Treatment Entry Research Articles

Simulated long-term outcomes of early use of long-acting injectable antipsychotics in early schizophrenia.

Duration of untreated psychosis in early schizophrenia impacts long-term outcomes. Because long-acting injectable (LAI) antipsychotic drugs improve adherence in early-stage patients, they could reduce additional time in uncontrolled psychosis (TUP) during the critical period of the illness. However, the long-term benefit of early LAI use over oral formulations has not been quantified. This study explores the potential magnitude of the benefit with a simulation approach. A microsimulation models the effects of 11 treatment pathways reflecting alternative decisions on whether and when LAI agents are used during a "calibration phase" that starts at treatment entry and lasts until the end of the 3-year critical period. Treatment failure prolongs time in psychosis. Long-term outcomes are predicted over the ensuing 7-year period as a function of TUP. An "early LAI" pathway where LAI treatment follows the second oral treatment failure is compared to an oral-only pathway. Under these pathways, 69% and 46% of patients, respectively, are estimated to exit the calibration phase with adequate symptom control (total positive and negative syndrome scale score below 68). Relative to the oral-only pathway, the early LAI pathway is predicted to increase competitive employment by 39% (25% vs 18%) and independent or family living by 22% (71% vs 58%), and to decrease receipt of disability benefits by 36% (42% vs 66%) and hospital admissions per 1000 patient-years by 15% (249% vs 294%). While these simulation results need to be confirmed empirically, they suggest that earlier use of LAI antipsychotics can meaningfully improve patient outcomes.

Arguments supporting and opposing legalization of safe consumption sites in the U.S.

BackgroundSafe consumption sites are spaces where people can legally use pre-obtained drugs under medical supervision and are currently in operation in Canada, Australia and Western Europe. These sites are effective in reducing opioid overdose mortality and other harms associated with opioid use, such as HIV infection, and increasing drug treatment entry. Various U.S. communities are considering establishing safe consumption sites, however, only 29% of U.S. adults support their legalization. This purpose of this study is to assess what types of arguments resonate with the public in support of and opposition to legalizing safe consumption sites to combat the opioid epidemic. MethodsA public opinion survey of U.S. adults in July-August 2017 (N = 1004) used a probability-based sample of respondents from a large, nationally representative online panel. The survey examined the public’s perception of the strength of common arguments offered in support of and opposition to legalizing safe consumption sites. Arguments were identified through a detailed scan of news media coverage, public reports, and advocacy materials. ResultsThe national sample of U.S. adults rated all arguments opposing legalization of safe consumption sites as stronger than any of the arguments supporting legalization. The most highly rated opposing arguments were that public funds were better spent on addiction treatment, and that sites were allowing illegal activity and encouraging people to use drugs. The highest rated arguments supporting legalization were that safe consumption sites were a better alternative than arresting people for using drugs, they would reduce HIV and hepatitis C by encouraging safe injection practices, and that they would lower emergency department admission and hospitalization costs. ConclusionLegalization of this evidence-based harm reduction approach in U.S. communities will be difficult to advance without public education to confront persistent myths that safe consumption sites encourage drug use and do not facilitate treatment access.

Assessment of medication for opioid use disorder as delivered within the Vermont hub and spoke system

Opioid overdose deaths in the United States have risen dramatically in the past decade. In response to this public health crisis, Vermont created an innovative system called the “hub-and-spoke” (H & S) system, initiated in January 2013. The H & S system has 7 regional “hubs” that offer methadone and buprenorphine, as well as intensive support, and 77 local “spokes” (primary care settings) that offer buprenorphine (and naltrexone to a much lesser extent). Questionnaires were administered to 80 participants in the H & S system (stratified by geographic region, treatment site, and gender) and 20 participants with opioid use disorder not currently in treatment. Data included demographics, drug and alcohol use; opioid use; injection use; education/employment; criminal justice involvement; family and relationship functioning; health and healthcare utilization; multiple areas of mental health functioning; opioid overdose; satisfaction with life areas; stigma; and perceived treatment effectiveness. In-treatment group participants reported use and functioning for the 90 days prior to the date of the interview (T2) and, retrospectively, a comparable 90-day period prior to treatment entry (T1). Out-of-treatment group participants were queried about functioning at the time of the interview (T2) and 12 months earlier (T1). Individuals not in treatment showed no meaningful changes in any domain from T1 to T2. Conversely, participants currently in treatment in the H & S system showed large reductions in substance use, overdoses, emergency department visits, police contacts, and family conflict, and improvements in mood and satisfaction with all areas of life, except work/school participation. Additionally, 85% of in-treatment participants reported 90-day abstinence from opioid use compared to 0% of out-of-treatment participants at T2. These findings illustrate that medication for opioid use disorders, as delivered in the H & S system in Vermont, is highly effective for reducing opioid use and overdose and improving functioning in many life domains.

Delivering information about medication assisted treatment to individuals who misuse opioids through a mobile app: a pilot study.

Digital therapeutic tools (e.g. mobile applications) can be accessible, low-cost interventions that counter misconceptions about medication assisted treatment (MAT) and/or improve deficits in MAT knowledge that are common barriers to treatment entry among individuals with opioid dependence. The purpose of this pilot study was to examine the preliminary effectiveness of a mobile application, 'uMAT-R', that includes health information about OUD recovery supported by science and MAT benefits. Twenty-six adult participants with OUD recruited via social media completed all modules and pre/post-assessments within uMAT-R. McNemar's test was used to compare interest in treatment before and after completing the app, and paired t tests were used to compare MAT attitude scores before and after completing the modules within uMAT-R. Before viewing uMAT-R, 32% agreed/strongly agreed that they were interested in starting treatment to recover from opioid misuse, compared to 48% after completing uMAT-R. The average scores on the MAT attitudes scale and its Aid to Behavior Change subscale improved from before to after viewing uMAT-R. Among the participants, 88% felt that uMAT-R would be useful to consult when making decisions about recovery. Our encouraging pilot findings support the use of uMAT-R to help address the current opioid epidemic.

Relapse after inpatient substance use treatment: A prospective cohort study among users of illicit substances

AimsThe main aim was to investigate the relative roles of mental distress and intrinsic motivation for relapse after inpatient substance use disorder (SUD) treatment, while adjusting for demographics and treatment variables. MethodsThe study is based on a prospective multicenter study with a baseline gross sample of 607 patients with SUD (response rate = 84%) admitted to an inpatient stay at one of five specialized SUD treatment centers in Norway. The analytical sample consisted of patients with illicit drug use (n = 374) who took part in a follow-up interview three months after discharge from inpatient treatment (n = 249) (retention rate = 67%). Data were collected using information from electronic medical records, a self-report questionnaire at treatment entry, and a follow-up interview. ResultsRelapse occurred among 37% of the sample by three-month follow-up. Results of multivariable analysis showed that younger age and having a psychiatric diagnosis were associated with an elevated relapse risk. Patients who received treatment at a short-term clinic (2–4 months), as opposed to a long-term clinic (>6 months) were also at increased risk of relapse, regardless of their length of stay. Reduced risk of relapse was predicted by having completed the inpatient treatment stay. ConclusionIdentifying the treatment needs of young patients and patients with co-occurring psychiatric diagnoses during and following inpatient SUD treatment may contribute to reduced post-treatment relapse rates. Further research is needed to illuminate the treatment-related factors that contribute to reduced risk of relapse after inpatient SUD treatment.

The prognosis of out-patient alcohol treatment among parents with childcare responsibility.

Despite expansive knowledge on the detrimental effects of growing up with parents with alcohol use disorders (AUDs), little is known about the prognosis of alcohol treatment among parents with childcare responsibility. This observational cohort study aimed to examine the prognosis of patients with and without childcare responsibility, in a conventional out-patient alcohol treatment clinic. A consecutive AUD sample (N = 2201), based on ICD-10 Diagnostic Criteria for Research, was assessed with the European Addiction Severity Index during the clinical routine, at treatment entry and conclusion. Data on addiction severity, treatment course and drinking outcomes were derived, and adjusted odds ratios (AORs) were calculated with logistic-regression models. Drinking outcomes were compared in an intention-to-treat analysis, including all patients in a logistic regression with inverse probability weighting. Patients with childcare responsibility (aged <18 years) had a less severe addiction profile and lower drop-out rate compared with patients without children or with children living out-of-home. They were also more likely to improve on all drinking-related outcomes, including abstinence (AOR 2.68, 95% CI 1.82-3.95), number of drinking days (AOR 2.45, 95% CI 1.50-4.03) and excessive drinking days (AOR 4.66, 95% CI 2.36-9.17); and those with children living out-of-home had better outcomes on abstinence (AOR 1.59, 95% CI 1.08-2.34) than patients without children. Childcare responsibility among out-patients was associated with better treatment course and outcomes than those without or not living with their children. This knowledge can help guide clinical practice, effectuate interventions and inform social authorities.

Fentanyl exposure among patients seeking opioid treatment

AimOverdoses attributed to the potent opioid agonist fentanyl have substantially increased in recent years. Despite these serious public health consequences, many opioid treatment providers do not currently include a fentanyl assay in their urine toxicology testing. As a result, extent of fentanyl exposure and related risks among individuals with opioid use disorder often remains unknown. We examined the prevalence of fentanyl exposure among patients seeking or enrolled in opioid agonist treatment. MethodsSix hundred urine specimens were collected from adults entering (n = 100) or enrolled in (n = 500) opioid agonist treatment and analyzed using the clinic's standard opioid panel, supplemented with a 100 ng/ml fentanyl assay. ResultsOf the 100 specimens collected from patients at treatment intake, 19 (19%) tested positive for fentanyl. Importantly, 17 (90%) of those fentanyl-positive specimens were also positive for heroin. Of the 500 collected from patients in treatment, 17 (3%) of specimens tested positive for fentanyl. Of those, 11 (92%) were also positive for heroin. ConclusionThese data illustrate a concerning degree of fentanyl exposure among patients seeking treatment and suggest that much of this exposure may have stemmed from fentanyl-containing heroin. Given the unprecedented recent surges in fentanyl-related overdoses, efforts to identify fentanyl exposure are critical. In particular, the point of treatment entry permits a rare systematic opportunity for medical and clinical staff to address fentanyl use and risks with incoming patients.

Characteristics of Pregnant Women Reporting Cannabis Use Disorder at Substance Use Treatment Entry.

The current study examined distinct characteristics of yearly trend, sociodemographic, and treatment-related variables of prenatal cannabis use as the primary drug of choice among pregnant women admitted to substance use treatment for the first time. The Treatment Episode Data Set-Admission between 1992 and 2015 was used for a cross-sectional study focused on prenatal cannabis use reported at treatment admission. Among pregnant women admitted to substance use treatment for the first time (n = 489,796), 40.6% reported any level of cannabis use, and 40.8% reported cannabis use as the primary drug of choice at treatment admission. Adjusted for other characteristics, a statistically significant change in overall trends for any prenatal cannabis use, and also in cannabis use as the primary drug of choice over 20 years was detected. While pregnant women reporting cannabis use as the primary drug of choice were significantly less likely to co-use other substances, those involved in the criminal justice system were significantly more likely to co-use cocaine and opioids, but significantly less likely to co-use alcohol. Continued monitoring of prenatal cannabis use and patterns of other substance co-use is encouraged, given the perceived harm of cannabis use in young generations has lessened in recent years, coinciding with the legalization process. Targeted education materials and treatment options to treating prenatal cannabis use should be developed tailored to substance use characteristics and criminal justice involvement.

Multidimensional family therapy in adolescents with a cannabis use disorder: long-term effects on delinquency in a randomized controlled trial

BackgroundSubstance use and delinquency are considered to be mutual risk factors. Previous studies have shown that multidimensional family therapy (MDFT) is effective in tackling both conditions on the short term. The current study examines the long-term effects of MDFT on criminal offending.Methods109 adolescents with cannabis use disorder and comorbid problem behavior were randomly assigned to either MDFT or cognitive behavioral therapy (CBT). Police arrest data were collected for 6 years: 3 years prior to and 3 years after treatment entry. Using survival analysis and repeated measure General Linear Models (rmGLM), the two treatment groups were compared on number of arrests, type of offence, and severity of offence. Moderator analyses looking at age, disruptive behavior disorders, history of crimes, family functioning, and (severe) cannabis use were conducted (rmGLM).ResultsWhile police arrest rates increased in the 3 years before treatment, the rates decreased substantially after the start of both treatments. No differences were found between the treatment groups with respect to either time to first offence from the start of the treatment or changes in frequency or severity of offending over time. A treatment effect trend favoring MDFT was found for property offending in the subgroup of adolescents with high baseline-severity of cannabis use.ConclusionsAcross a follow-up period of 3 years, MDFT and CBT were similarly effective in reducing delinquency in adolescents with a cannabis use disorder.Trial registration ISRCTN51014277, Registered 17 March 2010—Retrospectively registered, http://www.isrctn.com/ISRCTN51014277

Access to treatment for alcohol use disorders following Oregon's health care reforms and Medicaid expansion

The study examines impacts of delivery system reforms and Medicaid expansion on treatment for alcohol use disorders within the Oregon Health Plan (Medicaid). Diagnoses, services and pharmacy claims related to alcohol use disorders were extracted from Medicaid encounter data. Logistic regression and interrupted time series analyses assessed the percent with alcohol use disorder entering care and the percent receiving pharmacotherapy before (January 2010–June 2012) and after (January 2013–June 2015) the initiation of Oregon's Coordinated Care Organization (CCO) model (July 2012–December 2012). Analyses also examined changes in access following Medicaid expansion (January 2014).Treatment entry rates increased from 35% in 2010 to 41% in 2015 following the introduction of CCOs and Medicaid expansion. The number of Medicaid enrollees with a diagnosed alcohol use disorder increased about 150% from 10,360 (2013) to 25,454 (2014) following Medicaid expansion. Individuals with an alcohol use disorder who were prescribed a medication to support recovery increased from 2.3% (2010) to 3.8% (2015). In Oregon, Medicaid expansion and health care reforms enhanced access and improved treatment initiation for alcohol use disorders.

How patient navigators view the use of financial incentives to influence study involvement, substance use, and HIV treatment

Background and aimsWhile patient navigation has been shown to be an effective approach for linking persons to HIV care, and contingency management is effective at improving substance use-related outcomes, Project HOPE combined these two interventions in a novel way to engage HIV-positive patients with HIV and substance use treatment. The aims of this paper are to examine patient navigator views regarding how contingency management interacted with and affected their navigation process. DesignSemi-structured qualitative interviews. Participants22 patient navigators from the original 10 Project HOPE study sites. MeasurementsIndividual, semi-structured interviews lasting approximately 60 min addressed the patient navigator's professional background, descriptions of the participant population, substance use disorder versus HIV treatment entry and engagement issues, and the use of contingency management within the navigation service delivery protocol. FindingsPatient navigators believed that financial incentives helped motivate participant attendance at navigation sessions, particularly early in study involvement, which helped them to establish rapport and develop relationships with participants. Patient navigators often noted that financial incentives positively influenced targeted HIV health-related behaviors, such as attending medical appointments, which provided a rapid pay-off with an escalating sum. Contingency management was more complex when used by the patient navigators for substance use-related behaviors, particularly when incentives revolved around negative urine screening. Patient navigators noted that not all participants responded the same way to the contingency management and that the incentives were particularly helpful when participants were financially strained with limited resources or when internal motivation was lacking. ConclusionsOverall patient navigators found the inclusion of contingency management to be helpful and affective at influencing participant behaviors, particularly concerning navigation session attendance and HIV healthcare-related participation. However, issues and concerns surrounding the inclusion of contingency management for drug-related behaviors as delivered in Project HOPE were noted.Clinical Trials Registration: NCT01612169

Long-Term Opioid Agonist Treatment Participation after First Treatment Entry is Similar across 4 European Regions but Lower in Non-Nationals

Heroin users in opioid agonist treatment (OAT) show markedly reduced heroin consumption, less crime and a lower mortality rate. However, the extent of long-term OAT participation over subsequent treatment episodes remains unclear. We analysed the annual proportion of patients in treatment (at least 1 day) since the start of first OAT in 4 European regions: Barcelona (BA) 1996–2012: 8,602 patients; Czech ­Republic (CZ) 2000–2014: 4,377 patients; Netherlands (NL) 1994–2014: 33,235 patients, Zurich (ZU) 1992–2015: 11,795. We estimated the long-term decline of treatment need due to mortality or abstinence and also a “nuisance” short-term decline until the equilibrium level of cycling in and out of OAT is reached to obtain the adjusted treatment participation value. The adjusted treatment participation was around 50% (BA: 47.4–51.4%; CZ: 49.8–53.9%; NL: 52.3–54.0%; ZU: 46.4–49.3%), and the annual decline of treatment need was close to 4%. Non-nationals (NL patients with a migrant background) showed substantial lower adjusted treatment participation (rate ratio BA: 0.059–0.343; NL: 0.710–0.751; ZU: 0.681–0.797; CZ: n.a.). Our method may provide a policy-relevant indicator of long-term provision, quality and access to OAT following first treatment.

Efficiency and Sustainability in Teamwork: The Role of Entry Costs

This research studies how incentives to cooperation and sustainability through up-front pay mechanisms can impact teamwork. For this purpose, we carry out certain laboratory experiments on the two-player Minimum Effort Game. First, we compare two treatments: one with “free play teams”, against teams forced to make a non-refundable up-front payment that covers the total output in case of maximum contribution, which we call “optimal entry cost teams”. In the second comparison, experimental results are focused on different amounts in the up-front pay in order to test the theoretical prediction that higher entry costs might improve efficiency (optimal entry cost treatment vs. medium entry cost treatment). We find that the up-front pay mechanism induces higher effort levels compared to the “free play teams”, which converge to the efficient and sustainable solution. The increase in the up-front pay, however, does not seem to accelerate such a convergence. These findings provide evidence for a new mechanism to encourage efficiency and sustainability in firms.

The effect of financial incentives on patients\u2019 motivation for treatment: results of \u201cMoney for Medication,\u201d a randomised controlled trial

BackgroundOffering financial incentives is an effective intervention for improving adherence in patients taking antipsychotic depot medication. We assessed whether patients’ motivation for treatment might be reduced after receiving financial rewards.MethodsThis study was part of Money for Medication, a multicentre, open-label, randomised controlled trial, which demonstrated the positive effects of financial incentives on antipsychotic depot compliance. Three mental healthcare institutions in Dutch secondary psychiatric care services participated. Eligible patients were aged 18–65 years, had been diagnosed with schizophrenia or another psychotic disorder, had been prescribed antipsychotic depot medication or had an indication to start using depot medication, and were participating in outpatient treatment. For 12 months, patients were randomly assigned either to treatment as usual (control group) or to treatment as usual plus a financial reward for each depot of medication received (€30 per month if fully compliant; intervention group). They were followed up for 6 months, during which time no monetary rewards were offered for taking antipsychotic medication. To assess treatment motivation after 0, 12 and 18 months, interviews were conducted using a supplement to the Health of the Nation Outcome Scales (HoNOS) and the Treatment Entry Questionnaire (TEQ).ResultsPatients were randomly assigned to the intervention (n = 84) or the control group (n = 85). After 12 months, HoNOS motivation scores were available for 131 patients (78%). Ninety-one percent of the patients had no or mild motivational problems for overall treatment; over time, there were no significant differences between the intervention and control groups. TEQ data was available for a subgroup of patients (n = 61), and showed no significant differences over time between the intervention and control groups for external motivation (β = 0.37 95% CI: -2.49 – 3.23, p = 0.799); introjected motivation (β = − 2.39 95% CI: -6.22 – 1.44, p = 0.222); and identified motivation (β = − 0.91 95% CI: -4.42 – 2.61, p = 0.613). After the 6-month follow-up period, results for the HoNOS and TEQ scores remained comparable.ConclusionsOffering financial incentives for taking antipsychotic depot medication does not reduce patients’ motivation for treatment.Trial registrationNetherlands Trial registration, number NTR2350.

Initiating buprenorphine treatment prior to versus after release from prison: Arrest outcomes

BackgroundThis secondary analysis of a randomized trial examines the association between initiation of buprenorphine treatment prior to, versus post-release, and rearrests during the 12-months following release. MethodsOfficial rearrest data (N = 199) for the 12-months post-release were examined. Four outcomes were measured: (1) rearrested (yes/no), (2) time to rearrest, (3) number of rearrests, and (4) severity of charges (less severe vs. severe). ResultsA minority (43.1%) of the sample were rearrested (N = 91). There were no significant differences between study conditions in the proportion of rearrested participants [P = 0.28] nor in the mean number of arrests [P = 0.15]. Likewise, the condition was not a significant predictor of the hazard of rearrest [p = 0.10]. The mean number of days until rearrest for the in prison vs. post-release buprenorphine conditions were not significantly different (205.8 days (SD = 104.6) vs. 170.8 days (SD = 113.1), respectively; P = 0.13]. Treatment condition was not a significant predictor of the likelihood of rearrest for a severe crime compared to a less severe crime [P = 0.09]. ConclusionDespite the parent study finding of higher rates of post-release drug treatment entry in the group assigned to start buprenorphine treatment prior to, compared to post-release, there were no significant differences in the proportion of individuals arrested, the mean number of arrests, the time to first arrest, or the severity of their charges.

PMH52 - The Long-Term Benefits of Ensuring Timely Treatment and Improved Medication Adherence in Early Schizophrenia: A Microsimulation Study

In early-stage schizophrenia, the duration of untreated psychosis (DUP) accrued prior to treatment entry is known to have long-term prognostic implications. Emerging evidence suggests that “time in psychosis” accrued after treatment entry is similarly consequential. This evidence has spawned efforts to get patients into treatment earlier and ensure optimal treatment, including with antipsychotic drugs. We use a microsimulation model to quantify the 10-year impact of shortening overall time in uncontrolled psychosis, i.e., the sum of DUP and time in psychosis accrued due to ineffective antipsychotic treatment. The model varies DUP as a function of the success of efforts to promote treatment entry and in-treatment time in psychosis as a function of antipsychotic drug adherence affecting effectiveness. Patients enter treatment with a DUP randomly drawn from three published distributions (short, medium, and long). Based on published evidence, adherence is assumed to be 33% and 95% for oral and long-acting injectable (LAI) agents, respectively. Each ineffective treatment attempt increases DUP by three months. Accrued time in uncontrolled psychosis during the first three years predicts outcomes over the ensuing seven years. If only oral agents are used, short DUP is estimated to lead to relative reductions in schizophrenia-related hospital admissions of 12.6%-14.4% and receipt of disability benefits of 7.0%-8.5%, and relative increases in independent/family living of 41.5%-46% and competitive employment of 42%-58%, compared to medium and long DUPs, respectively. If patients with short DUP start LAI treatment after the second oral drug failure, admissions and receipt of disability benefits are reduced by an additional 17% and 40%, respectively, while probability of independent/family living and competitive employment increase by 27% and 49%, respectively. While these simulation results should be confirmed with direct empirical evidence, they imply substantial long-term benefits of combining timely treatment entry with pro-adherence interventions in early schizophrenia.

Preliminary psychometric evaluation of the micro-condescension scale for individuals in substance use treatment

Background: Stigma and discrimination are often experienced by individuals going through substance use treatment, and can influence treatment seeking, retention, and outcomes including long-term recovery.Aims: The aim of the current study was to evaluate the psychometric properties of the Micro-Condescension Scale (MCS), a newly developed tool to measure individuals’ perceptions of microlevel stigma and discrimination for seeking substance use treatment or being in recovery.Methods: The MCS was administered to individuals (n = 90) at the beginning and end of a mindfulness treatment program implemented in a substance use treatment facility in Southern California. Principal components analysis was used to evaluate the factor solution and psychometric analyses were applied to investigate reliability and validity of the MCS.Results: The principal component analysis yielded a single factor solution for the 12-item scale. Cronbach's alpha was 0.93 at treatment entry (pretest) and 0.91 at treatment exit (posttest). The scale showed acceptable test–retest reliability and correlated with measures of impulsivity, perceived devaluation–discrimination scores, and self-awareness in cross-sectional and prospective analyses.Discussion: Following additional validation research, future studies on discriminatory experiences and substance use treatment outcomes should consider using the MCS due to its brevity and acceptable psychometric properties.

What Happens After Treatment? Long-Term Effects of Continued Substance Use, Psychiatric Problems and Help-Seeking on Social Status of Alcohol-Dependent Individuals.

We examined whether alcohol-dependent individuals with sustained substance use or psychiatric problems after completing treatment were more likely to experience low social status and whether continued help-seeking would improve outcomes. Ongoing alcohol, drug and psychiatric problems after completing treatment were associated with increased odds of low social status (unemployment, unstable housing and/or living in high-poverty neighborhood) over 7 years. The impact of drug problems declined over time, and there were small, delayed benefits of AA attendance on social status. Alcohol-dependent individuals sampled from public and private treatment programs (N = 491; 62% male) in Northern California were interviewed at treatment entry and 1, 3, 5 and 7 years later. Random effects models tested relationships between problem severity (alcohol, drug and psychiatric problems) and help-seeking (attending specialty alcohol/drug treatment and Alcoholics Anonymous, AA) with low social status (unemployment, unstable housing and/or living in a high-poverty neighborhood) over time. The proportion of participants experiencing none of the indicators of low social status increased between baseline and the 1-year follow-up and remained stable thereafter. Higher alcohol problem scores and having any drug and/or psychiatric problems in the years after treatment were associated with increased odds of low social status over time. An interaction of drug problems with time indicated the impact of drug problems on social status declined over the 7-year period. Both treatment-seeking and AA attendance were associated with increased odds of low social status, although lagged models suggested there were small, delayed benefits of AA attendance on improved social status over time. Specialty addiction treatment alone was not sufficient to have positive long-term impacts on social status and social integration of most alcohol-dependent people.

Rehospitalization and substance use disorder (SUD) treatment entry among patients seen by a hospital SUD consultation-liaison service

BackgroundSubstance use disorders (SUD) are associated with non-adherence to medical care and high utilization of hospital services. This study characterized patterns and correlates of rehospitalization among patients seen by a hospital-based SUD consultation-liaison (CL) team. MethodsThis study was a retrospective medical record review of patients in a large urban academic hospital who received SUD consultation and were diagnosed with opioid, cocaine, and/or alcohol use disorder (N = 267). Data were collected on patient characteristics, substance-specific SUD diagnoses (opioids, cocaine, and alcohol), opioid agonist treatment (OAT) with methadone or buprenorphine (treatment status at admission; in-hospital initiation of OAT), and rehospitalization through 180 days post-discharge. Associations with rehospitalization were examined using bivariate tests of independence and multivariate logistic regression, with patient background and medical characteristics, substance-specific SUD diagnoses, and OAT status (at admission and in-hospital initiation) as predictors. ResultsRehospitalization rates were higher among patients with current opioid (38% vs. 24%; p < .05) and cocaine use disorders (39% vs. 26%; p < .05) compared to patients without these diagnoses. In multivariate logistic regression analysis, the number of medical comorbidities [Adjusted Odds Ratio (AOR) = 1.2; p < .01] and opioid use disorder (AOR = 2.4, p < .05) were independently associated with rehospitalization. ConclusionsIn this sample of hospital patients receiving SUD CL services, the risk of rehospitalization differed by type of SUD diagnosis. In-hospital initiation of OAT is promising for facilitating treatment linkage post-discharge, but this small study did not show differences in rehospitalization based on OAT initiation. These findings could inform services for hospital patients with comorbid SUDs.

How enough becomes enough: Processes of change prior to treatment for substance use disorder

ABSTRACTAim: Explore patient’s perceptions of change processes occurring prior to inpatient treatment for substance use disorder, forming the basis for treatment entry. Method: Four single focus-group interviews including a total of 14 patients (11 men and 3 women) were conducted in accordance with a brief interview guide. Interviews focused on patient’s perceptions of change processes prior to treatment entry, associated factors, decision-making and implications for their way forward. A content analysis was conducted to identify code and subcategorize meaning units. Results: Patients describe complex processes of change involving a new perception of life situation enabled by accumulation and escalation of negative consequences, especially related to loss and health, along with an external pressure or trigger. The transition to treatment entry is either based on a deliberate and active decision or a result of spontaneous action and less deliberate decision to initiate in treatment. Conclusions: Patient’s perceptions of treatment entry as a result of a more or less deliberate decision challenges patient’s readiness at treatment entry, constituting an important clinical challenge of relevance for clarifying treatment goals and interventions which in turn may affect the course of treatment applied to the patient.