Theory-based active ingredients of effective treatments for substance use disorders

The impact of reality therapy on self-efficacy for substance-involved female offenders in Taiwan

This study aimed to fulfill a twofold purpose. First, a 12-session reality therapy drug treatment program to enhance substance-involved females' self-efficacy in three aspects, which have been demonstrated to be essential to recovery, was designed and implemented. Second, to test the effectiveness of the treatment program, the Index of Sense of Self-Efficacy Scale was developed and validated using Principal Component Analysis and Confirmatory Factor Analysis. The participants in the drug treatment program were 40 incarcerated substance-involved female offenders, who were randomly assigned to equal-sized experimental and control groups. The results of the study, obtained by ANCOVA analysis, showed significant differences in the post-test scores for sense of self-efficacy in decision making, action-planning, and coping and social skills for the members of the two groups.

Distinct facets of impulsivity exhibit differential associations with substance use disorder treatment processes: a cross-sectional and prospective investigation among military veterans

Impulsivity, a multi-faceted construct characterized by rash, unplanned actions and a disregard for long-term consequences, is associated with poor substance use disorder (SUD) treatment outcomes. Little is known though about the influence of impulsivity on treatment process variables critical for initiating and maintaining behavioral change. This knowledge gap is important as different aspects of impulsivity may be susceptible to diverse cognitive, behavioral and pharmacological influences. The present study examined two distinct facets of impulsivity (lack of planning and immoderation--a proxy of urgency) as predictors of processes that impact SUD treatment success (active coping, avoidant coping, self-efficacy, and interpersonal problems). Participants were 200 Veterans who completed impulsivity and treatment process assessments upon entering an SUD treatment program and treatment process assessments at treatment discharge. Results from multivariate models revealed that lack of planning was associated with lower active coping and higher avoidant coping and interpersonal problems at intake, though not with lower self-efficacy to abstain from substances. Immoderation was associated with higher avoidant coping and lower self-efficacy to abstain from substances at intake, but not with lower active coping or higher interpersonal problems. Higher immoderation, but not lack of planning, predicted lower self-efficacy to abstain from substances at treatment discharge. These findings suggest that different facets of impulsivity confer risk for different SUD treatment process indicators and that clinicians should consider the behavioral expression of patients' impulse control problems in treatment planning and delivery.

The role of lifestyle in perpetuating substance use disorder: the Lifestyle Balance Model

Conceptualizing aetiology underpinning an individual's substance use disorder (SUD) not only facilitates insight and understanding, but also serves to identify targets for treatment and aid practitioners in selecting the most appropriate interventions. There is now a wealth of literature on aetiology and treatment approaches, and in more recent years, also literature to support the concept of 'recovery' from a condition which was previously thought of as a chronic, relapsing condition. The burgeoning literature around research into recovery is revealing how recovery can best be defined and what factors might be associated with recovery from SUD. To add further to this growing body of literature, a new six-domain, explanatory biopsychosocial model of substance dependence and recovery, the Lifestyle Balance Model (LBM) is proposed. Based on research findings and theory reported in the literature, the LBM is a generic model depicting six domains of biopsychosocial functioning and includes within it the role of lifestyle. The LBM has been constructed as a domain model, allowing conceptualisation of the relationships between the six domain areas that perpetuate dependence and may also be associated with recovery from SUD, providing service users and clinicians with a tool for the delivery of case formulation and identification of target areas for intervention.

Predicting Initiation of Smoking Cessation Treatment and Outcome Among Adolescents Using Stressful Life Events and Coping Style

BACKGROUND

Adolescent smoking is a major public health concern, and current treatments are only somewhat effective in promoting abstinence. One way to improve treatments is to identify psychosocial characteristics that impede cessation, allowing development of targeted treatments. This study examined the influence of 2 such characteristics, life event stressors and coping, on initiation of cessation treatment and end-of-treatment abstinence status.

METHODS

One hundred five adolescent smokers were eligible to participate in a validated contingency management (CM) and cognitive-behavioral (CBT) cessation treatment; of those, 72 completed at least 1 treatment session. Data included sociodemographic characteristics, questionnaires assessing past-year life events and coping behavior use, and abstinence status at the end of the 4-week treatment. Logistic regression was used to predict treatment initiation and abstinence status, with life event stressor number, coping, or their interaction as predictors.

RESULTS

Higher levels of cognitive and peer support coping predicted treatment initiation, whereas life events were unrelated. End-of-treatment abstinence was predicted by higher numbers of life events and greater use of avoidant coping. The interaction of helpless coping and life events also predicted abstinence, with greater increases in helpless coping as total life events rose in abstinent but not nonabstinent participants. Finally, greater use of behavioral coping predicted abstinence in participants exposed to only CM treatment, whereas lesser use of behavioral coping predicted abstinence in participants receiving combined CM/CBT treatment.

CONCLUSIONS

Exposure to life event stressors may promote cessation by forcing use of self-control resources prior to the quit attempt, which may strengthen such resources. Techniques that improve self-control resources may improve cessation outcome, and prevention programs may want to emphasize behavioral coping to improve rates of treatment initiation.

Change talk and relatedness in group motivational interviewing: a pilot study

BACKGROUND

Change talk (CT), or client speech in favor of change, is a hypothesized mechanism of action in motivational interviewing (MI) for substance use disorders. Although group-based treatment is the primary treatment modality for the majority of clients seeking substance use treatment, limited research has examined group motivational interviewing (GMI) among this population, and no study has examined CT within GMI. Therefore, in the current study we examined both standard CT (e.g., desire, ability, reason, need) and a novel phenomenon involving CT which we termed 'relatedness,' or the synergistic exchange of CT between and among group members.

METHOD

Data were utilized from an ongoing randomized controlled trial (RCT) examining the effectiveness of GMI relative to a treatment control condition (TCC) among U.S. veteran outpatients with a primary alcohol use disorder at a Veterans Affairs hospital. A subsample of participants (n = 52) from the RCT were randomly assigned to receive GMI or TCC. The majority of participants in the subsample had co-existing psychiatric (88%) and dual diagnosis drug use disorders (38%). Two of four treatment sessions were coded by trained raters for CT and relatedness.

RESULTS

Analyses demonstrated that CT and relatedness occurred with greater frequency in GMI compared to TCC, with effect sizes in the large range for each difference. Results held after controlling for number of group members in treatment sessions.

CONCLUSIONS

Findings suggest that GMI is associated with more frequent CT and relatedness than TCC, consistent with the broader literature demonstrating the influence of MI on CT.

The Use of New Communications Technologies to Evaluate and Intervene in Substance Use Disorders

The widespread availability of high speed, mobile cellular telephones and other advances in communication technology have the potential to change the way that interventions for substance use disorders (SUD) are delivered and how progress is monitored. This article reviews recent research on the use of new technology to monitor progress and deliver interventions for SUD. Several studies of telephone-based interventions show positive effects, but sometimes only in certain subgroups. However, other studies produced negative results. Studies support the use of interactive voice response (IVR) and personal digital assistants (PDAs) to conduct assessments, but there is little data on whether IVR- or PDA-based interventions improve outcomes. Text messaging has received comparatively little research, but appears promising as a means to conduct assessments and deliver automated interventions. Finally, smartphone technology provides the widest range of features and interventions and the greatest flexibility, but few intervention studies that use them have been conducted.

Young adults, social networks, and addiction recovery: post treatment changes in social ties and their role as a mediator of 12-step participation

Background

Social factors play a key role in addiction recovery. Research with adults indicates individuals with substance use disorder (SUD) benefit from mutual-help organizations (MHOs), such as Alcoholics Anonymous, via their ability to facilitate adaptive network changes. Given the lower prevalence of sobriety-conducive, and sobriety-supportive, social contexts in the general population during the life-stage of young adulthood, however, 12-step MHOs may play an even more crucial recovery-supportive social role for young adults, but have not been investigated. Greater knowledge could enhance understanding of recovery-related change and inform young adults’ continuing care recommendations.

Methods

Emerging adults (N = 302; 18–24 yrs; 26% female; 95% White) enrolled in a study of residential treatment effectiveness were assessed at intake, 1, 3, 6, and 12 months on 12-step attendance, peer network variables (“high [relapse] risk” and “low [relapse] risk” friends), and treatment outcomes (Percent Days Abstinent; Percent Days Heavy Drinking). Hierarchical linear models tested for change in social risk over time and lagged mediational analyses tested whether 12-step attendance conferred recovery benefits via change in social risk.

Results

High-risk friends were common at treatment entry, but decreased during follow-up; low-risk friends increased. Contrary to predictions, while substantial recovery-supportive friend network changes were observed, this was unrelated to 12-step participation and, thus, not found to mediate its positive influence on outcome.

Conclusions

Young adult 12-step participation confers recovery benefit; yet, while encouraging social network change, 12-step MHOs may be less able to provide social network change directly for young adults, perhaps because similar-aged peers are less common in MHOs. Findings highlight the importance of both social networks and 12-step MHOs and raise further questions as to how young adults benefit from 12-step MHOs.

Situational and psycho-social factors associated with relapse following residential detoxification in a population of Irish opioid dependent patients

AIMS

To identify and describe the context and factors involved in the opioid lapse process following discharge from an Irish inpatient opioid detoxification treatment programme. Design, participants, setting: Prospective follow-up study of consecutive detoxified opioid dependent patients treated in a specialist inpatient drug dependency unit.

MEASUREMENTS

The Maudsley Addiction Profile and a structured interview were administered to 109 patients, 18-36 months after discharge.

FINDINGS

Of 109 people interviewed at follow-up, 102 (94%) reported at least one episode of opioid use after leaving the residential treatment programme. Eighty eight patients (86% of the lapsers) identified more than one major factor contributing to their recidivism. The median number of factors identified as having a major role in the lapse was four. The most frequently reported major contributors to lapse were low mood (62%), difficulties with craving (62%), ease of access to heroin (48%) and missing the support of the treatment centre (43%).

CONCLUSIONS

Early lapse was common following inpatient treatment of opioid dependence. Lapse tended to result from a number of common, identifiable, high-risk situations, feelings and cognitions which may assist clinicians and patients develop lapse prevention strategies to anticipate and interrupt this process.

Stimulant use and HIV disease management among men in same-sex relationships

BACKGROUND

Research conducted to date has focused primarily on identifying individual-level, psychological determinants of stimulant use and HIV disease management. The present cross-sectional study examined relationship factors as correlates of stimulant use and HIV disease management among men who have sex with men (MSM).

METHODS

In total, 266 male couples completed a baseline assessment for a cohort study examining the role of relationship factors in HIV treatment. A computer-based assessment of relationship factors, self-reported alcohol and substance use, and self-reported anti-retroviral therapy (ART) adherence was administered. All HIV-positive participants also provided a blood sample to measure viral load.

RESULTS

After controlling for demographic characteristics and relationship factors, men in a primary relationship with a stimulant-using partner had more than six-fold greater odds of reporting any stimulant use in the past three months. Among HIV-positive participants on ART (n=371), having a stimulant-using partner was independently associated with 67% lower odds of reporting perfect 30-day ART adherence and more than two-fold greater odds of displaying a detectable HIV viral load. In contrast, more partner-level alcohol use was independently associated with greater odds of reporting perfect 3-day ART adherence and lower odds of displaying a detectable HIV viral load.

CONCLUSIONS

Partner-level stimulant use is an important risk factor for individual-level stimulant use and difficulties with HIV disease management among MSM. To optimize the effectiveness of HIV treatment as prevention, clinical research is needed to develop couples-based interventions targeting stimulant use as a potential driver of detectable HIV viral load.

Functional changes of the reward system underlie blunted response to social gaze in cocaine users

Social interaction deficits in drug users likely impede treatment, increase the burden of the affected families, and consequently contribute to the high costs for society associated with addiction. Despite its significance, the neural basis of altered social interaction in drug users is currently unknown. Therefore, we investigated basal social gaze behavior in cocaine users by applying behavioral, psychophysiological, and functional brain-imaging methods. In study I, 80 regular cocaine users and 63 healthy controls completed an interactive paradigm in which the participants' gaze was recorded by an eye-tracking device that controlled the gaze of an anthropomorphic virtual character. Valence ratings of different eye-contact conditions revealed that cocaine users show diminished emotional engagement in social interaction, which was also supported by reduced pupil responses. Study II investigated the neural underpinnings of changes in social reward processing observed in study I. Sixteen cocaine users and 16 controls completed a similar interaction paradigm as used in study I while undergoing functional magnetic resonance imaging. In response to social interaction, cocaine users displayed decreased activation of the medial orbitofrontal cortex, a key region of reward processing. Moreover, blunted activation of the medial orbitofrontal cortex was significantly correlated with a decreased social network size, reflecting problems in real-life social behavior because of reduced social reward. In conclusion, basic social interaction deficits in cocaine users as observed here may arise from altered social reward processing. Consequently, these results point to the importance of reinstatement of social reward in the treatment of stimulant addiction.

Comorbid mental health and substance abuse issues among individuals in recovery homes: Prospective environmental mediators

Individuals with comorbid internalizing psychological symptoms and substance abuse issues often have more negative outcomes and evidence a relative disparity in treatment gains compared to those with only substance abuse issues. The present study examined social mechanisms over time for individuals living in self-governed recovery homes (Oxford Houses) such as 12-step group activities and social support, which likely influence both abstinence and psychological outcomes. Participants (n = 567) from a national United States sample of Oxford Houses completed baseline and multiple follow-up self-report assessments over a one-year period. A structural equation model was utilized to evaluate predicted relationships among baseline symptoms, 12-step activities, social support, and outcome variables. Results indicated that internalizing symptoms were associated with subsequent mutual help activities, but not directly with social support. Living in an Oxford House for six months and number of 12-step meetings attended were partially mediated by social support variables in predicting abstinence outcomes, but not psychological outcomes. Environments such as Oxford Houses may be viable options for recovering individuals with comorbid internalizing psychological problems, although social support mechanisms primarily promote abstinence. Implications for future research and for Oxford House policies are discussed.

Latent practice profiles of substance abuse treatment counselors: do evidence-based techniques displace traditional techniques?

As more substance abuse treatment counselors begin to use evidence-based treatment techniques, questions arise regarding the continued use of traditional techniques. This study aims to (1) assess whether there are meaningful practice profiles among practitioners reflecting distinct combinations of cognitive-behavioral and traditional treatment techniques; and (2) if so, identify practitioner characteristics associated with the distinct practice profiles. Survey data from 278 frontline counselors working in community substance abuse treatment organizations were used to conduct latent profile analysis. The emergent practice profiles illustrate that practitioners vary most in the use of traditional techniques. Multinomial regression models suggest that practitioners with less experience, more education, and less traditional beliefs about treatment and substance abuse are least likely to mix traditional techniques with cognitive-behavioral techniques. Findings add to the understanding of how evidence-based practices are implemented in routine settings and have implications for training and support of substance abuse treatment counselors.

Practical support aids addiction recovery: the positive identity model of change

BACKGROUND

There is a need for studies that can highlight principles of addiction recovery. Because social relationships are involved in all change processes, understanding how social motivations affect the recovery process is vital to guide support programs.

METHODS

The objective was to develop a model of recovery by examining addicted individuals' social motivations through longitudinal assessment of non-professional support dyads. A qualitative, longitudinal study design was used, combining focus groups and in-depth interviews with addicted individuals and their sponsors. Data were analyzed using the principles of grounded theory: open coding and memos for conceptual labelling, axial coding for category building, and selective coding for theory building. The setting was an addiction recovery social support program in Oslo, Norway. The informants included nine adults affected by addiction, six sponsors, and the program coordinator. The participants were addicted to either alcohol (2), benzodiazepines (1), pain killers (1) or polydrug-use (5). The sponsors were unpaid, and had no history of addiction problems.

RESULTS

Support perceived to be ineffective emerged in dyads with no operationalized goal, and high emotional availability with low degree of practical support. Support perceived to be effective was signified by the sponsor attending to power imbalance and the addict coming into position to help others and feel useful.

CONCLUSIONS

The findings appear best understood as a positive identity-model of recovery, indicated by the pursuit of skill building relevant to a non-drug using identity, and enabled by the on-going availability of instrumental support. This produced situations where role reversals were made possible, leading to increased self-esteem. Social support programs should be based on a positive identity-model of recovery that enable the building of a life-sustainable identity.

Emerging adults' treatment outcomes in relation to 12-step mutual-help attendance and active involvement

BACKGROUND

Participation in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) during and following treatment has been found to confer recovery-related benefit among adults and adolescents, but little is known about emerging adults (18-24 years). This transitional life-stage is distinctive for greater distress, higher density of psychopathology, and poorer treatment and continuing care compliance. Greater knowledge would inform the utility of treatment referrals to 12-step organizations for this age-group.

METHODS

Emerging adults (N=303; 18-24 years; 26% female; 95% White; 51% comorbid [SCID-derived] axis I disorders) enrolled in a naturalistic study of residential treatment effectiveness assessed at intake, 3, 6, and 12 months on 12-step attendance and involvement and treatment outcomes (percent days abstinent [PDA]; percent days heavy drinking [PDHD]). Lagged hierarchical linear models (HLMs) tested whether attendance and involvement conferred recovery benefits, controlling for a variety of confounds.

RESULTS

The percentage attending 12-step meetings prior to treatment (36%) rose sharply at 3 months (89%), was maintained at 6 months (82%), but declined at 12 months (76%). Average attendance peaked at about 3 times per week at 3 months dropping to just over once per week at 12 months. Initially high, but similarly diminishing, levels of active 12-step involvement were also observed. Lagged HLMs found beneficial effects for attendance, but stronger effects, which increased over time, for active involvement. Several active 12-step involvement indices were associated individually with outcome benefits.

CONCLUSIONS

Ubiquitous 12-step organizations may provide a supportive recovery context for this high-risk population at a developmental stage where non-using/sober peers are at a premium.

Behavioral treatment for marijuana dependence: randomized trial of contingency management and self-efficacy enhancement

OBJECTIVE

The purpose of the present study was to develop a treatment for marijuana dependence specifically designed to enhance self-efficacy.

METHOD

The participants were 215 marijuana-dependent men and women randomized to one of three 9-week outpatient treatments: a condition intended to enhance self-efficacy through successful completion of treatment-related tasks (motivational enhancement plus cognitive-behavioral treatment plus contingency management reinforcing completion of treatment homework; MET+CBT+CM(Homework)); a condition that controlled for all elements except for reinforcement of homework (MET+CBT+contingency management reinforcing drug abstinence; MET+CBT+CM(Abstinence)); or a case management control condition (CaseM). Participants in the two MET+CBT conditions were also asked to complete interactive voice recordings three times per week during treatment to confirm homework completion.

RESULTS

All patients showed modest improvements over time through 14months, with few between-treatment effects on outcomes. Latent Class Growth Models, however, indicated that a subsample of patients did extremely well over time. This subsample was more likely to have been treated in the CM(Abstinence) condition. In turn, this treatment effect appears to have been accounted for by days of continuous abstinence accrued during treatment, and by pre-post increases in self-efficacy.

CONCLUSIONS

The most effective treatments may be those that elicit abstinence while increasing self-efficacy.

Continued Successful SA Recovery during the Maintenance Stage: Intra-Individual Resource Loss & Gain Predict Relapse

OBJECTIVES: We combine Hobfoll's Conservation of Resources (COR) theory and key components of self-help group "step work" ideology to investigate how dynamic changes in key intra-individual resource loss and gains (self-esteem, abstinence self-efficacy, existential growth) influence relapse rates in a sample of individuals in the Maintenance Stage of substance abuse recovery. METHODS: Participants (n = 579) completed two surveys over a nine month period that assessed baseline and changes in intra-individual loss and gain resources as well as relapse rates over study course. Multiple regression analyses were performed to predict whether baseline and dynamic changes in intra-individual scores predict relapse rates over time. RESULTS: Individuals that reported lower levels of resource gain at baseline, as well as decreased gain trajectories and increased loss trajectories over time were more likely to relapse. CONCLUSIONS: Findings support self-help group "step work" models and the application of COR theory for relapse likelihood prediction in a sample of individuals in longer term substance abuse recovery. Research efforts should examine the complex relationship between these dynamic intra-individual resources, social cognition, self-regulation and relapse risk. Future interventions should address the importance of the continual development and protection of these valuable intra-individual resources to prevent relapse.

Integrated treatment of substance use and psychiatric disorders

Epidemiological studies find that psychiatric disorders, including mental disorders and substance use disorders, are common among adults and highly comorbid. Integrated treatment refers to the focus of treatment on two or more conditions and to the use of multiple treatments such as the combination of psychotherapy and pharmacotherapy. Integrated treatment for comorbidity has been found to be consistently superior compared to treatment of individual disorders with separate treatment plans. This article focuses on a review of the risks for developing comorbid disorders and the combinations of treatments that appear to be most effective for clients with particular comorbid disorders.

Iatrogenic effects of psychosocial interventions: treatment, life context, and personal risk factors

Between 7% and 15% of individuals who participate in psychosocial interventions for substance use disorders may be worse off after treatment than before. Intervention-related predictors of iatrogenic effects include lack of bonding; lack of goal direction and monitoring; confrontation, criticism, and high emotional arousal; models and norms for substance use; and stigma and inaccurate expectations. Life context and personal predictors include lack of support, criticism, and more severe substance use and psychological problems. Ongoing monitoring and safety standards are needed to identify and counteract adverse consequences of intervention programs.

Ego-dystonic pregnancy and prenatal consumption of alcohol among first-time mothers

This study examines predictors of drinking during pregnancy among first-time mothers, in order to distinguish those in need of targeted screening and intervention. Data from the prenatal panel of the Parenting for the First Time study were used in hierarchical linear regressions to determine likelihood of prenatal alcohol consumption among a sample of 645 women. African-American women and those of race/ethnicities other than White were less likely to drink, regardless of age or level of education. Among all women, being in school was associated with abstention (P = 0.05). Among teens, endorsing a perception of feeling "pushed around" was a significant indicator of prenatal alcohol consumption (P = 0.05), as was not having plans for infant feeding shortly before delivery (P = 0.05). Among adults with some level of college education, having a first prenatal visit after the fourth month of pregnancy was a significant predictor of drinking (P = 0.01). This study indicates that women who evidence behaviors or attitudes indicating an ego-dystonic pregnancy (one that is psychologically or emotionally uncomfortable), may be more likely to self-medicate and cope via avoidance through drinking. These behaviors and attitudes may be indicators of the need for targeted screening and intervention, as well as indicators of underlying problems to be targeted in treatment. Further, among all women for whom continued education is a possibility, retaining the ability to attend school during the pregnancy can be protective.

Identification of behaviour change techniques to reduce excessive alcohol consumption

BACKGROUND

  Interventions to reduce excessive alcohol consumption have a small but important effect, but a better understanding is needed of their 'active ingredients'.

AIMS

  This study aimed to (i) develop a reliable taxonomy of behaviour change techniques (BCTs) used in interventions to reduce excessive alcohol consumption (not to treat alcohol dependence) and (ii) to assess whether use of specific BCTs in brief interventions might be associated with improved effectiveness.

METHODS

  A selection of guidance documents and treatment manuals, identified via expert consultation, were analysed into BCTs by two coders. The resulting taxonomy of BCTs was applied to the Cochrane Review of brief alcohol interventions, and the associations between the BCTs and effectiveness were investigated using meta-regression.

FINDINGS

  Forty-two BCTs were identified, 34 from guidance documents and an additional eight from treatment manuals, with average inter-rater agreement of 80%. Analyses revealed that brief interventions that included the BCT 'prompt self-recording' (P = 0.002) were associated with larger effect sizes.

CONCLUSIONS

  It is possible to identify specific behaviour change techniques reliably in manuals and guidelines for interventions to reduce excessive alcohol consumption. In brief interventions, promoting self-monitoring is associated with improved outcomes. More research is needed to identify other behaviour change techniques or groupings of behaviour change techniques that can produce optimal results in brief interventions and to extend the method to more intensive interventions and treatment of alcohol dependence.

Advances in the psychosocial treatment of addiction: the role of technology in the delivery of evidence-based psychosocial treatment

The clinical community has a growing array of psychosocial interventions with a strong evidence base available for the treatment of SUDs. Considerable opportunity exists for leveraging technology in the delivery of evidence-based interventions to promote widespread reach and impact of evidence-based care. Data from this line of research to date are promising, and underscore the potential public health impact of technology-based therapeutic tools. To fully realize the potential of technology-delivered interventions, several areas of inquiry remain important. First, scientifically sound strategies should be explored to ensure technology-based interventions are optimally designed to produce maximal behavior change. Second, efficient and effective methods should be identified to integrate technology-based interventions into systems of care in a manner that is most responsive to the needs of individual users. Third, payment, privacy, and regulatory systems should be refined and extended to go beyond electronic medical records and telehealth/distance care models, and support the deployment of technology-based systems to enhance the quality, efficiency and cost-effectiveness of care. Fourth, the mechanisms underlying behavior change derived from technology-based treatments should be explicated, including new mechanisms that may be tapped via novel, technology-based tools. Such work will be critical in isolating mechanisms that are useful in predicting treatment response, and in ensuring that key ingredients are present in technology-based interventions as they are made widely available.

Social Networks among Residents in Recovery Homes

Although evidence exists that substance abuse abstinence is enhanced when individuals in recovery are embedded in social networks that are cohesive, few studies examined the network structures underlying recovery home support systems. In two studies, we investigated the mechanisms through which social environments affect health outcomes among two samples of adult residents of recovery homes. Findings from Study 1 (n = 150) indicated that network size and the presence of relationships with other Oxford House (OH) residents both predicted future abstinence. Study 2 (n = 490) included individuals who lived in an OH residence for up to 6 months, and their personal relationship with other house residents predicted future abstinence. Implications of these findings are discussed.

Attendance and substance use outcomes for the Seeking Safety program: sometimes less is more

OBJECTIVE

This study uses data from the largest effectiveness trial to date on treatment of co-occurring posttraumatic stress and substance use disorders, using advances in statistical methodology for modeling treatment attendance and membership turnover in rolling groups.

METHOD

Women receiving outpatient substance abuse treatment (N = 353) were randomized to 12 sessions of Seeking Safety or a health education control condition. Assessments were completed at baseline and at 1 week, 3, 6, and 12 months posttreatment. Outcome measures were alcohol and cocaine use in the prior 30 days captured using the Addiction Severity Index. Latent class pattern mixture modeling (LCPMM) was used to estimate attendance patterns and to test for treatment effects within and across latent attendance patterns and group membership turnover.

RESULTS

Across LCPMM analyses for alcohol and cocaine use, similar treatment attendance patterns emerged: Completers never decreased below an 80% probability of attendance, droppers never exceeded a 41% probability of attendance, and titrators demonstrated a 50% to 80% probability of attendance. Among completers, there were significant decreases in alcohol use from baseline to 1-week posttreatment, followed by nonsignificant increases in alcohol during follow-up. No differences between treatment conditions were detected. Titrators in Seeking Safety had lower rates of alcohol use from 1-week through 12-month follow-up compared with control participants. Droppers had nonsignificant increases in alcohol during both study phases. Cocaine use findings were similar but did not reach significance levels.

CONCLUSIONS

The impact of client self-modulation of treatment dosage and group membership composition may influence behavioral treatment outcomes among this population.

Helping homeless individuals with co-occurring disorders: the four components

Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorder are one of the most vulnerable populations. This article provides practitioners with a framework and strategies for helping this client population. Four components emerged from a literature review: (1) ensuring an effective transition for individuals with CODs from an institution (such as a hospital, foster care, prison, or residential program) into the community, a particularly important component for clients who were previously homeless, impoverished, or at risk of homelessness; (2) increasing the resources of homeless individuals with CODs by helping them apply for government entitlements or supported employment (3) linking homeless individuals to supportive housing, including housing first options as opposed to only treatment first options, and being flexible in meeting their housing needs; and (4) engaging homeless individuals in COD treatment, incorporating modified assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help groups.

Treatment of substance abusing patients with comorbid psychiatric disorders

OBJECTIVE

To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients.

METHOD

Articles were extracted from Pubmed using the search terms "dual diagnosis," "comorbidity" and "co-occurring" and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity.

RESULTS

Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions.

CONCLUSIONS

Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.

Contrasting social climates of small peer-run versus a larger staff-run substance abuse recovery setting

This study compared the social climate of peer-run homes for recovering substance abusers called Oxford House (OH) to that of a staffed residential therapeutic community (TC). Residents of OHs (N = 70) and the TC (N = 62) completed the Community Oriented Programs Environment Scales. OHs structurally differ on two primary dimensions from TCs in that they tend to be smaller and are self-run rather than professionally run. Findings indicated significantly higher Involvement, Support, Practical Orientation, Spontaneity, Autonomy, Order and Organization, and Program Clarity scores among the OH compared to TC residents. Additional analyses found the OH condition was higher Support, Personal Problem Orientation, and Order and Organization scores among women compared to men residents. These results suggested that these smaller OH self-run environments created a more involving and supportive social milieu than a larger staff-run TC. These findings are interpreted within Moos' (2007) four theoretical ingredients (i.e., social control, social learning, behavioral economics, and stress and coping), which help account for effective substance abuse treatment environments.

Does acceptance and relationship focused behavior therapy contribute to bupropion outcomes? A randomized controlled trial of functional analytic psychotherapy and acceptance and commitment therapy for smoking cessation

This study evaluated a treatment combining bupropion with a novel acceptance and relationship focused behavioral intervention based on the acceptance and relationship context (ARC) model. Three hundred and three smokers from a community sample were randomly assigned to bupropion, a widely used smoking cessation medication, or bupropion plus functional analytic psychotherapy (FAP) and acceptance and commitment therapy (ACT). Objective measures of smoking outcomes and self-report measures of acceptance and relationship processes were taken at pretreatment, posttreatment, 6-month, and 1-year follow-up. The combined treatment was significantly better than bupropion alone at 1-year follow-up with 7-day point prevalence quit rates of 31.6% in the combined condition versus 17.5% in the medication-alone condition. Acceptance and the therapeutic relationship at posttreatment statistically mediated 12-month outcomes. Bupropion outcomes were enhanced with an acceptance and relationship focused behavioral treatment.

Alcoholics Anonymous attendance, decreases in impulsivity and drinking and psychosocial outcomes over 16 years: moderated-mediation from a developmental perspective

AIMS

To examine whether decreases in impulsivity account for links between Alcoholics Anonymous (AA) attendance and better drinking and psychosocial outcomes, and whether these mediational 'effects' are conditional on age.

DESIGN

A naturalistic study in which individuals were assessed at baseline, and 1, 8 and 16 years later.

SETTING

Participants initiated help-seeking through the alcohol intervention system (detoxification programs, information and referral centers).

PARTICIPANTS

Individuals with alcohol use disorders and no prior history of substance abuse treatment at baseline [n=628; 47% women; mean age=34.7 years (standard deviation=9.4)].

MEASUREMENTS

Self-reports of impulsivity and drinking pattern at baseline and year 1, duration of AA (number of weeks) in year 1 and drinking (alcohol use problems, self-efficacy to resist drinking) and psychosocial outcomes (emotional discharge coping, social support) at baseline and follow-ups.

FINDINGS

Controlling for changes in drinking pattern, decreases in impulsivity were associated with fewer alcohol use problems, better coping and greater social support and self-efficacy at year 1, and better coping and greater social support at year 8. Decreases in impulsivity statistically mediated associations between longer AA duration and improvements on all year 1 outcomes and indirect effects were moderated by participant age (significant only for individuals 25 years of age or younger).

CONCLUSIONS

Decreased impulsivity appears to mediate reductions in alcohol-related problems over 8 years in people attending Alcoholics Anonymous.

Mindful awareness in body-oriented therapy as an adjunct to women's substance use disorder treatment: a pilot feasibility study

This study examined mindful awareness in body-oriented therapy (MABT) feasibility as a novel adjunct to women's substance use disorder (SUD) treatment. As an individual therapy, MABT combines manual and mind-body approaches to develop interoception and self-care tools for emotion regulation. A 2-group randomized controlled trial repeated-measures design was used, comparing MABT to treatment as usual (TAU) on relapse to substance use and related health outcomes. Sixty-one women were screened for eligibility, and 46 enrolled. Participants randomized to MABT received 8 weekly MABT sessions. Results showed moderate to large effects, including significantly fewer days on substance use, the primary outcome, for MABT compared with TAU at posttest. Secondary outcomes showed improved eating disorder symptoms, depression, anxiety, dissociation, perceived stress, physical symptom frequency, and bodily dissociation for MABT compared with TAU at the 9-month follow-up. In conclusion, it is feasible to implement MABT in women's SUD treatment, and results suggest that MABT is worthy of further efficacy testing.

Influence of religiosity on 12-step participation and treatment response among substance-dependent adolescents

OBJECTIVE

Religious practices among adults are associated with more 12-step participation which, in turn, is linked to better treatment outcomes. Despite recommendations for adolescents to participate in mutual-help groups, little is known about how religious practices influence youth 12-step engagement and outcomes. This study examined the relationships among lifetime religiosity, during-treatment 12-step participation, and outcomes among adolescents, and tested whether any observed beneficial relation between higher religiosity and outcome could be explained by increased 12-step participation.

METHOD

Adolescents (n = 195; 52% female, ages 14-18) court-referred to a 2-month residential treatment were assessed at intake and discharge. Lifetime religiosity was assessed with the Religious Background and Behaviors Questionnaire; 12-step assessments measured meeting attendance, step work (General Alcoholics Anonymous Tools of Recovery), and Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)-related helping. Substance-related outcomes and psychosocial outcomes were assessed with toxicology screens, the Adolescent-Obsessive Compulsive Drinking Scale, the Children's Global Assessment Scale, and the Narcissistic Personality Inventory.

RESULTS

Greater lifetime formal religious practices at intake were associated with increased step work and AA/NA-related helping during treatment, which in turn were linked to improved substance outcomes, global functioning, and reduced narcissistic entitlement. Increased step work mediated the effect of religious practices on increased abstinence, whereas AA/NA-related helping mediated the effect of religiosity on reduced craving and entitlement.

CONCLUSIONS

Findings extend the evidence for the protective effects of lifetime religious behaviors to an improved treatment response among adolescents and provide preliminary support for the 12-step proposition that helping others in recovery may lead to better outcomes. Youth with low or no lifetime religious practices may assimilate less well into 12-step-oriented treatment and may need additional 12-step facilitation, or a different approach, to enhance treatment response.

Implementing evidence-based psychosocial treatment in specialty substance use disorder care

Implementing evidence-based psychosocial or behavioral treatments for clients with substance use disorders (SUDs) presents significant challenges. In this article, we first identify the treatments for which there is some consensus that sufficient empirical support exists to designate them as "evidence-based," and then briefly consider the nature of that evidence. Following that, we review data from a Substance Abuse and Mental Health Services Administration survey on the extent to which these evidence-based treatments (EBTs) are used in SUD treatment in the United States. The main focus of the article is a review of 21 studies attempting to implement EBTs from which we glean information on factors associated with more and less successful implementation. We conclude that more conceptually driven, organizationally focused (not just individual-provider-focused) approaches to implementation are needed and that, at least with some providers in some organizational contexts, it may be more effective to implement evidence-based practices or processes (EBPs) rather than EBTs.

Driving while intoxicated among individuals initially untreated for alcohol use disorders: one- and sixteen-year follow-ups

OBJECTIVE

This study examined associations between frequency of driving while intoxicated (DWI) at baseline and obtaining alcohol-related help at follow-up, and between obtaining help and subsequent reductions in DWI. It also examined improvements on personal functioning and life context indices as mediators between obtaining help and reduced occurrences of DWI.

METHOD

A total of 628 individuals who were initially untreated for alcohol use problems completed a baseline inventory; follow-ups were 1, 3, and 16 years later.

RESULTS

More extended participation in outpatient treatment and Alcoholics Anonymous (AA) during Year 1 was associated with a lower likelihood of DWI at the 1-year follow-up. More extended participation in AA through Year 3 was associated with a lower likelihood of DWI at the 16-year follow-up. Improvement on personal functioning and life context indices was associated with reduced risk of subsequent occurrences of DWI. Decreases in drinking-related problems, impulsivity, and drinking to reduce tension mediated associations between more AA participation and reductions in DWI at 1 year.

CONCLUSIONS

Among initially untreated individuals, sustained mutual help may be associated with a reduced number of occurrences of DWI via fewer drinking consequences and improved psychological functioning and coping. Treatment providers should attend to these concomitants of DWI and consider actively referring individuals to AA to ensure ongoing AA affiliation.

A randomized trial of two behavioral interventions to improve outcomes following inpatient detoxification for alcohol dependence

Participants (n=150), undergoing inpatient alcohol detoxification, were randomized into 3 groups: treatment as usual (TAU), motivation enhancement therapy (MET), or peer-delivered 12-step facilitation (P-TSF). The main outcome was the initiation of any type of subsequent rehabilitation service (i.e., professional treatment or self-help) within 30 and 90 days of discharge. At the 30-day follow-up interview, there was no significant difference among the groups in the rate of initiation of any type of subsequent care (82%, 74%, and 82%, respectively, p=0.617); however, the MET group had significantly more patients initiate subsequent inpatient treatment by the 90-day follow-up interview compared to the P-TSF group (31% and 61%, respectively, p=0.007) and a greater proportion of MET participants completed subsequent inpatient treatment compared to both the TAU and P-TSF groups. There were no differences in drinking-related outcomes. MET during inpatient detoxification may help patients initiate subsequent inpatient rehabilitation treatment.

Impulsivity is an independent predictor of 15-year mortality risk among individuals seeking help for alcohol-related problems

BACKGROUND

Although past research has found impulsivity to be a significant predictor of mortality, no studies have tested this association in samples of individuals with alcohol-related problems or examined moderation of this effect via socio-contextual processes. The current study addressed these issues in a mixed-gender sample of individuals seeking help for alcohol-related problems.

METHODS

Using Cox proportional hazard models, variables measured at baseline and Year 1 of a 16-year prospective study were used to predict the probability of death from Years 1 to 16 (i.e., 15-year mortality risk). There were 628 participants at baseline (47.1% women); 515 and 405 participated in the follow-up assessments at Years 1 and 16, respectively. Among Year 1 participants, 93 individuals were known to have died between Years 1 and 16.

RESULTS

After controlling for age, gender, and marital status, higher impulsivity at baseline was associated with an increased risk of mortality from Years 1 to 16; however, this association was accounted for by the severity of alcohol use at baseline. In contrast, higher impulsivity at Year 1 was associated with an increased risk of mortality from Years 1 to 16, and remained significant when accounting for the severity of alcohol use, as well as physical health problems, emotional discharge coping, and interpersonal stress and support at Year 1. In addition, the association between Year 1 impulsivity and 15-year mortality risk was moderated by interpersonal support at Year 1, such that individuals high on impulsivity had a lower mortality risk when peer/friend support was high than when it was low.

CONCLUSIONS

The findings highlight impulsivity as a robust and independent predictor of mortality and suggest the need to consider interactions between personality traits and socio-contextual processes in the prediction of health-related outcomes for individuals with alcohol use disorders.

The role of Alcoholics Anonymous in mobilizing adaptive social network changes: a prospective lagged mediational analysis

OBJECTIVE

Many individuals entering treatment are involved in social networks and activities that heighten relapse risk. Consequently, treatment programs facilitate engagement in social recovery resources, such as Alcoholics Anonymous (AA), to provide a low risk network. While it is assumed that AA works partially through this social mechanism, research has been limited in rigor and scope. This study used lagged mediational methods to examine changes in pro-abstinent and pro-drinking network ties and activities.

METHOD

Adults (N=1726) participating in a randomized controlled trial of alcohol use disorder treatment were assessed at intake, and 3, 9, and 15 months. Generalized linear modeling (Generalized linear modeling) tested whether changes in pro-abstinent and pro-drinking network ties and drinking and abstinent activities helped to explain AA's effects.

RESULTS

Greater AA attendance facilitated substantial decreases in pro-drinking social ties and significant, but less substantial increases in pro-abstinent ties. Also, AA attendance reduced engagement in drinking-related activities and increased engagement in abstinent activities. Lagged mediational analyses revealed that it was through reductions in pro-drinking network ties and, to a lesser degree, increases in pro-abstinent ties that AA exerted its salutary effect on abstinence, and to a lesser extent, on drinking intensity.

CONCLUSIONS

AA appears to facilitate recovery by mobilizing adaptive changes in the social networks of individuals exhibiting a broad range of impairment. Specifically by reducing involvement with pro-drinking ties and increasing involvement with pro-abstinent ties. These changes may aid recovery by decreasing exposure to alcohol-related cues thereby reducing craving, while simultaneously increasing rewarding social relationships.

Relationship of cognitive function and the acquisition of coping skills in computer assisted treatment for substance use disorders

BACKGROUND

Coping skills training is an important component of cognitive behavioral therapy (CBT), yet cognitive impairment and related limitations that are often associated with chronic substance use may interfere with an ability to learn, retain, or use new information. Little previous research has examined the cognitive or neuropsychological factors that may affect substance users' ability to learn new coping skills in CBT.

METHODS

Fifty-two substance dependent individuals randomized to receive a computerized version of cognitive behavioral therapy (CBT4CBT) or treatment as usual (TAU) were administered several cognitive and neuropsychological measures, as well as a coping skills measure prior to and upon completing an 8-week treatment period.

RESULTS

Across treatment conditions, participants who scored above the median on a measure of IQ demonstrated greater improvement in the quality of their coping skills than those below the median on IQ (Group×Time, F(1,49)=4.31, p<.05). Also, IQ had a significant indirect effect on substance use outcomes through an effect on the quality of coping skills acquired, specifically for those who received CBT4CBT.

CONCLUSION

Individuals with higher IQ at baseline improved the quality of their coping skills more than those with lower IQ, which in turn reduced rates of substance use following treatment. This highlights the impact of substance users' cognitive functioning and abilities on the acquisition of coping skills from CBT, and suggests need for greater awareness and tailoring of coping skills training for those with poorer functioning.