Posttreatment Substance Use Research Articles

Not Two Sides of the Same Coin: A Qualitative Comparative Analysis of Post-Treatment Abstinence and Relapse.

Substance use disorder (SUD) can be a chronic relapsing condition with poor treatment outcomes. Studies exploring factors associated with abstinence or relapse after treatment are often quantitative in nature, applying linear statistical approaches, while abstinence and relapse result from non-linear, complex, dynamic and synergistic processes. This study aims to explore these underlying dynamics using qualitative comparative analysis (QCA) as a mixed methods approach to further our understanding of factors contributing to post-treatment abstinence and relapse. In a prospective study, we gathered both qualitative and quantitative data pertaining to post-treatment substance use and the factors linked to substance use outcomes. These factors encompassed psychiatric comorbidity, intellectual disability, social disintegration, post-treatment support, and engagement in activities among patients who had undergone inpatient treatment for severe SUD (n = 58). QCA, a set-theoretic approach that considers the complex interplay of multiple conditions, was applied to discern which factors were necessary or sufficient for the occurrence of either abstinence or relapse. We found two solutions predicting abstinence, and five for relapse. Post-treatment conditions (support and engagement in activities) were important for retaining abstinence. For relapse, individual baseline characteristics (intellectual disability, social disintegration, psychiatric comorbidity) combined with (post-)treatment factors (post-treatment support, activities) were important. Although abstinence and relapse represent opposing outcomes, they each exhibit distinct dynamics. To gain a comprehensive understanding of these dynamics, it is advisable to examine them as separate outcomes. For clinical practice, it can be worthwhile to recognize that fostering the conditions conducive to abstinence may differ from preventing the factors that trigger relapse.

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.

Identifying relative strength of methadone versus health and social services in comprehensive substance use disorder treatment using a variance decomposition approach

BackgroundThe purpose of this study is to identify the relative strengths of association of medication and health and social services in comprehensive substance use disorder (SUD) treatment. Objectives: The study uses a novel variance decomposition method to assess the relative strength of association of six active ingredients of comprehensive SUD treatment: methadone medication, access services, SUD counseling, matched service ratio, client–provider relationship, and treatment duration. MethodsThe study uses data from the National Treatment Improvement Evaluation Study (1992–1997), a dataset with an unusual number of services and service strategies measured. The data include 3012 clients from 45 SUD treatment programs. Linear mixed models are used to assess the relation of service variables to the outcome of posttreatment substance use. Variance decomposition methods are used to assess the relative importance of the ingredients in the treatment model. ResultsAlong with a random intercept and background variables, receipt of methadone accounted for the greatest relative strength of association at 35.4%, compared with 23.8% for treatment duration, 15.4% for client–provider relationship, and 11.2% for matched service ratio. Access and SUD counseling accounted for modest strengths of association at 1% and 3% each. ConclusionFindings indicate somewhat greater strength of association of methadone compared with other services and service strategies and overall, reinforce the importance of both medication and services and service strategies in the design and development of effective models of service delivery. SignificanceThis study, among the first to evaluate the relative importance of specific services and service strategies of comprehensive SUD treatment, provides insights relevant to the development of effective models of service delivery.

Exposure to Violence and Posttreatment Substance Use Among Patients With Opioid Use Disorder.

Exposure to violence can lead to a dramatic increase in the likelihood of the development of a substance use disorder (SUD). Given the overlap between the two, substance use for survivors of violence, then, can be a coping mechanism to manage the traumatic effects of abuse and persistent use can evolve into a diagnosable SUD. This study was designed to examine the posttreatment substance use among adults who have a history of exposure to violence and sought treatment for opioid use disorder. Data for this study were drawn from the Comprehensive Addiction Treatment Outcome Research system. Among the 13,105 patients included in the study, 444 (3.4%) received a formal diagnosis for opioid use disorder. Female victims of violence are at a greater risk of suffering injuries related to violence, resulting in increased levels of medical care utilization, which may prompt the initiation and prolonged use of prescription pain relief medication. Related to this important finding is another indicating that exposure to violence at multiple points in the past was associated with more severe indicators of substance use. These data show that there is a relationship between exposure to violence, SUDs, and relapse among patients seeking treatment. Not only must patients and treatment providers address these past violent experiences as important psychological factors in recovery, but in the context of opioid use disorder, physical injuries contributing to chronic pain may also trigger persistent substance use.

Predictive validity of the SOCRATES in a clinical sample of Latina/o adolescents.

The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) is a widely used measure of a client's motivation to change their substance use behavior. It is comprised of 3 subscales, recognition, ambivalence, and taking steps, which correspond to one's awareness, uncertainty, and behavior relative to their substance use. Typically the measure has been examined in adult treatment samples, whereas less attention has been paid to its use with adolescents, especially racial/ethnic minority youth. The purpose of the current study was to test the predictive validity of the SOCRATES subscales on posttreatment substance use levels with a clinical sample of Latina/o adolescents (N = 105) in substance use treatment. Hypotheses were tested via generalized linear models for each of the 3 subscales. Results indicated that higher scores on the Taking Steps subscale of the SOCRATES at pretreatment were predictive of lower days of substance use after treatment for adolescents in the sample. Implications of the results and suggestions for future research are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Exposure to Violence and Substance Use Treatment Outcomes Among Female Patients

Background: Many female substance use patients have experienced violence in the past, with most estimates showing the majority of patients reporting violent experiences at some point. Prior experience with violence has been linked to increased severity of substance use, and this may contribute to more challenges in the path to recovery. Objectives: Existing research has confounded the timing at which violence has occurred with the type of violence to which patients have been exposed. The current study was conducted to specify the extent to which the timing of exposure and the type of violence were associated with substance use after discharge from treatment. Methods: Data were collected from 3,439 female patients included in the Comprehensive Assessment and Treatment Outcome Research (CATOR) system. Results: With regard to the type of exposure, findings indicated female patients who were exposed to multiple forms of violence (i.e. physical and sexual) displayed the greatest severity of substance use upon treatment initiation, as well as the greatest likelihood for use following discharge from treatment. In terms of the timing, female patients who experienced violence at various time points (i.e. before and after 18 years of age) displayed the greatest severity of substance use, but patients who experienced violence after 18 years of age had the highest probability of substance use following discharge from treatment. Conclusions/Importance: Clinicians should collect information related to these important details as treatment protocols are developed, and as patients are connected to aftercare services to minimize post-treatment substance use.

Criminal Justice Contact and Relapse Among Patients Seeking Treatment for Opioid Use Disorder

The rapid rise in opioid use has recently contributed to several pressing concerns, including an unprecedented number of fatal overdoses, a marked increase in treatment admissions, a spike in emergency department visits, and a significant proportion of adults who test positive for opioids at the time of arrest. The majority of arrestees who test positive for opioids after being booked into jail also report prior engagement with a substance use treatment program, highlighting the need to address posttreatment substance use and involvement in the criminal justice system. The current study was conducted to untangle the posttreatment substance use–arrest relationship and better understand how one may influence the other. Analyses conducted with 396 adults, drawn from a nationwide sample of patients seeking treatment for opioid use disorder, demonstrated that posttreatment arrest increased the likelihood of substance use, but the evidence suggested that this relationship was not reciprocal. These results have significant implications for criminal justice practices with regard to using alternatives to arrest as methods to minimize posttreatment substance use.

How many or how much? Testing the relative influence of the number of social network risks versus the amount of time exposed to social network risks on post-treatment substance use

BackgroundHaving high-risk, substance-using friends is associated with young adult substance use disorder (SUD) relapse. It is unclear, however, whether it is the total number of high-risk friends, or the amount of time spent with high-risk friends that leads to relapse. Unclear also, is to what extent low-risk friends buffer risk. This study examined the influence of number of high-risk and low-risk friends, and the amount time spent with these friends on post-treatment percent days abstinent (PDA). MethodYoung adult inpatients (N=302) were assessed at intake, and 3, 6, and 12 months on social network measures and PDA. Mixed models tested for effects of number of high- and low-risk friends, and time spent with these friends on PDA, and for net-risk friend effects to test whether low-risk friends offset risk. ResultsWithin and across assessments, number of, and time spent with high-risk friends was negatively associated with PDA, while the inverse was true for low-risk friends. Early post-treatment, time spent with friends more strongly predicted PDA than number of friends. Participants were more deleteriously affected by time with high-risk friends the longer they were out of treatment, while contemporaneously protection conferred by low-risk friends increased. This interaction effect, however, was not observed with number of high- or low-risk friends, or number of friends net-risk. ConclusionsYoung adult SUD patients struggling to break ties with high-risk friends should be encouraged to minimize time with them. Clinicians should also encourage patients to grow their social network of low-risk friends.

Culturally sensitive substance use treatment for racial/ethnic minority youth: A meta-analytic review

This systematic review and meta-analysis synthesized findings from studies examining culturally sensitive substance use treatment for racial/ethnic minority youth. An extensive literature search located eight eligible studies using experimental or quasi-experimental designs. The meta-analysis quantitatively synthesized findings comparing seven culturally sensitive treatment conditions to seven alternative conditions on samples composed of at least 90% racial/ethnic minority youth.The results from the meta-analysis indicated that culturally sensitive treatments were associated with significantly larger reductions in post-treatment substance use levels relative to their comparison conditions (g=0.37, 95% CI [0.12, 0.62], k=7, total number participants=723). The average time between pretest and posttest was 21weeks (SD=11.79). There was a statistically significant amount of heterogeneity across the seven studies (Q=26.5, p=0.00, τ2=0.08, I2=77.4%). Differential effects were not statistically significant when contrasts were active generic counterparts of treatment conditions (direct “bona fide” comparisons; g=−0.08, 95% CI [−0.51, 0.35]) and ‘treatment as usual’ conditions (g=0.39, 95% CI [−0.14, 0.91]).Strong conclusions from the review were hindered by the small number of available studies for synthesis, variability in comparison conditions across studies, and lack of diversity in the adolescent clients served in the studies. Nonetheless, this review suggests that culturally sensitive treatments offer promise as an effective way to address substance use among racial/ethnic minority youth.

The cumulative risk associated with demographic background characteristics among substance use treatment patients

Background: A significant amount of research has been conducted on the association between demographic background characteristics and substance use treatment outcomes among adults, but this body of work has not yet examined how multiple factors in combination magnify the risk for post-treatment substance use.Methods: The current study utilized a sample of 12,320 adults drawn from the Comprehensive Assessment and Treatment Outcome Research (CATOR) system to investigate how multiple demographic risk factors increase the likelihood of substance use after treatment.Results: A series of bivariate analyses and multivariate binary logistic regression results demonstrated a clear pattern of increased risk in the presence of a greater number of positive demographic risk factors. These demographic risk factors also amplified the risk of post-treatment substance use in the presence of additional clinical indicators of treatment prognosis.Conclusion: Select patient demographic background characteristics must be taken into consideration in the early treatment planning stages to improve long-term clinical outcomes.

Family Matters: Engaging Parents in Youth Treatment

One of the keys to successful adolescent development is a healthy family dynamic. It is thus beneficial for adolescent treatment agencies to recognize, address, and foster family health such that the home system can support and sustain treatment gains made by the adolescent. In this paper, we describe how one residential program defines and facilitates the family work that happens in conjunction with youth therapy, called the Parallel Process. We also detail how parental skills learned during therapy are quantitatively associated with youth length of stay and post-treatment youth substance use and internalizing and externalizing problems.

Personal support networks, social capital, and risk of relapse among individuals treated for substance use issues

BackgroundThe success of treatment for substance use issues varies with personal and social factors, including the composition and structure of the individual's personal support network. This paper describes the personal support networks and social capital of a sample of Italian adults after long-term residential therapeutic treatment for substance use issues, and analyses network correlates of post-treatment substance use (relapse). MethodsUsing a social network analysis approach, data were obtained from structured interviews (90–120min long) with 80 former clients of a large non-governmental therapeutic treatment agency in Italy providing voluntary residential treatments and rehabilitation services for substance use issues. Participants had concluded the program at least six months prior. Data were collected on socio-demographic variables, addiction history, current drug use status (drug-free or relapsed), and the composition and structure of personal support networks. Factors related to risk of relapse were assessed using bivariate and multivariate logistic regression models. ResultsA main goal of this study was to identify differences between the support network profiles of drug free and relapsed participants. Drug free participants had larger, less dense, more heterogeneous and reciprocal support networks, and more brokerage social capital than relapsed participants. Additionally, a lower risk of relapse was associated with higher socio-economic status, being married/cohabiting, and having network members with higher socio-economic status, who have greater occupational heterogeneity, and reciprocate support. ConclusionsPost-treatment relapse was found to be negatively associated with the socioeconomic status and occupational heterogeneity of ego's support network, reciprocity in the ties between ego and network members, and a support network in which the members are relatively loosely connected with one another (i.e., ego possesses “brokerage social capital”). These findings suggest the incorporation into therapeutic programming of interventions that address those aspects of clients’ personal support networks.

Pathways to change: Use trajectories following trauma-informed treatment of women with co-occurring post-traumatic stress disorder and substance use disorders.

Despite advances towards integration of care for women with co-occurring substance use disorder (SUD) and post-traumatic stress disorder (PTSD), low abstinence rates following SUD/PTSD treatment remain the norm. The utility of investigating distinct substance use trajectories is a critical innovation in the detection and refining of effective interventions for this clinical population. The present study reanalysed data from the largest randomised clinical trial to date for co-occurring SUD and PTSD in women (National Drug Abuse Treatment Clinical Trials Network; Women and Trauma Study). Randomised participants (n = 353) received one of two interventions in addition to treatment as usual for SUD: (i) trauma-informed integrative treatment for PTSD/SUD; or (ii) an active control psychoeducation course on women's health. The present study utilised latent growth mixture models (LGMM) with multiple groups to estimate women's substance use patterns during the 12-month follow-up period. Findings provided support for three different trajectories of substance use in the post-treatment year: (i) consistently low likelihood and use frequency; (ii) consistently high likelihood and use frequency; and (iii) high likelihood and moderate use frequency. Covariate analyses revealed improvement in PTSD severity was associated with membership in a specific substance use trajectory, although receiving trauma-informed treatment was not. Additionally, SUD severity, age and after-care efforts were shown to be related to trajectory membership. Findings highlight the necessity of accounting for heterogeneity in post-treatment substance use, relevance of trauma-informed care in SUD recovery and benefits of incorporating methodologies like LGMM when evaluating SUD treatment outcomes.

Family history density predicts long term substance use outcomes in an adolescent treatment sample

AimsThis study explored whether the density of family history (FH) of substance use disorders relates to post-treatment substance use outcomes in adolescents, with the primary aim of determining whether FH exerts a relatively stronger influence on longer-term outcomes. MethodThe present investigation examined adolescents (ages 12–18, n=366) from two independent samples who were treated for alcohol/substance use disorder (ASUD) and re-assessed during the eight years following treatment with identical methodology. Primary substance use outcomes were assessed at 1, 2, 4, 6, and 8 years post-treatment and included total drinks, days using marijuana, and days using other drugs. ResultsIn hierarchical linear models there were significant FH density×linear time interactions for total drinks (z=12.75, p<0.001) and marijuana use days (z=4.39, p<0.001); greater FH density predicted more total drinks and more marijuana use days, with both associations becoming stronger over time. The increasing linkage between FH and other drug use was not significant over time. ConclusionsFindings are consistent with previous research indicating that the risk associated with FH increases over time, especially in relation to quantity/frequency measures of alcohol and marijuana use. By extending these findings to an adolescent clinical sample, the current study highlights that FH density of alcohol and drug dependence is a risk factor for poorer long-term outcomes for adolescent-onset ASUD youth as they transition into adulthood. Future work should explore the mechanisms underlying greater post-treatment substance use for adolescents/young adults with greater FH density.

Substance Abuse Treatment Response in a Latino Sample: The Influence of Family Conflict

Latino Americans report underutilization of treatment and poor treatment response for substance use and abuse compared to other racial/ethnic groups; thus, it is important to assess factors that contribute to these disparities. The current study objective was to assess the influence of family conflict on substance abuse treatment response in a sample of Latino Americans using two different yet complementary analyses. First, ordinary least squares regression was used to assess the association between overall family conflict and pre- and post-treatment substance use. Second, repeated measures latent class analysis was used to identify groups based on family member conflict and timing of conflict during treatment. Findings indicated that family conflict contributed unique variance to concurrent substance use; however pre-treatment family conflict was not related to post-treatment outcomes. Results also identified three distinct family conflict groups: no/low conflict, pre-treatment conflict, and post-treatment conflict who differed in pre- and post-treatment substance use. Post hoc investigation revealed that those who experienced pre-treatment conflict but low post-treatment conflict showed the greatest decrease in substance use. Findings highlight the importance of considering family conflict during all stages of treatment for Latino American substance users.

Self-efficacy and social networks after treatment for alcohol or drug dependence and major depression: disentangling person and time-level effects.

Proximal personal and environmental factors typically predict outcomes of treatment for alcohol or drug dependence (AODD), but longitudinal treatment studies have rarely examined these factors in adults with co-occurring psychiatric disorders. In adults with AODD and major depression, the aims of this study were to: (a) disaggregate person-and time-level components of network substance use and self-efficacy, (b) examine their prospective effects on posttreatment alcohol/drug use, and (c) examine whether residential environment moderated relations between these proximal factors and substance use outcomes. Veterans (N = 201) enrolled in a trial of group psychotherapy for AODD and independent MDD completed assessments every 3 months during 1 year of posttreatment follow-up. Outcome variables were percent days drinking (PDD) and using drugs (PDDRG). Proximal variables included abstinence self-efficacy and social network drinking and drug use. Self-efficacy and network substance use at the person-level prospectively predicted PDD (ps < .05) and PDDRG (ps < .05). Within-person, time-level effects of social networks predicted future PDD (ps < .05) but not PDDRG. Controlled environments moderated person-level social network effects (ps < .05), such that greater time in controlled settings attenuated the association between a heavier drinking/using network and posttreatment drinking and drug use. Both individual differences and time-specific fluctuations in proximal targets of psychosocial interventions are related to posttreatment substance use in adults with co-occurring AODD and MDD. More structured environmental settings appear to alleviate risk associated with social network substance use, and may be especially advised for those who have greater difficulty altering social networks during outpatient treatment.

Gender disparities in utilization and outcome of comprehensive substance abuse treatment among racial/ethnic groups

This study examined gender differences within Black, Latino, and White subgroups in the utilization of comprehensive services and their relation to posttreatment substance use. Survey data were collected during the National Treatment Improvement Evaluation Study (NTIES), a prospective, longitudinal, multisite study of substance abuse treatment programs and their clients in the United States. The analytic sample consisted of 1,812 Blacks (734 women and 1,078 men), 486 Latinos (147 women and 339 men), and 844 Whites (147 women and 339 men) from 59 service delivery organizations. Results related to service utilization indicated that compared to men, women in all racial and ethnic groups needed and received more services targeted to their needs and reported more positive relations with service providers. Gender was a significant moderator of the relationship between service receipt and treatment outcomes for all racial and ethnic groups, but especially for the Latino subsample. Findings point to the need to consider race-specific gender differences in the development of culturally competent, comprehensive substance abuse treatment.

Therapeutic Engagement and Posttreatment Substance Use in Adolescent TC Clients

The problem of adolescent drug use places a huge toll on society and a heavy burden on the criminal justice system. Despite the ability of therapeutic communities (TCs) to lower drug relapse, a great deal remains unknown in terms of how the process of treatment actually works for adolescents. Using data collected as part of the Drug Abuse Treatment Outcomes Studies–Adolescents, this study examines the direct and indirect relationship between therapeutic engagement and posttreatment substance use. Though there are few direct effects of therapeutic engagement on substance use, findings suggest that those more engaged in treatment are more likely to complete treatment and, therefore, less likely to use substances. This suggests that instruments that evaluate therapeutic engagement are important in assessing involvement in treatment, and that programming designed to engage the adolescents in TC treatment should be utilized to reduce the risk of posttreatment relapse.

12-Step Affiliation and Attendance Following Treatment for Comorbid Substance Dependence and Depression: A Latent Growth Curve Mediation Model

ABSTRACT Among substance-dependent individuals, comorbid major depressive disorder (MDD) is associated with greater severity and poorer treatment outcomes, but little research has examined mediators of posttreatment substance use outcomes within this population. Using latent growth curve models, the authors tested relationships between individual rates of change in 12-step involvement and substance use, utilizing posttreatment follow-up data from a trial of group Twelve-Step Facilitation (TSF) and integrated cognitive-behavioral therapy (ICBT) for veterans with substance dependence and MDD. Although TSF patients were higher on 12-step affiliation and meeting attendance at end-of-treatment as compared with ICBT, they also experienced significantly greater reductions in these variables during the year following treatment, ending at similar levels as ICBT. Veterans in TSF also had significantly greater increases in drinking frequency during follow-up, and this group difference was mediated by their greater reductions in 12-step affiliation and meeting attendance. Patients with comorbid depression appear to have difficulty sustaining high levels of 12-step involvement after the conclusion of formal 12-step interventions, which predicts poorer drinking outcomes over time. Modifications to TSF and other formal 12-step protocols or continued therapeutic contact may be necessary to sustain 12-step involvement and reduced drinking for patients with substance dependence and MDD.

A Simplified Method for Routine Outcome Monitoring after Drug Abuse Treatment

The routine collection of drug treatment outcomes to manage quality of care, improve patient satisfaction, and allocate treatment resources is currently hampered by two key difficulties: (1) problems locating clients once they leave treatment; and (2) the prohibitive cost of obtaining meaningful and reliable post-treatment data. This pilot describes precise methods for an economical staff-based routine outcome monitoring (ROM) system using an 18-item core measure telephone survey. As implemented at Narconon™ of Oklahoma, a behavioral and social skills based, residential drug rehabilitation program, the system was psychometrically adequate for aggregate reporting while providing clinically useful information. Standardized procedures for staff training, collecting client contact information, structuring exit interviews and maintaining post-treatment telephone contact produced follow-up rates that improved from 57.6% to 100% over the course of the project. Aggregate data was used to improve program delivery and thereby post-treatment substance use and social outcomes. These methods and use of data may contribute to the discussion on how to best monitor outcomes.