Community-based relapse prevention for opiate dependents: a randomized community controlled trial

Recent Opioid Use Impedes Range Adaptation in Reinforcement Learning in Human Addiction

BACKGROUND

Drugs like opioids are potent reinforcers thought to co-opt value-based decisions by overshadowing other rewarding outcomes, but how this happens at a neurocomputational level remains elusive. Range adaptation is a canonical process of fine-tuning representations of value based on reward context. Here, we tested whether recent opioid exposure impacts range adaptation in opioid use disorder, potentially explaining why shifting decision making away from drug taking during this vulnerable period is so difficult.

METHODS

Participants who had recently (<90 days) used opioids (n = 34) or who had abstained from opioid use for ≥ 90 days (n = 20) and comparison control participants (n = 44) completed a reinforcement learning task designed to induce robust contextual modulation of value. Two models were used to assess the latent process that participants engaged while making their decisions: 1) a Range model that dynamically tracks context and 2) a standard Absolute model that assumes stationary, objective encoding of value.

RESULTS

Control participants and ≥90-days-abstinent participants with opioid use disorder exhibited choice patterns consistent with range-adapted valuation. In contrast, participants with recent opioid use were more prone to learn and encode value on an absolute scale. Computational modeling confirmed the behavior of most control participants and ≥90-days-abstinent participants with opioid use disorder (75%), but a minority in the recent use group (38%), was better fit by the Range model than the Absolute model. Furthermore, the degree to which participants relied on range adaptation correlated with duration of continuous abstinence and subjective craving/withdrawal.

CONCLUSIONS

Reduced context adaptation to available rewards could explain difficulty deciding about smaller (typically nondrug) rewards in the aftermath of drug exposure.

Identity Construction in Recovery from Substance Use Disorders

Long-term recovery from substance use disorders has been described as a process of identity construction, through which the stigma of being a substance user is replaced by a new identity of a non-user. Identity construction has been widely acknowledged as a significant factor in different pathways of substance use cessation, such as self-change and treatment-change. However, almost no articles have discussed the role of identity construction in desistance and recovery among both self-changers and treatment-change. The aim of this narrative review was to explore this subject in the two groups. Based on the recovery capital approach and the social identity model of recovery, I posited that self-changers and treatment-changers undergo different processes of identity construction. Moreover, the prospects for successful identity construction depend upon personal and social resources (recovery capital) that provide identity-building materials such as relationships, attitudes, and role models. This article contributes to the field by presenting the different identity constructions in the process of long-term recovery from SUDs.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Family Neglect and Perspectives on Patients Living with Mental Health Disorders on the Street

In Ghana, some persons living with mental illness end up on the street. Whereas most instances have resulted from family neglect, the paucity of effective social services to cater for neglected persons with mental health disorder persons is disturbing. The present study explored family caregivers' perspectives on reasons why families neglect persons living with mental illness to be homeless and their suggestions on how families and society could prevent such occurrences. Using a qualitative approach, individual interviews were conducted with twenty family caregivers of persons living with a mental health disorder. Results revealed multifactorial causation to family neglect and provide directions for future research. Findings highlight the need for mental health rehabilitation programmes to consider family caregivers' perspectives on the causes of neglect and ways to improve mental health rehabilitation, which must be factored into policies for effectiveness. Suggestions on family and society's role to prevent such occurrences are discussed.

Peer-delivered services for substance use in low- and middle-income countries: A systematic review

BACKGROUND AND AIMS

Addressing the burden of disease associated with substance use is a global priority, yet access to treatment is limited, particularly in low- and middle-income countries (LMICs). Peers, individuals with lived experience of substance use, may play an important role in expanding access to treatment, supporting outcomes, and reducing stigma. While peer-delivered services for substance use have been scaling up in high-income countries (HICs), less is known about their application in LMICs. This systematic review synthesizes the evidence of peer-delivered services for substance use in LMICs.

METHODS

PsycINFO, Embase, Global Health, PubMed, and six region-specific databases were searched, and articles that described peer-delivered services for substance use and related outcomes in LMICs were included. Risk of bias was evaluated using tools appropriate for each study design. To provide a more stringent evaluation of structured interventions, a subset of articles was analyzed using the Cochrane Effective Practice and Organization of Care (EPOC) framework.

RESULTS

The search yielded 6540 articles. These were narrowed down to 34 included articles. Articles spanned four continents, included quantitative and qualitative methodologies, and primarily targeted infectious disease risk behaviors. Ten articles were included in the EPOC sub-analysis. In the context of high risk of bias, some of these articles demonstrated positive impacts of the peer-delivered services, including reductions in risk behaviors and increases in infectious disease knowledge scores, while many others showed no significant difference in outcomes between peer intervention and control groups.

CONCLUSIONS

Peer-delivered services may be feasible for addressing substance use and reducing infectious disease risk behaviors in LMICs, where there are severe human resource shortages. Globally, peers' lived experience is valuable for engaging patients in substance use treatment and harm reduction services. Further research is needed to better characterize and quantify outcomes for peer-delivered services for substance use in LMICs.

Psychoeducation Program for Substance Use Disorder: Effect on Relapse Rate, Social Functioning, Perceived Wellness, and Coping

The current study was designed to assess the effect of a psychoeducation program on relapse rate, social functioning, perceived wellness, and ways of coping in individuals with substance use disorder (SUD). The study sample comprised 92 individuals (n = 46 intervention group, n = 46 control group) who received SUD treatment, had undergone detoxification, and agreed to participate in the study. A 10-session psychoeducation program was applied to individuals in the intervention group. Data collection included a urine sample and completion of the Personal Information Form, Social Functioning Scale, Perceived Wellness Scale, and Ways of Coping Scale. The relapse rate in the control group was found to be higher than in the intervention group; thus, it was determined that the relapse prevention psychoeducation program led to positive changes in relapse rate, social functioning, perceived wellness, and stress in individuals with SUD. [Journal of Psychosocial Nursing and Mental Health Services, 58(8), 39-47.].

Commentary: Applying the Community Partners in Care Approach to the Opioid Crisis

Background

Given national concern over rising mortality from opioid use disorders (OUD) and challenges to increasing OUD treatment access, a coalition approach may hold promise to improve access and outcomes for diverse populations. We present considerations of a community-partnered working group on adapting the Community Partners in Care (CPIC) study and coalition approach to OUD.

Method

During January 2016 through January 2017, academic, provider, consumer and policy stakeholders reviewed options to adapt CPIC's Resources for Services (RS) for individual program technical assistance and Community Engagement and Planning (CEP) for coalition support to OUD treatments, integrating stakeholder input into design options with estimated sample sizes.

Findings

The working group recommended Community Reinforcement and Family Treatment (CRAFT) as a stakeholder-support intervention to facilitate uptake and adherence to Medications for Addiction Treatment (MAT). Recommended implementation interventions for MAT/CRAFT were expert technical assistance supplemented by organizational readiness, and CEP for coalition support with a Learning Collaborative. Power estimation suggests that to compare implementation intervention effects on abstinence would require a somewhat larger enrolled sample and 3-4 times the screening sample as CPIC, and for mortality, at least 5-10 times the enrolled sample as CPIC.

Discussion

Stakeholders viewed the CPIC design and interventions as feasible and acceptable as community-wide approaches for addressing the opioid epidemic, but comparing impacts on mortality would require large, multi-site trials.

Psychometric properties of the Persian version of the Time to Relapse Questionnaire (TRQ) in substance use disorder

BACKGROUND

Predicting time to relapse provides an opportunity for the development of relapse prevention interventions in drug users.

OBJECTIVES

The aim of the present study was to describe the development of the Persian version of the 9-item Time to Relapse Questionnaire (TRQ) and to evaluate its psychometric properties in an Iranian sample of treatment-seeking individuals with substance dependence (n = 150).

METHODS

The forward-backward method was used to translate the TRQ scale from English into Persian. After linguistic validation and a pilot check, a cross-sectional study was performed, and psychometric properties of the Iranian version of the questionnaire were assessed. The reliability was evaluated by Cronbach's alpha and test-retest analyses. In addition, the factor structure of the scale was extracted by applying confirmatory factor analysis.

RESULTS

The mean age of participants was 40.52 (SD = 11.30) years. The mean scores for the content validity index (CVI) and the content validity ratio (CVR) were 0.93 and 0.81, respectively. A confirmatory factor analysis (CFA) demonstrated that the three-factor model of the TRQ was a good fit for the data and thus replicated the factor structure of the original English language TRQ. Cronbach's alpha presented good internal consistency (alpha = 0.76), and test-retest reliability of the TRQ instrument with 2-week intervals was appropriate (ICC = 0.84).

CONCLUSION

The findings demonstrate that the Persian version of the TRQ is a reliable and valid scale for measuring time to relapse in Iranian drug users. The TRQ can be applied at the start of treatment so that clinical interventions can be targeted toward the different relapse styles.

Trajectories of Drug Abuse and Addiction Development Among FSU Immigrant Drug Users in Israel

This qualitative study explores the trajectories of drug abuse and addiction development among former Soviet Union (FSU) immigrant users. It is based on in-depth interviews with 19 Russian-speaking recovering addict counselors employed in Israeli addiction treatment centers. The interview analysis yielded two main trajectories: one of abuse deterioration and the other of abuse initiation in the context of coping with immigration. The core issue that characterizes both trajectories is the immigrant users’ sense of loneliness. Participation in treatment appears as a path for regaining their sense of belonging. Implications for prevention and treatment based on the interviewees’ reflections, as well as on extant literature, are discussed.