Predictors Of Treatment Retention Research Articles

Effect of early working alliance on retention in outpatient substance abuse treatment

This study examined the client–therapist early working alliance effect on retention in outpatient substance abuse treatment. The study was implemented on naturalistic principles adopting a prospective design. Data were collected in southern and western Finland in a multisite clinical trial including outpatient treatment units (N = 7). The sample consisted of clients (N = 327, 111 women, 216 men) starting a new treatment period. Clients were assigned randomly to therapists (N = 33). Both clients and therapists’ ratings of the working alliance were measured. Generalised linear mixed model was used in the analyses. The covariate was client's per cent days abstinent before treatment. Therapist's rating of the alliance of the first therapy session and the client's percentage of days abstinent predicted treatment retention. The therapists’ ratings were better for clients whose treatment continued than for those whose treatment was discontinued. There was considerable between-therapist variation in retention and this became wider as treatment progressed. Lower per cent days abstinent at baseline negatively predicted retention. Since the therapist's evaluation of the working alliance has proved to be a predictor of retention in treatment and differences between the therapists exist in this particular and also in earlier studies, future research should be directed more towards the therapists and their characteristics associated with good treatment results.

A National Study of the Retention of Irish Opiate Users in Methadone Substitution Treatment

Background: Retention in treatment is a key indicator of methadone treatment success. The study aims to identify factors that are associated with retention. Objectives: To determine retention in treatment at 12 months for Irish opiate users in methadone substitution treatment and to indicate factors that increase the likelihood of retention. Methods: National cohort study of randomly selected opiate users commencing methadone treatment in 1999, 2001, and 2003 (n = 1269). Results: Sixty-one percent of patients attending methadone treatment remained in continuous treatment for more than 1 year. Retention in treatment at 12 months was associated with age, gender, facility type, and methadone dose. Age and gender were no longer significant when adjusted for other variables in the model. Those who attended a specialist site were twice as likely to leave methadone treatment within 12 months compared with those who attended a primary care physician. The most important predictor of retention in treatment was methadone dose. Those who received <60 mg of methadone were three times more likely to leave treatment. Conclusion: Retention in methadone treatment is high in Ireland in a variety of settings. The main factors influencing retention in methadone treatment was an adequate methadone dose and access to a range of treatment settings including from primary care physicians. Scientific Significance: Providing an adequate dose of methadone during treatment will increase the likelihood of treatment retention. Methadone treatment by the primary care physician is a successful method of retaining opioid users in treatment.

Clients' Self-efficacy and Outcome Expectations

Objectives To understand better client's self-efficacy, anticipated treatment outcome, and clients' objective and their impact on effectiveness in substance abuse treatment. Methods The study was conducted on naturalistic principles. Participants (N=327, 111 females and 216 males) from outpatient treatment units (N=7) were studied at entering treatment and at 6-month follow-up. Therapists reported clients' status concerning treatment retention. In addition, abstinent days of the participants for the month preceding follow-up and their satisfaction with the treatment received were assessed. Different regression models were used to test client-related predictors of treatment effectiveness. Results Higher self-efficacy at baseline predicted treatment retention and higher expectations on anticipated treatment outcome predicted ending therapy in mutual agreement. Moreover, higher self-efficacy together with higher expectation on treatment outcome predicted higher percent days abstinent at follow-up compared with those with lower self-efficacy and outcome expectations. Satisfaction with therapist at follow-up was predicted by higher expectations on treatment outcome. Conclusions Positive baseline expectations as regards treatment outcome and client's self-efficacy improved most outcome measures used in this study. Better expectations on treatment outcome and self-efficacy are an asset and they seem to improve treatment retention and results. Therefore, paying attention to improve those clients' expectations on themselves and on treatment must be seen as a significant treatment goal, and it should be taken into account in treatment practices.

Predictive factors for treatment retention in methadone programs in Indonesia

This article presents the results of a 6-month prospective cohort study of methadone maintenance treatment (MMT) in Indonesia. The study aimed to investigate the predictor variables of retention in MMT in Indonesia. The duration of treatment (in days) was the main outcome of the study. For the study, program, client, social network, and accessibility factors were investigated as potential predictors of retention. The study analyzed the relative weight of each factor in predicting treatment retention. The sample consisted of 178 clients drawn from three participating clinics: Rumah Sakit Ketergantungan Obat and Tanjung Priok in Jakarta and Sanglah in Bali. The 3- and 6-month retention rates were 74.2% and 61.3%, respectively. These rates are comparable with previous studies conducted in developed countries. A survival analysis using a robust estimation for the Cox PH regression found that the strongest predictors of retention were methadone dose followed by an interaction between take-home dose and the experience of the clinic providing this treatment. Other significant predictor variables included age, perceived clinic accessibility, and client's belief in the program. The study concludes that MMT cannot solely rely on the pharmacology for retention but should also promote informed access to take-home doses.

Client Characteristics and Therapist Style: A Combined Analysis of Impact on Retention and Effectiveness in Outpatient Substance Abuse Treatment

AIMS To explore the effects of client and therapist characteristics along with percentage of days abstinent before admission on retention and effectiveness of outpatient substance abuse treatment. DESIGN The study was implemented with naturalistic principles and prospective design. The clients (N = 327) and the therapists (N = 33) were recruited from Finnish outpatient treatment units (N = 7). Results The client's low readiness to change, the therapist's low directiveness and low empathy predicted short duration of treatment. Client's past substance use frequency was likewise a significant predictor of retention in treatment; clients with low percentage of days abstinent at baseline dropped out much more easily. The client's high anger and low percentage of days abstinent at baseline was found to predict low percentage of days abstinent at follow-up. Greater satisfaction with support from therapist was predicted by client's high readiness to change and lower substance use frequency at baseline. Conclusions Retention in treatment was predicted by both client's and therapist's characteristics, while effectiveness in outpatient substance abuse treatment was more dependent on client's characteristics and earlier substance use.

Retention of adolescents with substance dependence and coexisting mental health disorders in outpatient alcohol and drug group therapy

The aim of this study was to investigate characteristics that might enhance retention among adolescents attending outpatient alcohol and drug group therapy within a youth mental health setting. An important goal was to provide information for nurses and other clinicians who work with adolescents with coexisting substance use and mental health disorders. A retrospective file audit reviewed the files of 64 adolescents who attended a weekly alcohol and drug group between 2002 and 2004. Five characteristics were shown to have a significant impact on enhancing participant group retention. These were Māori and Pacific Island ethnicity, past or current legal charges, youth drug court (YDC) involvement, having a diagnosis of cannabis dependence, and a diagnosis of conduct disorder. Logistic regression found that YDC involvement on its own significantly predicted treatment retention. In an area of limited research, the findings from this study expand the literature on enhancing treatment retention for a vulnerable and hard-to-engage adolescent group with complex treatment needs, and highlight the need for further investigation of the potential role of the YDC. From a practice perspective, the findings support group therapy interventions as a cost-effective treatment modality for assisting adolescents with coexisting substance use and mental health issues, including those with conduct disorder and YDC involvement.

Pretreatment Characteristics as Predictors of Retention in Cocaine-dependent Outpatients

Objective One of the principal problems traditionally found by clinicians in drug-dependence treatment programs has been the high rate of dropout. This study presents a mathematical model that predicts, through the assignment of probabilities, treatment retention in a sample of cocaine addicts. Methods The model was defined through a logistic regression analysis. Participants were 70 in number with a cocaine-dependence diagnosis, treated at a public outpatient unit in the city of Valencia (Spain). Patients were assessed at the beginning and end of the treatment period (6 mo). Results Retention rate was 50%. The results showed that the variables best predicting treatment retention were years of education and family and social situation (sociocultural context conditions). Conclusions Therefore, we suggest the application of programs, which assess patient needs and include specific intervention strategies in the areas of education and family and vocational counseling.

Validation of a contemplation ladder in an adult substance use disorder sample.

Developing brief measures of motivation to abstain from substance use that reliably predict treatment retention and outcome is a high priority in the addiction field. This study examined the psychometric properties of a contemplation ladder designed to assess readiness to abstain from alcohol and drug use respectively, on the basis of the contemplation ladder for smoking cessation developed by Biener and Abrams (1991). Participants were 394 substance-using male and female welfare recipients referred for treatment. The combined alcohol and other drug (AOD) ladder showed discriminant validity with demographic and health characteristics, convergent validity with conceptually related treatment motivation variables, concurrent validity with baseline AOD treatment and substance use variables, and predictive validity for participation in treatment services up to 1 month later and abstinence outcomes up to 1 year later. The AOD ladder showed predictive validity for those in drug-free treatment and no treatment at baseline but not for those in methadone maintenance.

Opioid agonist pharmacotherapy in New South Wales from 1985 to 2006: patient characteristics and patterns and predictors of treatment retention

The aims of this study were to: examine the number and characteristics of patients entering and re-entering opioid replacement treatment between 1985 and 2006, to examine select demographic and treatment correlates of leaving treatment between 1985 and 2000, and to compare retention rates in methadone and buprenorphine maintenance treatment from 2001 to 2006. A retrospective cohort study using register data from the Pharmaceutical Drugs of Addiction System. Opioid substitution treatment in New South Wales (NSW), Australia. A total of n = 42 690 individuals prescribed opioid replacement treatment between 1985 and 2006 in NSW. Client characteristics over time, retention in days in first treatment episode, number of episodes of treatment and proportion switching medication. Overall, younger individuals were significantly more likely to leave their first treatment episode than older individuals. In 2001-06, after controlling for age, sex and first administration point, the hazard of leaving treatment was 1.9 times for those on buprenorphine relative to those on methadone. Retention in treatment varied somewhat across historical time, with those entering during 1995-2000 more likely to leave at an earlier stage than those who entered before that time. Retention in treatment appears to fluctuate in inverse proportion to the availability of heroin. Individuals in contemporary treatment are older users with a lengthy treatment history. This study has provided population-level evidence to suggest that retention in methadone and buprenorphine differ in routine clinical practice. Future work might investigate ways in which patient adherence and retention may be improved.

Cognition, commitment language, and behavioral change among cocaine-dependent patients.

Patients' cognitive abilities and verbal expressions of commitment to behavioral change predict different aspects of substance abuse treatment outcome, but these 2 traits have never been examined conjointly. The authors therefore investigated patients' cognitive abilities and verbal expressions of commitment to behavioral change as predictors of retention and drug use outcomes in an outpatient cognitive behavioral treatment (CBT) of adult cocaine-dependent patients. A neuropsychological battery was administered at baseline. Two independent raters used recordings of CBT sessions to code commitment language strength across the temporal segments (e.g., beginning, middle, and end) of 1 session per patient. Better cognitive abilities predicted treatment retention (p < .01) but not drug use, whereas mean commitment strength across the session segments predicted reduced drug use (p = .01). Results indicate that although commitment to behavioral changes such as abstinence may occur independently of patients' cognitive abilities, engagement in the behavioral intervention process appears to depend on cognitive abilities. Future clinical studies should further investigate the relations between cognition and commitment to change and their differential contributions to treatment processes and outcome.

Predictors of outcome for short-term medically supervised opioid withdrawal during a randomized, multicenter trial of buprenorphine–naloxone and clonidine in the NIDA clinical trials network drug and alcohol dependence

Few studies in community settings have evaluated predictors, mediators, and moderators of treatment success for medically supervised opioid withdrawal treatment. This report presents new findings about these factors from a study of 344 opioid-dependent men and women prospectively randomized to either buprenorphine–naloxone or clonidine in an open-label 13-day medically supervised withdrawal study. Subjects were either inpatient or outpatient in community treatment settings; however not randomized by treatment setting. Medication type (buprenorphine–naloxone versus clonidine) was the single best predictor of treatment retention and treatment success, regardless of treatment setting. Compared to the outpatient setting, the inpatient setting was associated with higher abstinence rates but similar retention rates when adjusting for medication type. Early opioid withdrawal severity mediated the relationship between medication type and treatment outcome with buprenorphine–naloxone being superior to clonidine at relieving early withdrawal symptoms. Inpatient subjects on clonidine with lower withdrawal scores at baseline did better than those with higher withdrawal scores; inpatient subjects receiving buprenorphine–naloxone did better with higher withdrawal scores at baseline than those with lower withdrawal scores. No relationship was found between treatment outcome and age, gender, race, education, employment, marital status, legal problems, baseline depression, or length/severity of drug use. Tobacco use was associated with worse opioid treatment outcomes. Severe baseline anxiety symptoms doubled treatment success. Medication type (buprenorphine–naloxone) was the most important predictor of positive outcome; however the paper also considers other clinical and policy implications of other results, including that inpatient setting predicted better outcomes and moderated medication outcomes.

Do dimensions of therapeutic community treatment predict retention and outcomes?

First-week Dimensions of Change Instrument (DCI) assessments from a cohort of 519 adults entering six therapeutic communities (TCs) were used to predict treatment retention and outcomes. A more positive first-week response to TC social processes ( Community Responsibility; Resident Sharing, Support, and Enthusiasm; Group Process; and Clarity and Safety) and to one TC personal-development process ( Positive Self-Attitude and Commitment to Abstinence) predicted retention for the first month. Improvement in Clarity and Safety and Resident Sharing, Support, and Enthusiasm scores at 30 days predicted retention in treatment for 3, 6, and 9 months. In multivariate analyses available to a subset of the entry cohort, a longer tenure in treatment was a robust predictor of posttreatment outcomes. First-week DCI scores on the community process scales predicted posttreatment alcohol-and-other-drug abstinence and functioning.

A pilot study for a randomized controlled and patient preference trial of buprenorphine versus methadone maintenance treatment in the management of opiate dependent patients

Aims: To assess the feasibility of conducting an RCT comparing buprenorphine and methadone maintenance therapy in Norfolk.Design: Forty‐two opiate dependent patients were given the option of being randomized or choosing between open label buprenorphine or methadone maintenance treatment for 6 months. Dosage was assessed individually using a flexible regime.Findings: No subjects agreed to randomization. At 6 months more methadone patients were retained (68 vs. 55% for buprenorphine), however, after adjustment for baseline differences between the groups results favoured buprenorphine, but were not statistically significant (odds ratio for retention BMT vs. MMT = 1.57, 95% CI, 0.30–8.29, p = 0.60). The buprenorphine group showed a non‐significant advantage in illicit opiate use (45 vs. 66% p = 0.43) and CHRISTO scores at 6 months (−0.85 units lower score, 95% CI, −4.93 to +3.23, p = 0.67). In this study, predictors of retention in treatment at six months were lower (better) CHRISTO score (p = 0.01), age below 29.5 years (p = 0.02) and of borderline statistical significance was being married or cohabiting (p = 0.06).Conclusions: A local RCT is not feasible. As a pilot this study lacked power but the results suggest that, in practice, in the UK, buprenorphine may be more able to retain patients in treatment, suppress illicit opiate use and improve functioning. Given the significantly higher cost of buprenorphine a larger study is needed to answer these questions.

Treatment Retention in a Prison-based Residential Sex Offender Treatment Program

This study assessed the role of static factors, a dynamic factor (motivation to change sexually deviant behavior), and an administrative factor in predicting treatment retention within a prison-based sex offender treatment program. The analyses also included assessing differences in initial levels of motivation and differences in beginning-versus end-of-treatment motivation scores for various types of program discharges. The sample consisted of 251 individuals who were admitted to a residential prison-based sex offender treatment program where 46% completed the program. Paired comparison t-tests showed higher motivation scores at the end of treatment only among treatment completers. Multivariate analyses showed that treatment retention was associated with higher initial motivation scores, higher levels of education and admission to treatment within 3 months of initial commitment to prison. Implications for motivational enhancement programming as well as for changes in admission criteria are discussed.

Treatment Retention in a Prison-based Residential Sex Offender Treatment Program

This study assessed the role of static factors, a dynamic factor (motivation to change sexually deviant behavior), and an administrative factor in predicting treatment retention within a prison-based sex offender treatment program. The analyses also included assessing differences in initial levels of motivation and differences in beginning-versus end-of-treatment motivation scores for various types of program discharges. The sample consisted of 251 individuals who were admitted to a residential prison-based sex offender treatment program where 46% completed the program. Paired comparison t-tests showed higher motivation scores at the end of treatment only among treatment completers. Multivariate analyses showed that treatment retention was associated with higher initial motivation scores, higher levels of education and admission to treatment within 3 months of initial commitment to prison. Implications for motivational enhancement programming as well as for changes in admission criteria are discussed.

The impact of a social network intervention on retention in Belgian therapeutic communities: a quasi‐experimental study

Although numerous studies recognize the importance of social network support in engaging substance abusers into treatment, there is only limited knowledge of the impact of network involvement and support during treatment. The primary objective of this research was to enhance retention in Therapeutic Community treatment utilizing a social network intervention. The specific goals of this study were (1) to determine whether different pre-treatment factors predicted treatment retention in a Therapeutic Community; and (2) to determine whether participation of significant others in a social network intervention predicted treatment retention. Consecutive admissions to four long-term residential Therapeutic Communities were assessed at intake (n = 207); the study comprised a mainly male (84.9%) sample of polydrug (41.1%) and opiate (20.8%) abusers, of whom 64.4% had ever injected drugs. Assessment involved the European version of the Addiction Severity Index (EuropASI), the Circumstances, Motivation, Readiness scales (CMR), the Dutch version of the family environment scale (GKS/FES) and an in-depth interview on social network structure and perceived social support. Network members of different cohorts were assigned to a social network intervention, which consisted of three elements (a video, participation at an induction day and participation in a discussion session). Hierarchical regression analyses showed that client-perceived social support (F1,198 = 10.9, P = 0.001) and treatment motivation and readiness (F1,198 = 8.8; P = 0.003) explained a significant proportion of the variance in treatment retention (model fit: F7,197 = 4.4; P = 0.000). By including the variable 'significant others' participation in network intervention' (network involvement) in the model, the fit clearly improved (F1,197 = 6.2; P = 0.013). At the same time, the impact of perceived social support decreased (F1,197 = 2.9; P = 0.091). Participation in the social network intervention was associated with improved treatment retention controlling for other client characteristics. This suggests that the intervention may be of benefit in the treatment of addicted individuals.

Motivation and readiness for therapeutic community treatment: Psychometric evaluation of the Dutch translation of the Circumstances, Motivation, Readiness, and Suitability scales

There is empirical evidence that treatment motivation and readiness are closely linked to retention. Several instruments have been developed to measure these concepts; such instruments can reliably assess the stages of motivation and readiness, and predict treatment retention and outcome. However, limited efforts have been undertaken in Europe to translate those instruments and to determine their reliability and validity. In this study, the psychometric properties of a Dutch translation of the Circumstances, Motivation, Readiness, and Suitability (CMRS) scales by De Leon and Jainchill [Journal of Psychoactive Drugs 8 (1986) 203–208] and the shortened CMR Intake Version are illustrated in a Flemish sample of therapeutic community residents ( n = 207). Exploratory factor analyses confirm three CMR subscales, although confirmatory factor analysis reveals only a moderate fit for both the CMRS and the CMR. In contrast, the predictive power of the instrument is strong, specifically for 1-year retention. Significant correlations were found between CMRS measures and age, drug severity, legal referral, and social problems. It is concluded that the Dutch translation of the CMRS and the CMR can be employed as a valid indicator of treatment motivation and readiness, although additional research concerning factorial structures is needed.

Predicting Treatment Retention with a Brief “Opinions About Methadone” Scale

It is important to identify social conditions, program factors, and client characteristics that predict retention because time in substance abuse treatment is associated with improved health, mood, and social functioning. Treatment dropouts also are at high risk for serious harms, including relapse. Most opioid-dependent persons require long-term stabilization in methadone maintenance treatment (MMT) to normalize brain function and control withdrawal symptoms. The purpose of this study was to determine whether a client characteristic. namely, attitude toward methadone, was related to retention. Analysis of 14 opinion statements about methadone identified a reliable five-item scale with factorial validity. This scale (Opinions About Methadone; OAM-5) also predicted retention in MMT. Of 338 clients followed for one year after MMT enrollment, 48% dropped out of treatment; those who were more likely to remain had more favorable opinions. A supplementary qualitative study with MMT counselors demonstrated face validity for the OAM-5; counselors found the items easy to interpret and relevant to client attitudes towards MMT. The findings suggest that it would be worthwhile for MMT staff to assess client attitudes at intake, using the OAM-5. This would help them to identify and intervene promptly with those in greatest need of support for remaining in treatment.

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations.

Treatment motivation in drug users: A theory-based analysis

Motivation for drug use treatment is widely regarded as crucial to a client's engagement in treatment and success in quitting drug use. Motivation is typically measured with items reflecting high treatment readiness (e.g., perceived need for treatment and commitment to participate) and low treatment resistance (e.g., skepticism regarding benefits of treatment). Building upon reactance theory and the psychotherapeutic construct of resistance, we conceptualized these two aspects of treatment motivation – readiness and resistance – as distinct constructs and examined their predictive power in a sample of 1295 drug-using offenders referred to treatment while on probation. The sample was 60.7% African Americans, 33.5% non-Hispanic Whites, and 21.2% women; their ages ranged from 16 to 63 years old. Interviews occurred at treatment entry and 6 months later. Readiness (but not resistance) predicted treatment retention during the 6-month period. Resistance (but not readiness) predicted drug use, especially among offenders for whom the treatment referral was coercive. These findings suggest that readiness and resistance should both be assessed among clients entering treatment, especially when the referral is coercive. Intake and counseling protocols should address readiness and resistance separately.