Individual and program predictors of attrition from VA substance use treatment

Cannabis Use Among U.S. Military Veterans Following Residential Substance Use Disorder Treatment

INTRODUCTION

Use rates of cannabis, a substance associated with a host of comorbid physical and mental health concerns, continue to rise for military veterans. Despite this prevalence, descriptive patterns of use among veterans and research on treatment factors that predict cannabis outcomes are lacking. This study aimed to conduct a descriptive profile of veterans who endorse cannabis use, compare veterans endorsing cannabis use to those who do not endorse use, and investigate what factors (other substance use, psychiatric symptoms, and treatment outcomes) predicted return to cannabis use following residential treatment.

MATERIALS AND METHODS

The study was a secondary data analysis of a longitudinal sample of U.S. military veterans (N = 200, 193 males, Mage = 50.14, SD = 9) participating in residential substance use disorder treatment through a Veterans Affairs medical center. Interview, survey, and electronic health data were collected over 12 months. Analyses included descriptive and frequency statistics to identify patterns in cannabis use behaviors and motives, independent t-tests to examine differences between the cannabis-using group and non-using group, and a series of univariate logistic regressions to examine potential predictors for cannabis use after treatment discharge.

RESULTS

Lifetime cannabis use was common among veterans (77.5%), and 29.5% reported use during the study. On average, veterans had made one quit attempt before treatment entry. Veterans who endorsed cannabis use consumed more alcohol in the past 30 days at baseline and reported less impulse control and less confidence in maintaining abstinence at discharge. Length of stay in the residential program and no diagnosis of Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV cannabis use disorder criteria predicted post-treatment cannabis use such that veterans who remained in the program longer were more likely to abstain from cannabis use following treatment, and those who did not meet DSM-IV cannabis use disorder criteria were more likely to use following treatment.

CONCLUSIONS

Identification of relevant risk factors and treatment processes, such as impulse control, confidence in treatment, and length of stay in treatment, provides practical recommendations for future intervention efforts. This study calls for further examination of cannabis use outcomes among veterans, particularly those participating in substance use treatment.

Intranasal Oxytocin for Stimulant Use Disorder Among Male Veterans Enrolled in an Opioid Treatment Program: A Randomized Controlled Trial

The increasing prevalence of illicit stimulant use among those in opioid treatment programs poses a significant risk to public health, stimulant users have the lowest rate of retention and poorest outcomes among those in addiction treatment, and current treatment options are limited. Oxytocin administration has shown promise in reducing addiction-related behavior and enhancing salience to social cues. We conducted a randomized, double-blind, placebo-controlled clinical trial of intranasal oxytocin administered twice daily for 6 weeks to male Veterans with stimulant use disorder who were also receiving opioid agonist therapy and counseling (n = 42). There was no significant effect of oxytocin on stimulant use, stimulant craving, or therapeutic alliance over 6 weeks. However, participants receiving oxytocin (vs. placebo) attended significantly more daily opioid agonist therapy dispensing visits. This replicated previous work suggesting that oxytocin may enhance treatment engagement among individuals with stimulant and opioid use disorders, which would address a significant barrier to effective care.

Factors associated with early and later dropout from methadone maintenance treatment in specialist addiction clinics: a six-year cohort study using proportional hazards frailty models for recurrent treatment episodes

BACKGROUND

Retention in methadone maintenance treatment (MMT) is associated with reduced illicit drug use, criminal activity, and mortality; however, many clients move in and out of MMT. This study aims to identify determinants of time to dropout of MMT across multiple treatment episodes in specialist addiction services in Ireland.

METHODS

Cohort study of persons attending specialist addiction clinics between 2010 and 2015. MMT episodes were periods of continuous treatment if there were no interruptions to treatment lasting > 7days. Proportional hazards frailty models were used to assess factors associated with time to dropout from recurrent MMT episodes at 3 (90 days) and 12 months (91-365 days). MMT episodes were right- censored at time of death, transfer to prison or primary care, and study end.

RESULTS

A total of 2,035 individuals experienced 4,969 MMT episodes, with 2,724 dropout events during the six-year follow-up. Factors associated with dropout at 3 months included low dose methadone (<60 mg/day) (HR = 1.49, 95% CI 1.29-1.73) and previous dropout (HR = 1.65, 95% CI 1.41-1.92). Adherence was protective (HR = 0.91, 95% CI 0.90-0.92). Dropout at 12 months was associated with low dose methadone (HR = 1.44, 95% CI 1.23-1.68), previous dropout (HR = 1.37, 95% CI 1.16-1.61), males (HR 1.26, 95% CI 1.06-1.50), benzodiazepines (HR = 1.22, 95% CI 1.03-1.45) and number of comorbidities (HR = 1.12, 95% CI 1.05-1.20); adherence was protective (HR = 0.86, 95% CI 0.84-0.87).

CONCLUSIONS

Clients with a previous history of treatment dropout and those on low dose methadone should be identified as high risk for both early and later dropout. Inversely, adherence to treatment, not missing methadone doses, is protective.

The Role of Personality Functioning on Early Drop out in Outpatient Substance Misuse Treatment

Treatment initiation is a major factor contributing to positive outcomes, but the supporting literature remains limited. It is difficult to draw conclusions regarding predictors of dropout, and there is a need to target clients' major early attrition vulnerabilities. Despite empirically validated models for assessing personality, little is known about its role in the treatment process. Studies that have been conducted in this area have focused mainly on stable personality traits and provide conflicting evidence. Aims: The aim of this study is to examine to what extent service users' personality functioning are potential determinants of early drop out. Methodology: A cross-sectional multi-site design examined the therapy process in a naturalistic setting in 5 outpatient preparation treatment centers with 210 service users. The current study adopts a contemporary dimensional-based framework, similar to the Alternative Model of Personality Disorder of the DSM-V and examines the role of characteristic adaptations (SIPP-118) on early drop out (CEST-Intake). Findings: From the broad spectrum of personality traits, only Depression remained significant predictor of drop out. Higher dysfunctional levels in Social Concordance [OR] = 1.85, Wald =19.87, p =.002, 95% CI [1.1, 1.9] as well as the facets Aggression Regulation, Respect and Purposefulness were also predictors of early drop out, while Treatment Readiness and Desire for Help accounted for a significant amount of variance. Conclusions: These findings extend our knowledge of the predictive role of characteristic adaptations in treatment and suggest it may be important to assess these individual differences early on and to design personalized-informed interventions.

Prediction of drop-out and outcome in integrated cognitive behavioral therapy for ADHD and SUD: Results from a randomized clinical trial

BACKGROUND

Patients with substance use disorder (SUD) or Attention Deficit Hyperactivity Disorder (ADHD) have a high risk of drop out from treatment. Few studies have investigated predictors of therapy drop out and outcome in SUD patients with comorbid ADHD. Recently, integrated cognitive behavioral therapy (CBT/Integrated) was shown to be more effective than standard CBT (CBT/SUD) in the treatment of SUD + ADHD.

OBJECTIVE

To investigate the association of demographic, clinical and neurocognitive variables with drop-out and treatment outcome, and to examine which of these variables are suitable for patient-treatment matching.

METHODS

We performed an RCT in which 119 patients were allocated to CBT/Integrated (n = 60) or CBT/SUD (n = 59). In addition, 55 patients had dropped out before randomization. Demographic variables, clinical characteristics and measures of cognitive functioning (Stroop, Tower of London (ToL) and Balloon Analogue Risk Task (BART)) were included as predictors. Outcome measures were: early treatment drop-out, ADHD symptom severity, and substance use severity at end of treatment and follow up.

RESULTS

Primary substance of abuse (drugs as opposed to alcohol only) and lower accuracy scores on the ToL were significant predictors of early treatment drop-out. Having more depression and anxiety symptoms and using ADHD medication at baseline significantly predicted more ADHD symptoms at end of treatment, and higher accuracy scores on the ToL significantly predicted higher substance use at end of treatment. No significant predictor-by-treatment interactions were found.

CONCLUSION

The results add to the existing realization that also relatively mild cognitive deficits are a risk factor for treatment drop-out in these patients.

Factors Contributing to Substance Misuse Treatment Completion among Native Hawaiians, Other Pacific Islanders, and Asian Americans

Background: Research on substance abuse treatment completion (SATC) among Asian Americans and Native Hawaiian and Other Pacific Islanders (NHOPIs) is extremely limited despite growing concern of SA among these groups. Objectives: This study examined predictors of SATC among and within Asian, NHOPI, and White racial groups. Methods: 129,939 cases from the SA and Mental Health Services, Treatment Episode Data Set-Discharges-2016 were used in this study. Logistic regressions were employed to examine the differential impact of race on SATC and to investigate the moderating effect of race on the relationship between socioeconomic factors, type of substance used, and type of treatment setting on SATC. Results: NHOPIs were less likely to complete SA treatment than Whites. Within-group analysis indicated that NHOPIs who were in outpatient non-intensive treatment were more likely to complete treatment compared to ones in inpatient (more than 30 days), and outpatient intensive settings. In contrast, Asians and Whites in outpatient non-intensive treatment settings were less likely to complete compared to all other types of treatment settings. Older adults for Whites were more likely to complete treatment compared with younger adults. Age was not a significant predictor of SATC for Asians and NHOPIs. Asian and NHOPI methamphetamine users were less likely to complete treatment compared with White users. Conclusion/Importance: Findings highlight the importance of disaggregating Asians and NHOPIs in future SA studies to better understand how specific factors are relevant to each group, and to guide the development of cultural and race-informed treatments for these groups.

Outpatient Addiction Treatment for Problematic Alcohol Use: What Makes Patients Who Dropped Out Different from Those Who Did Not?

BACKGROUND

A minority of individuals with problematic alcohol use effectively seek help. Moreover, dropouts from care are not uncommon. It remains a major concern for health professionals, as adherence to treatment is significantly associated with better physical and psychological outcomes.

OBJECTIVES

The main aim of this research was to assess what factors could distinguish patients with problematic alcohol use who dropped out from those who did not.

METHODS

The sample included 150 patients followed-up in an outpatient treatment center in France for a problematic alcohol use. Two measurement times were planned: at the first appointment and after six month of treatment. A large set of individual, environmental and institutional variables were considered to compare both subgroups.

RESULTS

Patients who dropped out mostly differ from patients who did not with a higher level of alcohol-related problems, ambivalence, inclinations to use the substance, number of missed appointments. Significant results were also observed regarding a lower time gap between the first contact with the center and the first appointment, as well as the season of the last appointment.

CONCLUSIONS

Tailored motivational interventions could be offered to ambivalent patients, especially during the beginning of the treatment and some significant periods of the year. A particular focus should be brought on patients presenting such profiles in terms of level of alcohol problems, inclinations to drink and motivation to change. Overall, the study provides elements to better understand what may bring one patient to drop out of the treatment, and to improve the continuity of care.

Factors associated with attrition in substance using patients enrolled in an intensive outpatient program

BACKGROUND AND OBJECTIVES

Data suggest individuals with substance use disorders (SUD) have high rates of attrition from treatment and exhibit impairments on measures of executive functioning (EF). The primary aim of this pilot study was to investigate if EF is associated with attrition from a 1 month intensive outpatient program (IOP) for SUD, and examine the feasibility of implementing the project.

METHODS

Baseline neurocognitive functioning was assessed by the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the self-reported Behavior Rating Inventory of Executive Functioning (BRIEF-A) questionnaire.

RESULTS

Thirty subjects enrolled in the pilot study: including 20 "completers" (age 39.5 ± 13.1 years) and 10 "drop-outs" who discontinued the IOP prior to completion (age 32 ± 11.1 years). IOP drop-out was associated with earlier age of substance use onset (all p-values <0.05) and male gender, as well as greater SUD, opiate use, and past week substance use. Overall a high level of executive dysfunction was found on the BRIEF-A and CANTAB assessments, and specific differences emerged between completers and drop outs. However, no statistically significant differences were found between these groups on measures of depression, anxiety, or ADHD.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Overall, findings from this pilot study suggest high levels of self-reported executive dysfunction, but EF's predictive association with drop-out was limited. Measures of addiction severity were more strongly associated with attrition, suggesting potential utility of brief motivational interventions prior to commencing an IOP may improve retention. Further investigations with larger and more diverse samples are warranted. (Am J Addict 2017;26:780-787).

Patient satisfaction with treatments and outcomes in residential addiction institutions

Aim:

The objective of the present study was to investigate associations between patients’ satisfaction with different domains of inpatient substance use treatment and their perceived treatment outcome. The primary purpose was to identify domains of treatment satisfaction most strongly associated with a positive treatment outcome.

Design:

Data were based on a survey among 188 patients with alcohol and/or illicit substance use disorders completing a three–six-month inpatient stay at one of two public clinics in Central Norway. The survey was carried out shortly before discharge. The 15-item questionnaire covered ratings of staff and programme factors, and services received for medical and mental problems and ancillary services. The outcome score was based on items measuring perceived substance use improvements and benefit of treatment.

Results:

A significant proportion of patients were dissatisfied with the support provided for housing, financial issues and employment. Confidence in staff competence was the domain of treatment satisfaction most strongly associated with the outcome score. Furthermore, patients were more likely to report a positive outcome when they were actively involved in the treatment, as indicated by satisfaction with opportunities to affect treatment plans.

Conclusion:

Our results suggest that patient-experienced improvements are connected to confidence in staff competence and user involvement. The findings may be interpreted as supporting a collaborative relationship between patients and counsellors.

Stratifying delays for assessment by type of substance to improve the probability of attendance in outpatient services

AIMS

1) To confirm the association between delay for assessment (DFA) and probability of first-time attendance in outpatient substance use disorder (SUD) treatment. 2) To evaluate whether this association varies by the type of primary substance for which the assessment was requested. 3) To assess the possibility of estimating differential DFAs to conform to equal probabilities of attendance across various types of primary substance.

METHODS

A prospective observational cohort of consecutive patients (N=1015) who requested a first-time assessment appointment at a publicly funded outpatient SUD treatment center in France between January 2014 and December 2015 was conducted. Logistic regression analyses were performed to evaluate associations between DFA (after log-transformation) and attendance and to provide estimates of attendance probability over time by the type of primary substance.

FINDINGS

After adjusting for gender, age and referral status, the attendance rate was observed to decrease significantly with longer DFA (OR=0.54; 95%CI: 0.44-0.66). The strength of this association differed across types of primary substance (p for heterogeneity <0.0001), with the strongest association being found for opioids (adjusted OR=0.21; 95%CI: 0.10-0.45). DFA was also associated with attendance for alcohol (OR=0.51; 95%CI: 0.37-0.71) and cannabis (OR=0.60; 95%CI: 0.37-0.96), but not for tobacco (OR=0.95; 95%CI: 0.60-1.50). Differential DFAs reflecting equal probabilities of attendance across types of substance could be estimated.

CONCLUSION

Our study suggests that the approach of stratifying DFAs by the type of primary substance could be helpful to improve the probability of first-time attendance in outpatient SUD treatment services.

Clinician-delivered contingency management increases engagement and attendance in drug and alcohol treatment

OBJECTIVE

This study examined the impact of a low-cost contingency management (CM) delivered by program clinicians on treatment attendance and utilization for patients enrolled in outpatient psychosocial substance abuse treatment.

METHODS

The study used a pre-posttest design to compare substance abuse patients who received Reinforcement-Based Treatment (RBT) plus low cost CM (n=130; RBT+CM) to patients who received RBT only (n=132, RBT). RBT+CM participants received a $10 incentive for returning to treatment the day following intake assessment (day one), and a $15 incentive for attending treatment on day five following admission. RBT clients received standard care intervention without the addition of the CM procedures. Groups were compared on proportion of participants who returned to treatment on day one, mean days of treatment attendance, individual sessions attended, and treatment utilization during the first week and the first month following treatment admission.

RESULTS

Both the RBT+CM and RBT group participants returned to the clinic on day one at high rates (95% versus 89%, respectively). However, the RBT group participants were more likely to attend the intake assessment only (i.e., never return to treatment) compared to the RBT+CM participants. Additionally, the RBT+CM participants attended significantly more treatment days, attended more individual counseling sessions, and had higher rates of overall treatment utilization compared to the RBT participants during the one week and one month following treatment admission.

CONCLUSIONS

Findings support the feasibility and effectiveness of a CM intervention delivered by clinicians for increasing treatment attendance and utilization in a community substance abuse program.

Treatment choices and subsequent attendance by substance-dependent patients who disengage from intensive outpatient treatment

In an effort to increase engagement in effective treatment, we offered a choice of alternate evidence-based treatments to 137 alcohol- or cocaine-dependent adults (110 males, 27 females) who entered an intensive outpatient program (IOP) but disengaged within the first 8 weeks. We hypothesized that disengaged patients would choose and subsequently attend alternatives to IOP when given the chance, that their choices would be consistent with their previously-stated preferences, and that demographic and clinical characteristics would be predictive of alternatives chosen. Of 96 participants reached by phone, 19% chose no treatment; 49% chose to return to IOP; 24% chose individual psychotherapy; 6% chose telephone counseling; 2% chose naltrexone with medication management. There were few relationships between participant characteristics and choices made upon disengagement. Participants who chose alternative treatments were equally likely to attend their chosen treatment as those who chose IOP. Limited interest in alternative treatments may reflect allegiance to IOP, which was initially chosen by all participants. Implications for implementation of patient-centered adaptive treatment are discussed.

Predictors of Attrition in a Cohort Study of HIV Infection and Methamphetamine Dependence

Longitudinal cohort studies of HIV and substance use disorders play an important role in understanding these conditions, but high rates of attrition can threaten their integrity and generalizability. This study aimed to identify factors associated with attrition in a 5-year observational cohort study of 469 individuals with and without HIV infection and methamphetamine (MA) dependence. Rates of attrition in our four study groups were approximately 24% in HIV-MA-, 15% in HIV+MA-, 56% in HIV-MA+, and 47% in HIV+MA+ individuals. Predictors of attrition in the overall cohort included history of MA, alcohol, and other substance dependence, learning impairment, reduced cognitive reserve, and independence in activities of daily living (all ps < .05), but varied somewhat by clinical group. Of particular note, enrollment in a neuroimaging substudy was associated with significantly boosted rates of retention in the MA groups. Results from this investigation highlight the complexity of the clinical factors that influence retention in cohort studies of HIV-infected MA users and might guide the development and implementation of targeted retention efforts.

Examining attrition rates at one specialty addiction treatment provider in the United States: a case study using a retrospective chart review

Background

Engaging individuals who have a substance use disorder (SUD) in treatment continues to be a challenge for the specialty addiction treatment field. Research has consistently revealed high rates of missed appointments at each step of the enrollment process: 1. between calling for services and assessment, 2. between assessment and enrollment, and 3. between enrollment and completion of treatment. Extensive research has examined each step of the process; however, there is limited research examining the overall attrition rate across all steps.

Methods

A single case study of a specialty addiction treatment agency was used to examine the attrition rates across the first three steps of the enrollment process. Attrition rates were tracked between August 1, 2011 and July 31, 2012. The cohort included 1822 unique individuals who made an initial request for addiction treatment services. Monthly retrospective reviews of medical records, phone logs, and billing data were used to calculate attrition rates. Attrition rates reported in the literature were collected and compared to the rates found at the target agency.

Results

Median time between request for treatment and assessment was 6 days (mean 7.5) and between assessment and treatment enrollment was 8 days (mean 12.5). An overall attrition rate of 80% was observed, including 45% between call and assessment, 32% between assessment and treatment enrollment (another 17% could not be determined), and 37% left or were removed from treatment before 30 days. Women were less likely to complete 30 days of treatment compared to men. No other demographics were related to attrition rates.

Discussion

One out of every five people who requested treatment completed a minimum of 30 days of a treatment. The attrition rate was high, yet similar to rates noted in the literature. Limitations of the single case study are noted.

Conclusion

Attrition rates in the U.S. are high with approximately 75% to 80% of treatment seekers disengaging at one of the multiple stages of the enrollment and treatment process. Significant changes in the system are needed to improve engagement rates.

Predictors of dropout from psychosocial treatment in opioid-dependent outpatients

BACKGROUND AND OBJECTIVES

Early dropout is common in substance abuse treatment settings and may lead to poorer outcomes relative to those completing a full course of treatment. Attempts to identify predictors of dropout have yielded mixed results, highlighting the need for additional research in this area to clarify risk and protective factors to guide intervention and retention efforts. This study evaluated predictors of dropout from psychosocial treatment among opioid-dependent patients on methadone maintenance therapy.

METHODS

Participants included 78 patients who had failed to respond to at least 4 months of methadone maintenance plus group counseling with clinic substance abuse counselors, and were enrolled in a study of randomized psychosocial treatment in addition to treatment-as-usual. Several factors that have been implicated in previous studies as well as two affective variables (distress intolerance and coping motives for drug use) were examined.

RESULTS

Results indicated that when controlling for various risk factors, age was the only significant predictor of dropout, with younger patients more likely to discontinue treatment early.

CONCLUSIONS

This study replicates previous findings in opioid-dependent samples that younger patients are at an increased risk of early treatment dropout.

CONCLUSIONS AND SIGNIFICANCE

Targeted intervention may be needed to retain young patients in drug abuse treatment.

Drop-out from addiction treatment: a systematic review of risk factors

Completion of addiction treatment is one of the most consistent factors associated with a favorable treatment outcome. Unfortunately, it is more common for a patient to drop-out of addiction treatment than to complete the treatment. To prevent drop-out, risk factors must be identified. This box-score review focuses on studies investigating the risk factors associated with drop-out from addiction treatment published in peer-reviewed journals from 1992 to 2013. A total of 122 studies involving 199,331 participants met the inclusion criteria. Contrary to recommendations from previous reviews, 91% of the included studies focused primarily on enduring patient factors, mainly demographics. The most consistent risk factors across the different study designs, samples, and measurement methods were cognitive deficits, low treatment alliance, personality disorder, and younger age. With the exception of younger age, none of the demographic factors emerged as consistent risk factors. Further research on the relationship between simple demographic factors and drop-out risk is of limited value. However, little is known about the potential risk factors related to treatment programs and to the treatment processes. Based on the review, clinical recommendations include assessing cognitive functioning and personality disorders at baseline and continuous monitoring of treatment alliance.

Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders

Research has documented the significant challenges of engaging individuals with comorbid serious mental illness (SMI) and substance use disorders (SUDs) in substance abuse treatment. To date it is unclear which factors predict treatment initiation and engagement in this group of individuals with SUDs. In this study we conducted two analyses using data from a randomized trial of substance abuse treatment in outpatients with SMI: the first examining predictors (collected during screening) of completing an initial intake assessment and the second examining predictors (collected during the intake assessment) of becoming engaged in treatment. Results indicated that males and those with schizophrenia spectrum diagnoses were less likely to complete the intake assessment. Participants who reported more positive feelings about their family were more likely to engage in substance abuse treatment. Participants who were recently arrested were less likely to engage in treatment. Those who met criteria for current drug dependence were less likely to engage in treatment. Overall, these findings are a useful step in determining factors that predict substance abuse treatment initiation and engagement in individuals with SMI and SUDs.

Predictors of attrition from a national sample of methadone maintenance patients

BACKGROUND

Methadone substitution therapy is an effective harm reduction treatment method for opioid dependent persons. Ability to retain patients in methadone treatment is an accepted predictor of treatment outcomes.

OBJECTIVES

The current study evaluates the roles of psychiatric comorbidity, medical comorbidity, and sociodemographic characteristics as predictors of retention in methadone treatment utilizing retrospective analysis of data from a nationwide sample of patients in methadone treatment in the VA.

METHODS

Data were gathered using the VA's national health services use database. A cohort of veterans with a new episode of "opiate substitution" in fiscal year 1999 was identified, and their continuous service use was tracked through fiscal year 2002. The sample included a total of 2,363 patients in 23 VA medical centers. Survival analysis was used to explore factors associated with retention in methadone treatment.

RESULTS

Younger age, having a serious mental illness, being African American, or having race recorded as unknown were associated with lower rates of retention in methadone treatment programs in this population of veterans (controlling for site).

CONCLUSION

Given that extended methadone treatment is associated with improved outcomes while patients remain in treatment, more longitudinal studies using primary data collection are needed to fully explore factors related to retention. For the VA population specifically, further research is necessary to fully understand the relationship between race/ethnicity and treatment retention.

SCIENTIFIC SIGNIFICANCE

This is the first retention study the authors are aware of that utilizes data from a nationwide, multisite, population of participants in methadone treatment.