials Ten adults receiving outpatient treatment for SUD. Methods Phase 1 (n = 5) involved developing and testing a single introductory digital lesson. Phase 2 included a separate sample (n = 5) and involved testing all 15 digital lessons (each 30- to 45-minutes) over a 6-week period, while also receiving weekly brief phone coaching for motivational/technical support. Results Across both phases, quantitative ratings (rated on a 5-point scale) were all at or above a 4 (corresponding with ‘agree’) for key acceptability dimensions, such as usability, understandability, appeal of visual content, how engaging the content was, and helpfulness for recovery. Additionally, in both phases, qualitative feedback indicated that participants particularly appreciated the BOAT (Breath, Observe, Accept, Take a Moment) tool for breaking down mindfulness into steps. Qualitative feedback was used to iteratively refine the intervention. For example, based on feedback, we added a second core mindfulness tool, the SOAK (Stop, Observe, Appreciate, Keep Curious), and we added more example clients and group therapy videos. In Phase 2, 4 out of 5 participants completed all 15 lessons, providing initial evidence of feasibility. Participants reported that the phone coaching motivated them to use the app. The final version of Mindful Journey was a smartphone app with additional features, including brief on-the-go audio exercises and a library of mindfulness practices. Although, participants used these additional features infrequently. Conclusions Based on promising initial findings, future acceptability and feasibility testing in a larger sample is warranted. Future versions might include push notifications to facilitate engagement in the additional app features.

Availability of substance use disorder treatment in Spanish: Associations with state-level proportions of Spanish speakers and treatment facility characteristics in the United States.

Spanish is the second most spoken language in the United States. Not all substance use disorder (SUD) treatment facilities provide treatment in Spanish. This study examined factors associated with SUD treatment facilities having counselors that provide treatment in Spanish. State-level estimates of Spanish-speaking individuals were derived from the American Community Survey 2019. SUD treatment facility characteristics were captured from the National Survey of Substance Abuse Treatment Services 2020. We examined a sample of 15,246 facilities which included 12,798 outpatient, 3554 nonhospital residential, and 1106 with both outpatient and residential programs. Binary logistic regression models were used to observe state-level proportions of Spanish speakers and facility-level characteristics as factors associated with a facility having counselors that provide treatment in Spanish. Approximately 23.3% of facilities had counselors able to provide treatment in Spanish. Among outpatient or nonhospital residential SUD facilities, those in a state with a larger proportion of Spanish-speaking individuals, facilities with pay assistance, facilities that accept Medicaid, and facilities that engage in community outreach had higher odds of having counselors that provide treatment in Spanish. Considering that less than a quarter of facilities provide treatment in Spanish, increasing the availability of linguistically appropriate and culturally responsive services for SUD is imperative. This national study is the first of its kind to examine associations between estimates of Spanish speakers and treatment facility characteristics associated with counselors that provide treatment in Spanish in outpatient and nonhospital residential SUD treatment.

Gradual improvement in functioning and mental distress during long-term outpatient SUD treatment – A prospective pre-post study

BackgroundGlobally, outpatient programs for substance use disorder (SUD) treatment have gained prominence. To assess the broader clinical implications of this trend we investigated shifts in functioning experienced by outpatients undergoing treatment. MethodsWe describe the clinical characteristics of a cohort of 93 SUD patients in a Norwegian outpatient treatment clinic. Using paired-samples t-tests, we examined changes in perceived functioning, mental distress, and other clinically relevant outcome variables in a 5-month time interval during the treatment course. ResultsWe obtained follow-up data for 67 (72%) of the included patients, with no significant difference in patient-related factors between those who completed the treatment course and those who were not assessed at follow-up. Perceived functioning increased significantly from study inclusion (Time 0) (mean 19.8, standard deviation ± 8.8) to its conclusion (Time 1) (24.3, ±9.3; t (66) = 4.5, (95% CI: 2.5–6.5, p < 0.001). We also identified significant improvement in most other measured variables, including mental distress, self-reported sleep quality, restlessness, and obsessive thinking. Substance use–related variables showed a modest, non-significant improvement at T1. ConclusionDuring a 5-month course of outpatient treatment, patients’ subjective experience of functioning improved significantly. Those with the lowest functioning levels at T0 improved the most. Structured monitoring may be a valuable clinical tool for personalizing intervention, enhancing treatment outcomes, and supporting the clinical decision-making process.

Exploring the Impact of External Facilitation Using Evidence-Based Implementation Strategies for Increasing Motivational Interviewing Capacity Among Outpatient Substance Use Disorder (SUD) Treatment Providers.

The large majority of individuals who access substance use disorders (SUD) treatment do not receive evidence-based care. Little attention has been paid to the notion that the scale-up of evidence-based practices (EBPs) has been limited in large part due to a weakness in the "distribution system" for bringing new innovations to the attention of practitioners and into practice settings. This study explores the impact of the Training and Practice Implementation Institute (TPII; funded by the New York City Department of Health and Mental Hygiene), an intensive technical assistance initiative that offers external facilitation to outpatient SUD treatment providers via the incorporation of multiple evidence-based implementation strategies to enhance the practice of motivational interviewing (MI). Findings from this study show that staff completed a large majority (86%) of required training/technical assistance (TTA) activities across the 9-month implementation period, demonstrating a high level of engagement among staff and the feasibility of externally facilitated intensive TTA delivered to community-based organizations for the purpose of enhancing implementation of MI for SUDs. Results also show statistically significant improvements in the delivery of MI's technical components among staff, though did not reveal corresponding improvements in the delivery of MI's relational components. An understanding of the potential return on investment associated with externally facilitated TA, offers organizations an opportunity to inform the allocation of limited resources to areas where they will have the greatest impact and ultimately improve the quality and efficacy of services.

Cognitive behavioral therapy for suicide prevention among Veterans receiving substance use disorder treatment: Results from a randomized trial

Veterans receiving substance use disorder (SUD) treatment are at a clear elevated risk for engaging in suicidal behaviors. Intervening to reduce suicide risk during an episode of SUD treatment could meaningfully target a key high-risk group of Veterans. Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) was developed to reduce the frequency and duration of suicidal ideation, as well as decrease suicidal behaviors. The form of CBT-SP in this study progressed from building an understanding of the cognitive model to practicing new skills, and highlighted the links between substance use, craving, self-efficacy and suicidal ideation and attempts. CBT-SP was compared to an attention matched 8-session control condition (termed Supportive Psychoeducational Control [SPC]) during a multi-site randomized controlled trial for 299 Veterans receiving outpatient SUD treatment services within the Veterans Health Administration. The frequency of suicidal ideation remained relatively constant over 24-months of follow-up, however the duration of suicidal ideation decreased, and suicide attempts decreased relative to baseline in both conditions. Forty-two participants (14%) reported at least one suicide attempt during the 2-year follow-up period. No statisticallysignificant differences were found between CBT-SP and SPC on any of these outcomes. Analyses of secondary outcomes indicate that preparatory behaviors for suicide were less common among those in the CBT-SP condition than SPC across the 24-month follow-up (OR, 95%CI = 0.44 (0.25, 0.79); p = 0.02). Veterans in SUD treatment are a high-risk group and delivery of suicide-specific interventions is feasible during SUD care. However, results did not indicate that CBT-SP was superior to SPC on any primary outcomes, underscoring the importance of identifying and testing alternative approaches that support suicide reduction in this group.

An unexplored equity factor: differential beliefs and attitudes toward contingency management by providers’ ethnicity

BackgroundAlthough considered one of the most effective interventions for substance use disorders (SUD), the widespread implementation of contingency management (CM) has remained limited. In more recent years there has been surge in the implementation of CM to address increasing rates of substance use. Prior studies at the provider-level have explored beliefs about CM among SUD treatment providers and have tailored implementation strategies based on identified barriers and training needs, to promote implementation of CM. However, there have been no implementation strategies that have actively sought to identify or address potential differences in the beliefs about CM that could be influenced by the cultural background (e.g., ethnicity) of treatment providers. To address this knowledge gap, we examined beliefs about CM among a sample of inpatient and outpatient SUD treatment providers.MethodsA cross-sectional survey of SUD treatment providers was completed by 143 respondents. The survey asked respondents about their attitudes toward CM using the Contingency Management Beliefs Questionnaire (CMBQ). Linear mixed models examined the effect of ethnicity (non-Hispanic White and Hispanic) on CMBQ subscale (general barriers, training-related barriers, CM positive-statements) scores.ResultsFifty-nine percent of respondents to the CMBQ self-identified as non-Hispanic White and 41% as Hispanic. Findings revealed that treatment providers who identified as Hispanic had significantly higher scores on the general barriers (p < .001) and training-related barriers (p = .020) subscales compared to the non-Hispanic White treatment providers. Post-hoc analyses identified differences in the endorsement of specific individual scale items on the general barriers (e.g., CM interventions create extra work for me) and training-related (e.g., I want more training before implementing CM) subscales.ConclusionsDissemination and implementation strategies for CM need to consider equity-related factors at the provider-level that may be associated with the adoption and uptake of CM.

Subjective effects as predictors of substance use disorders in a clinical sample: A longitudinal study

BackgroundThe literature on the association between subjective effects (SEs; i.e., how an individual perceives their physiological and psychological reactions to a drug) and substance use disorders (SUDs) is largely limited to community samples. The present study addressed the following aims in a clinical sample: whether SEs predict general versus substance-specific SUD in adolescence and adulthood after controlling for conduct disorder symptoms (CDsymp); whether SEs predict SUDs across drug classes; whether SEs predict change in SUD from adolescence to adulthood; and whether there are racial/ethnic differences in associations. MethodsLongitudinal analyses were conducted using data from a sample of 744 clinical probands recruited from residential and outpatient SUD treatment facilities in CO during adolescence (Mage = 16.26) and re-assessed twice in adulthood (Mages = 22.56 and 28.96), approximately seven and twelve years after first assessment. SEs and CDsymp were assessed in adolescence. SUD severity was assessed at adolescence and twice during adulthood. ResultsSEs assessed in adolescence robustly predicted general SUD for legal and illegal substances in adolescence and adulthood, whereas CDsymp predicted SUD primarily in adolescence. Higher positive and negative SEs in adolescence were associated with greater SUD severity after controlling for CDsymp, with similar magnitudes. Results indicated cross-substance effects of SEs on SUD. We found no evidence for racial/ethnic differences in associations. ConclusionsWe investigated the progression of SUD in a high-risk sample with greater odds of sustained SUD. In contrast to CDsymp, both positive and negative SEs consistently predicted general SUD across substances in adolescence and adulthood.

Assessment of Screening Tools to Identify Substance Use Disorders Among Adolescents

Efficient screening tools that effectively identify substance use disorders (SUDs) among youths are needed. To evaluate the psychometric properties of 3 brief substance use screening tools (Screening to Brief Intervention [S2BI]; Brief Screener for Tobacco, Alcohol, and Drugs [BSTAD]; and Tobacco, Alcohol, Prescription Medication, and Other Substances [TAPS]) with adolescents aged 12 to 17 years. This cross-sectional validation study was conducted from July 1, 2020, to February 28, 2022. Participants aged 12 to 17 years were recruited virtually and in person from 3 health care settings in Massachusetts: (1) an outpatient adolescent SUD treatment program at a pediatric hospital, (2) an adolescent medicine program at a community pediatric practice affiliated with an academic institution, and (3) 1 of 28 participating pediatric primary care practices. Participants were randomly assigned to complete 1 of the 3 electronic screening tools via self-administration, followed by a brief electronic assessment battery and a research assistant-administered diagnostic interview as the criterion standard measure for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnoses of SUDs. Data were analyzed from May 31 to September 13, 2022. The main outcome was a DSM-5 diagnosis of tobacco/nicotine, alcohol, or cannabis use disorder as determined by the criterion standard World Mental Health Composite International Diagnostic Interview Substance Abuse Module. Classification accuracy of the 3 substance use screening tools was assessed by examining the agreement between the criterion, using sensitivity and specificity, based on cut points for each tool for use disorder, chosen a priori from previous studies. This study included 798 adolescents, with a mean (SD) age of 14.6 (1.6) years. The majority of participants identified as female (415 [52.0%]) and were White (524 [65.7%]). High agreement between screening results and the criterion standard measure was observed, with area under the curve values ranging from 0.89 to 1 for nicotine, alcohol, and cannabis use disorders for each of the 3 screening tools. These findings suggest that screening tools that use questions on past-year frequency of use are effective for identifying adolescents with SUDs. Future work could examine whether these tools have differing properties when used with different groups of adolescents in different settings.

Pharmacist‐delivered comprehensive medication management in a substance use disorder clinic, an 18‐month descriptive study

AbstractIntroductionPharmacists have expanded their roles within interprofessional teams in substance use disorder (SUD) care, but data characterizing pharmacist‐delivered comprehensive medication management (CMM) in outpatient SUD treatment are limited.ObjectivesThe purpose of this study was to characterize the patient population, and medication therapy problems (MTPs), and describe considerations for CMM development and implementation in an outpatient SUD treatment setting.MethodsAn observational, prospective, descriptive study was conducted in an outpatient SUD center. A clinical pharmacist provided CMM services to referred clients and documented data elements after each visit. The pharmacist comprehensively assessed clients' complete regimens to optimize medication use through collaboration with the clients and other healthcare providers. A post‐CMM electronic survey was sent to the clients' care teams to assess their attitudes and collect feedback regarding the collaboration process. Descriptive statistics were employed to describe the population, CMM services, MTPs, and survey responses.ResultsFrom April 1, 2021, to September 30, 2022, a total of 187 CMM encounters were delivered to a total of 112 clients with SUD. Nearly all patients (99%) had opioid use disorder as their primary diagnosis and the vast majority (95%) were receiving methadone treatment. Clients’ mean age was 39‐years‐old with an average of eight medications and six medical conditions. Of 201 MTPs identified, 54 MTPs (27%) were marked as “resolved” at follow‐up visits. The most commonly identified MTP category was the need for additional drug therapy (31%). The care team survey showed 100% agreed or strongly agreed that the CMM consult was helpful to the clients and the care team members.ConclusionPharmacist‐delivered CMM in a SUD treatment setting was feasible and well perceived by care team members as helpful to bridge existing gaps in access to biomedical care, medication optimization, and medication use care coordination.

Building medication for opioid use disorder prescriber capacity during the opioid epidemic: Prescriber recruitment trends and methods

IntroductionPhysicians are a critical clinical resource for patient care. Yet physician recruitment has been considerably understudied, particularly in substance use disorder (SUD) settings. This study proposes a conceptual model called the “Physician Recruitment Descriptive Factors Framework” to investigate the role of environmental, organizational, and individual factors in the use of physician recruitment strategies. MethodsThe study setting was 75 sites that provided outpatient SUD treatment services in Florida, Ohio, and Wisconsin from 2016 to 2019. Central to the analysis is the use of five targeted physician recruitment strategies. The study investigated whether financial conditions, location (urban v. non-urban), external implementation coaching, and recruiters’ roles influenced use of the targeted physician recruitment strategies. ResultsDuring the study period, a formal plan to recruit physicians was the most common strategy used (n = 67.6 %). The director or chief executive officer (CEO) was most likely to conduct physician recruitment (n = 58.7 %). During the study, use of four of the five recruitment strategies significantly declined (at p ≤ 0.01), while the perceived need for new prescribing capacity significantly declined (p ≤ 0.01), and prescribers per site increased from 1.54 to 3.21. Sixty-four percent of this increase in prescribers was due to more physician prescribers, while 36 % was due to the onset of the ability of advanced nurse practitioners and physician assistants to prescribe buprenorphine. In year 3 of the study, the strategies most closely aligned with the current number of prescribers were conducting weekly outreach to prescriber candidates (p = .018), having a dedicated prescriber recruiter (p = .011), and having a dedicated budget for prescriber recruiting (p = .002). ConclusionsThe study describes which physician recruitment strategies SUD treatment sites used and how the need to recruit physicians for specialty treatment SUD clinics declined as prescriber capacity increased. The proposed multi-level framework provides the scaffolding for future physician recruitment research and practice.

Characteristics of Outpatient and Residential Substance Use Disorder Treatment Facilities with a Tailored LGBT Program.

Lesbian, gay, bisexual, and transgender (LGBT) individuals have a high prevalence of substance use disorders (SUDs) and experience unique barriers to treatment. Little is known about the characteristics of SUD treatment facilities providing LGBT-tailored programs at the outpatient and residential levels of care. The purpose of this study is to examine the availability of LGBT-tailored programs in outpatient and residential SUD treatment facilities. Using the National Survey of Substance Abuse Treatment Services 2020, we conducted logistic regression to examine facility characteristics, including ownership, pay assistance, region, outreach, and telehealth services, associated with having an LGBT-tailored program among SUD treatment facilities. Outpatient facilities that were for-profit, had pay assistance, had community outreach services, and provided telemedicine/telehealth were more likely to have an LGBT-tailored program. Those that were government-owned, in the Midwest, and that accepted Medicaid were less likely to have an LGBT-tailored program. Residential facilities that were in the West, for-profit, and had community outreach services were more likely to have an LGBT-tailored program. This study offers a national examination of the availability of LGBT-tailored programs in SUD treatment facilities. Differences in availability based on ownership, region, pay assistance, and outreach highlight potential gaps in treatment availability.

Group behavioral activation with and without a smartphone app in intensive outpatient treatment for substance use disorder: A three-arm randomized controlled trial

IntroductionReward deficits negatively impact recovery from substance use disorder (SUD). LETS ACT, a behavioral activation treatment targeting substance-free reward, has demonstrated effectiveness in reducing post treatment substance use. There remains room for modifications to extend recovery gains, and LETS ACT remains largely untested in outpatient treatment. We tested the effect of LETS ACT when delivered alongside intensive outpatient SUD treatment, with and without a smartphone app designed to extend access to treatment content outside of clinician-administered sessions. MethodsIn this three-arm randomized controlled trial (N = 206; 54 % White, 67 % male), all participants received intensive outpatient SUD treatment as usual (TAU) and either LETS ACT (n = 56), smartphone-enhanced LETS ACT (n = 65), or assessments only (n = 61). Substance use days and substance related problems were assessed through 12 months posttreatment. ResultsGeneralized estimating equations indicated a significant condition*time interaction for substance use days; Days of substance use significantly declined from pretreatment until 1-month for TAU, 3-months for LETS ACT-SE, and 6-months for LETS ACT. Decreases in substance-related problems were maintained across all conditions through 12 months. ConclusionsAdding LETS ACT to intensive outpatient treatment resulted in significant decreases in substance use through 6 months posttreatment, yet these gains were not sustained through 12 months posttreatment. A smartphone app did not facilitate superior treatment outcomes. Future studies should consider factors impacting treatment efficacy in outpatient settings and the utility of providing more than six sessions of behavioral activation.

A comparison of cognitive behavioral therapy for insomnia to standard of care in an outpatient substance use disorder clinic embedded within a therapeutic community: a RE-AIM framework evaluation

BackgroundRates of substance use disorders (SUDs) continue to rise in the USA with parallel rises in admissions to outpatient SUD treatment programs. Insomnia symptoms reduce treatment adherence, trigger relapse, and generally undermine SUD recovery efforts. Cognitive-behavioral therapy for insomnia (CBT-I) is the first-line treatment recommended for chronic insomnia. No study has examined the effectiveness of CBT-I for individuals who recently entered an outpatient SUD treatment program embedded within a therapeutic community (i.e., long-term drug-free residential setting).MethodsA randomized controlled trial conducted at a SUD program embedded in a therapeutic community aimed to compare group-based CBT-I (gCBT-I) (N = 10) with the standard of care (SOC) (N = 11) among individuals who have SUDs and comorbid insomnia. We present a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework evaluation to provide empirical data on gCBT-I feasibility and facilitators and barriers of conducting an insomnia-focused clinical effectiveness study within a therapeutic community.ResultsParticipants in both study arms reported moderately severe insomnia symptoms at admission and reductions in insomnia symptoms over time. Among participants who completed the Insomnia Severity Index (ISI) beyond admission, ISI decreased to ≤ 8 (the clinical cutoff for mild insomnia) in 80% of individuals in the gCBT-I group compared with 25% of individuals in the SOC group. A RE-AIM framework evaluation showed initial success with Reach and Adoption while Implementation, and Maintenance were limited. Effectiveness was inconclusive because of challenges with recruitment, intervention integrity, and missing data that precluded meeting the planned recruitment and study aims and led to study termination. Coordination and communication with staff and leadership facilitated gCBT-I implementation, yet well-known CBT-I barriers including time- and resource-intensive sleep medicine training for interventionalists and maintenance of treatment integrity during an 8-week intervention limited gCBT-I sustainability.ConclusionsThis analysis supports the feasibility of conducting behavioral sleep medicine research in outpatient SUD treatment programs embedded within therapeutic communities. Implementation of an insomnia-focused intervention was widely accepted by patients and providers and has potential to address insomnia symptoms in early SUD recovery. Addressing patient- and organizational-level implementation barriers may enhance the sustainability and scalability of sleep interventions and provide new hope to effectively treat insomnia among people living with SUDs.Trial registrationClinicaltrials.gov: NCT03208855. Registered July 6, 2017https://clinicaltrials.gov/ct2/show/NCT03208855?term=NCT03208855&draw=2&rank=1

Childhood adversity increases risk of psychotic experiences in patients with substance use disorder

IntroductionAdverse childhood experiences (ACEs) increase the risk of psychotic experiences (PE), but little is known about heterogeneities of this association in different developmental stages, dimensions, or whether they are affected by substance use disorder (SUD). This study examines the association between different types of ACEs at various developmental stages and lifetime PE in patients with SUD in Chile. MethodsWe included 399 consenting adults in outpatient or residential SUD treatment programs. Sociodemographic data and information about PE and ACEs were obtained by trained clinical psychologists. ResultsPatients reporting PE experienced more ACEs compared to patients without PE (4.2 versus 3.4). They also experienced more complex adversities (41.8% versus 25.1%), had more psychiatric comorbidities (85% versus 70.4%), and reported using more substances (mean 4.5 versus 3.9). Adjusted association between ACEs and PE showed the highest OR for arrests (1.88), sexual abuse (1.81), alcohol abuse by parents (1.48), school exclusion (1.39), foster or residential care (18.3). ConclusionEarly exposure to ACEs is a risk factor for later PE among patients with SUD. Type of ACE and the period when they occurred is important, suggesting the existence of critical periods where the individual is more susceptible to adverse environmental stimuli.

Associations of tobacco cigarette use and dependence with substance use disorder treatment completion by sex/gender and race/ethnicity

IntroductionIndividuals with substance use disorders (SUD) are approximately five times more likely to smoke cigarettes than the general population. Individuals who smoke cigarettes have greater odds of SUD relapse compared to individuals who do not smoke cigarettes, but we know little about how cigarette use is related to SUD treatment completion overall by sex/gender or race/ethnicity. MethodsThis study examined 2855 adults (71.98 % male; >70 % racial/ethnic minority) in outpatient and residential SUD treatment at a New York–based treatment agency over a six-month period in 2018. ResultsOverall, approximately three-fourths of SUD treatment-seeking participants smoked cigarettes, with high rates across sex/gender and racial/ethnic groups. Nicotine dependence did not differ by sex/gender, and White Non-Hispanic adults had the highest levels of nicotine dependence across racial/ethnic groups. Those who smoked cigarettes were significantly less likely to complete treatment compared to those who did not smoke cigarettes (OR = 0.69; 95 % CI: 0.58, 0.82). The study found no overall differences in SUD treatment completion and length of stay by sex/gender or race/ethnicity. ConclusionsGiven the high prevalence of cigarette smoking and lower odds of completing SUD treatment, the current system of care for SUD treatment may be enhanced by addressing cigarette smoking from onset of treatment.

Sex Specific Sleep Parameters Among People With Substance Use Disorder.

IntroductionSleep can have substantial impacts in substance use disorder (SUD) pathogenesis, treatment, and recovery. Sex differences exist in both sleep and SUD, but how sleep is uniquely associated with SUD by sex is not known. The study objective was to compare, within sex, sleep parameters between individuals with SUD and non-substance misusing controls.MethodsSecondary analyses of a parent cross-sectional study examining the feasibility and acceptability of a novel neurocognitive phenotyping assessment battery were completed. SUD and control subjects were recruited through local advertising and an established research registry. Subjects with SUD were also recruited through a university-based outpatient SUD treatment clinic. Self-reported sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Sex-stratified t-tests compared sleep between SUD and control subjects while Crosstab analyses explored group differences in the proportion of individuals reporting poor sleep (defined as PSQI ≥ 5).ResultsData from 162 males (44 controls, 118 SUD) and 146 females (64 controls, 82 SUD) were included in the present study. For females only, a significantly lower proportion of controls reported PSQI-defined poor sleep than individuals with any SUD or specifically with opioid use disorder. Male, but not female, controls reported shorter sleep latency, longer sleep duration, and less sleep disturbance than males with each SUD type.Discussion/ImplicationsSleep holds promise as an avenue to address SUD within a biopsychosocial model. Future work at the intersection of SUD and sleep should prioritize investigations of their interplay with sex to identify targets for tailored SUD interventions.

Factors supporting substance use improvement for Black Americans: A population health observational study

BackgroundBlack clients in substance use disorder (SUD) treatment are associated with the lowest successful completion and substance use reductions. More work is needed to identify specific factors that support successful recovery of Black clients. MethodsData from U.S. outpatient SUD treatment facilities receiving public funding from 2015 to 2019 were analyzed (N = 2239,197). Primary analyses consisted of Black clients (n = 277,726) reporting admission and discharge substance use frequency. Multiple logistic regression was used to predict substance use frequency improvement from Black client demographic, recovery capital, treatment characteristics, and state. Disparities were compared between Black and non-Black clients. ResultsThe overall Black client improvement percentage was 46.95%. Mutual-help group attendance and Length of Stay demonstrated clinically meaningful effect sizes controlling for all other variables and state. Attending mutual-help groups 8–30 times per month (State aOR = 2.54, 95% CI = 2.43, 2.64) and outpatient treatment stays of 4 months or more (State aOR = 2.50, 95% CI = 2.44, 2.56) were factors supporting Black client improvement. Importantly, states are associated with disparate Black client risk differences and only South Dakota had greater Black improvement (RD = 6.35, 95% CI = 1.00, 11.71). ConclusionsBlack client factors supporting substance use improvement include ancillary mutual-help group attendance and increased treatment retention. These factors may be more critical in states with larger Black improvement disparities. In general, treatment providers increasing access to mutual-help groups, and adjusting program inclusiveness and motivational factors for retention, would make strides in increasing improvement outcomes for Black clients.

Continuing Care App for Probationers and Parolees with Substance use Disorders.

This pilot proof-of-concept study examined the feasibility and acceptability of a Continuing Care mobile application (app) designed to meet the recovery and personal support needs of individuals under justice supervision who were receiving outpatient substance use disorder (SUD) treatment. The study included adults on probation or parole who were enrolled in an outpatient SUD treatment program (N = 15; 86.7% males). Participants were instructed to utilize the Continuing Care app daily for 4 weeks. At the end of the study, they completed a satisfaction questionnaire. Of the 15 participants enrolled in the study, 12 (80%) completed the Continuing Care app modules and the satisfaction questionnaire, and all of these participants indicated high levels of satisfaction with the app (on a scale of 1-10, Mean = 1.8, SD = 1.2). The Continuing Care app was well-utilized and perceived as valuable by this group of low-income, underserved, and hard-to-reach individuals. Further research is needed to refine app content and evaluate its ability to meaningfully enhance and extend the benefits of SUD treatment.