Transitioning opioid-dependent patients from detoxification to long-term treatment: efficacy of intensive role induction

An explainable machine learning framework for predicting the risk of buprenorphine treatment discontinuation for opioid use disorder among commercially insured individuals

OBJECTIVES

Buprenorphine is an effective evidence-based medication for opioid use disorder (OUD). Yet premature discontinuation undermines treatment effectiveness, increasing the risk of mortality and overdose. We developed and evaluated a machine learning (ML) framework for predicting buprenorphine care discontinuity within 12 months following treatment initiation.

METHODS

This retrospective study used United States (US) 2018-2021 MarketScan commercial claims data of insured individuals aged 18-64 who initiated buprenorphine between July 2018 and December 2020 with no buprenorphine prescriptions in the previous six months. We measured buprenorphine prescription discontinuation gaps of ≥30 days within 12 months of initiating treatment. We developed predictive models employing logistic regression, decision tree classifier, random forest, extreme gradient boosting, Adaboost, and random forest-extreme gradient boosting ensemble. We applied recursive feature elimination with cross-validation to reduce dimensionality and identify the most predictive features while maintaining model robustness. For model validation, we used several statistics to evaluate performance, such as C-statistics and precision-recall curves. We focused on two distinct treatment stages: at the time of treatment initiation and one and three months after treatment initiation. We employed SHapley Additive exPlanations (SHAP) analysis that helped us explain the contributions of different features in predicting buprenorphine discontinuation. We stratified patients into risk subgroups based on their predicted likelihood of treatment discontinuation, dividing them into decile subgroups. Additionally, we used a calibration plot to analyze the reliability of the models.

RESULTS

A total of 30,373 patients initiated buprenorphine and 14.98% (4551) discontinued treatment. C-statistic varied between 0.56 and 0.76 for the first-stage models including patient-level demographic and clinical variables. Inclusion of proportion of days covered (PDC) measured after one month and three months following treatment initiation significantly increased the models' discriminative power (C-statistics: 0.60 to 0.82). Random forest (C-statistics: 0.76, 0.79 and 0.82 with baseline predictors, one-month PDC and three-months PDC, respectively) outperformed other ML models in discriminative performance in all stages (C-statistics: 0.56 to 0.77). Most influential risk factors of discontinuation included early stage medication adherence, age, and initial days of supply.

CONCLUSION

ML algorithms demonstrated a good discriminative power in identifying patients at higher risk of buprenorphine care discontinuity. The proposed framework may help healthcare providers optimize treatment strategies and deliver targeted interventions to improve buprenorphine care continuity.

Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center

INTRODUCTION

Substance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel.

METHODS

To address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses.

RESULTS

Analyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment.

CONCLUSIONS

Future studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.

Increasing Attendance in Addiction Treatment With Limited Resources: A Narrative Review

Treatment nonattendance frequently compromises client outcomes in psychosocial addiction treatment services. However, there is limited literature on strategies that increase attendance and retention without a significant resource burden on clinician or organization. This review of 13 studies describes strategies that do not financially reward clients for attendance or require more than 1 day of training/supervision to implement. These strategies are as follows: role induction; pretreatment written or verbal contact; short message service and telephone reminders; and contracting, prompting, and reinforcement. There is some evidence that role induction strategies can increase attendance in early treatment, with stronger evidence for a more intensive approach. Short message service and telephone reminders show a consistent positive impact on early attendance, although the relationship may weaken over time and for individuals with more complex needs (ie, high impulsivity). The strategy: contracting, prompting, and reinforcement shows promising findings, particularly in the first 3 months of treatment. There is considerable variability in study designs, interventions, and sample sizes-future research should more precisely identify relationships between outcomes and the "active ingredients" in each strategy. However, preliminary evidence suggests that some low clinician/organization-burden strategies increase treatment attendance and retention. The mechanisms underpinning these strategies may overlap with therapeutic engagement theories (eg, outcome expectations, common-factors model). Although these interventions have small to moderate effect sizes, their relative simplicity and low cost increase the likelihood of being implemented at a broad scale, amplifying their benefits.

Psychosocial and behavioral therapy in conjunction with medication for opioid use disorder: Patterns, predictors, and association with buprenorphine treatment outcomes

INTRODUCTION

Current evidence indicates that buprenorphine is a highly effective treatment for opioid use disorder (OUD), though premature medication discontinuation is common. Research on concurrent psychosocial and behavioral therapy services and related outcomes is limited. The goal of this study was to define patterns of OUD-related psychosocial and behavioral therapy services received in the first 6 months after buprenorphine initiation, identify patients' characteristics associated with service patterns, and examine the course of buprenorphine treatment, including the association of therapy with medication treatment duration.

METHODS

We analyzed 2013-2018 MarketScan Multi-State Medicaid claims data. The sample included adults aged 18-64 years at buprenorphine initiation with treatment episodes of at least 7 days (n = 61,976). We used group-based trajectory models to define therapy service patterns and multinomial logistic regression to identify pre-treatment patient characteristics associated with therapy trajectories. Multinomial propensity-score weighted Cox proportional hazards regression estimated time to buprenorphine discontinuation and unweighted Cox proportional hazards models estimated risk of adverse health care events during buprenorphine treatment (all-cause and opioid-related inpatient and emergency department services, overdose treatment).

RESULTS

We identified three trajectories of psychosocial and behavioral therapy services: none (73.8%), low-intensity (17.2%), and high-intensity (9.0%). Compared to those without therapy, low-intensity and high-intensity service patterns were associated with behavioral health diagnoses and medical treatment for opioid overdose in the baseline period prior to buprenorphine initiation. The hazard of buprenorphine discontinuation was significantly lower for low-intensity (HR = 0.55; 95% CI, 0.54-0.57) and high-intensity (HR = 0.71; 95% CI, 0.67-0.74) therapy groups compared to those without therapy services. Yet patients in the high-intensity therapy group had increased risk of opioid-related health care events during buprenorphine treatment, including medical treatment for opioid overdose (HR = 1.29; 95% CI, 1.01-1.64).

CONCLUSION

Most patients received little or no OUD-related psychosocial and behavioral therapy after initiating buprenorphine treatment. Patients who received therapy had characteristics indicating greater treatment needs as well as more complex treatment courses. Concurrent therapy services may help to address premature buprenorphine discontinuation, particularly for patients with high-risk clinical profiles; however, future prospective research should determine whether therapy is effective for extending buprenorphine retention.

Negative affect-associated drug refusal self-efficacy, illicit opioid use, and medication use following short-term inpatient opioid withdrawal management

INTRODUCTION

Persons with opioid use disorder (OUD) are prone to frequent relapse following brief inpatient medically managed withdrawal. This longitudinal, naturalistic study examines associations among illicit opioid use, use of medication for opioid use disorder (MOUD), and one's confidence in the ability to resist drug use in the face of negative emotions (i.e., negative affect-associated drug refusal self-efficacy).

METHOD

Participants were 220 adults with OUD who recently completed a short-term inpatient program and the study followed for 6 months. At baseline, participants reported demographics, illicit opioid use, recent engagement with MOUD, and negative affect-associated drug refusal self-efficacy. At follow-up (1 week and 1-, 3-, and 6-months following discharge), participants reported illicit opioid use and MOUD.

RESULTS

Participants averaged 30.7 years of age, 63.2% were male, and 84.1% were white. Both illicit opioid use and rates of MOUD increased during the 6-month follow-up period, although only 34.1% received MOUD. At baseline, participants reported less than 50% self-confidence to resist using opioids during negative emotional states. Baseline negative affect-associated drug refusal self-efficacy inversely predicted illicit opioid use (p = .01) at follow-up but was not associated with follow-up MOUD.

CONCLUSION

Among persons with OUD, lower confidence to resist using opioids in negative emotional states predicts greater use of illicit opioids in the months following medically managed withdrawal, even with receipt of MOUD.

Development of the Highly Processed Food Withdrawal Scale for Children

INTRODUCTION

Highly processed foods (with added fats and/or refined carbohydrates) may trigger an addictive-like process, including withdrawal when these foods are reduced. Withdrawal is marked by affective, cognitive, and physical symptoms that may hinder dietary change. A recently developed scale of highly processed food withdrawal in adults (ProWS) provides evidence for this construct. Children commonly consume highly processed foods, but no measures currently exist to examine highly processed food withdrawal in children. The purpose of this study was to develop a measure (ProWS-C) to assess for signs of highly processed food withdrawal in children.

METHODS

Parents who had recently attempted to reduce their child's highly processed food consumption were recruited through an online crowdsourcing platform. 304 parents (56.9% mothers) reported on their 3-11-year-old children (63.8% male). The ProWS-C was designed to reflect parents' observations of child behavior. Internal consistency and validity were evaluated using the Dimensional Yale Food Addiction Scale Version 2.0 for Children (dYFAS-C 2.0.), Children's Food Neophobia Scale-Modified (CFNS), and body mass index (BMI) silhouettes.

RESULTS

Exploratory factor analysis revealed a one-factor structure with 21 items (α = 0.94). The ProWS-C demonstrated convergent validity with more child food addiction symptoms (r = 0.55, p < 0.001) and higher child BMI (r = 0.24, p < 0.001) and discriminant validity with child food neophobia (r = -0.10, p = 0.08). The ProWS-C was associated with less success in reducing child highly processed food intake independent of child addictive-like eating and BMI (p = 0.001).

DISCUSSION

The ProWS-C provides preliminary evidence for highly processed food withdrawal in children and appears to be a psychometrically sound tool for assessing parent-reported withdrawal symptoms in children. Illuminating specific challenges families face when reducing highly processed foods may improve parents' ability to help their children make sustainable dietary changes.

Expectations vs reality: The expectations and experiences of psychiatric treatment reported by young adults at a mood and anxiety outpatient mental health program

AIM

To compare young adults' expectations of psychiatric treatment to their actual experiences and identify myths and assumptions that youth might hold prior to receiving care.

METHODS

We interviewed youth who engaged in at least 4 months of treatment at the First Episode Mood and Anxiety Program to theme saturation (N = 20). They were asked about their experience of treatment and the expectations they had prior to care. Transcribed interviews were analysed for themes.

RESULTS

Results indicated that participants often expected a cold, serious atmosphere, a "quick fix," and a directive therapeutic relationship. Although most patients had a negative experience at some point in their care, they overall described a welcoming environment with engaged providers and a collaborative therapeutic relationship. Participants found treatment more complex than they had anticipated, but ultimately experienced strengthening of agency and a change in perspective.

CONCLUSIONS

These results identify a need to recognize assumptions held by young adults seeking treatment for mental health symptoms. Addressing these preconceptions might reduce apprehension and improve readiness for treatment. This research provides direction on how to dispel myths and better prepare youth for the work involved in effective psychiatric care.

The Availability of Ancillary Counseling in the Practices of Physicians Prescribing Buprenorphine

OBJECTIVE

We set out to examine physicians' perceptions of the provision of ancillary services for opioid dependent patients receiving buprenorphine.

METHODS

An e-mail invitation describing the study was sent out by the American Society of Addiction Medicine to its membership (approximately 3700 physicians) and other entities (for a total of approximately 7000 e-mail addresses). E-mail recipients were invited to participate in a research study funded by the National Institutes on Drug Abuse involving completion of an online survey; 346 physicians completed the survey.

RESULTS

The majority of the 346 respondents were internal or family medicine (37%), or addiction medicine providers (30%), who were practicing in urban (57%) or suburban settings (27%). Most respondents reported either offering (66%) or referring patients for ancillary counseling (31%). Interventions that were most frequently offered or referrals provided were individual counseling (51%) and self-help groups (63%), respectively. Counseling availability differed significantly by provider specialization for any, individual, group, family or couples, and self-help groups.

CONCLUSIONS

Generally, respondents reported compliance with ancillary counseling requirements for buprenorphine treatment of opioid use disorder. In addition to examining the efficacy of a variety of ancillary counseling services for patients receiving opioid agonist treatment, further research should examine physicians' attitudes toward the role of such counseling in buprenorphine treatment. Although the study sample was relatively large, the generalizability of the findings is unclear, suggesting that further investigation of the availability of ancillary counseling in buprenorphine treatment among a larger nationally representative sample of providers may be warranted.

Severity of Withdrawal Symptoms, Plasma Oxytocin Levels, and Treatment Outcome in Heroin Users Undergoing Acute Withdrawal

Pre-clinical studies show that, following chronic opioid exposure, oxytocin neurons exhibit over-excitation upon withdrawal, causing an increase in oxytocin brain and plasma levels. Relevant clinical data on humans are scarce. This study investigates the opioid withdrawal stress effect on oxytocin plasma levels in humans. We evaluated 57 male chronic heroin users in a residential detoxification program. We determined plasma oxytocin levels by ELISA and measured the stress effects of withdrawal using the COWS scale for opioid withdrawal, the VAS scale for craving, and the Hamilton scales for anxiety and depression on the second day of admission. Out of the 57 patients enrolled in the study, 27 completed the 21-day program, while the remaining 30 dropped out prior to completion. Plasma oxytocin levels were significantly higher in those individuals who dropped out than in those who completed the program. Participants who dropped out at some stage scored higher in the COWS, VAS-Craving, and Hamilton-anxiety scales, indicating a higher stress and explaining the higher oxytocin levels. In addition, plasma oxytocin levels correlated positively with the scores achieved in the COWS and Hamilton-anxiety scales. Higher withdrawal stress levels are associated with higher plasma oxytocin levels and early treatment discharge.

A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction

Opioid use and overdose rates have risen to epidemic levels in the United States during the past decade. Fortunately, there are effective medications (ie, methadone, buprenorphine, and oral and injectable naltrexone) available for the treatment of opioid addiction. Each of these medications is approved for use in conjunction with psychosocial treatment; however, there is a dearth of empirical research on the optimal psychosocial interventions to use with these medications. In this systematic review, we outline and discuss the findings of 3 prominent prior reviews and 27 recent publications of empirical studies on this topic. The most widely studied psychosocial interventions examined in conjunction with medications for opioid addiction were contingency management and cognitive behavioral therapy, with the majority focusing on methadone treatment. The results generally support the efficacy of providing psychosocial interventions in combination with medications to treat opioid addictions, although the incremental utility varied across studies, outcomes, medications, and interventions. The review highlights significant gaps in the literature and provides areas for future research. Given the enormity of the current opioid problem in the United States, it is critical to gain a better understanding of the most effective ways to deliver psychosocial treatments in conjunction with these medications to improve the health and well-being of individuals suffering from opioid addiction.

Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial

IMPORTANCE

Prescription opioid dependence is increasing and creates a significant public health burden, but primary care physicians lack evidence-based guidelines to decide between tapering doses followed by discontinuation of buprenorphine hydrochloride and naloxone hydrochloride therapy (hereinafter referred to as buprenorphine therapy) or ongoing maintenance therapy.

OBJECTIVE

To determine the efficacy of buprenorphine taper vs ongoing maintenance therapy in primary care-based treatment for prescription opioid dependence.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a 14-week randomized clinical trial that enrolled 113 patients with prescription opioid dependence from February 17, 2009, through February 1, 2013, in a single primary care site.

INTERVENTIONS

Patients were randomized to buprenorphine taper (taper condition) or ongoing buprenorphine maintenance therapy (maintenance condition). The buprenorphine taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioid withdrawal, after which patients were offered naltrexone treatment. The maintenance group received ongoing buprenorphine therapy. All patients received physician and nurse support and drug counseling.

MAIN OUTCOMES AND MEASURES

Illicit opioid use via results of urinanalysis and patient report, treatment retention, and reinitiation of buprenorphine therapy (taper group only).

RESULTS

During the trial, the mean percentage of urine samples negative for opioids was lower for patients in the taper group (35.2% [95% CI, 26.2%-44.2%]) compared with those in the maintenance group (53.2% [95% CI, 44.3%-62.0%]). Patients in the taper group reported more days per week of illicit opioid use than those in the maintenance group once they were no longer receiving buprenorphine (mean use, 1.27 [95% CI, 0.60-1.94] vs 0.47 [95% CI, 0.19-0.74] days). Patients in the taper group had fewer maximum consecutive weeks of opioid abstinence compared with those in the maintenance group (mean abstinence, 2.70 [95% CI, 1.72-3.75] vs 5.20 [95% CI, 4.16-6.20] weeks). Patients in the taper group were less likely to complete the trial (6 of 57 [11%] vs 37 of 56 [66%]; P < .001). Sixteen patients in the taper group reinitiated buprenorphine treatment after the taper owing to relapse.

CONCLUSIONS AND RELEVANCE

Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioid dependence who receive buprenorphine therapy in primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00555425.

A conceptual model to facilitate transitions from primary care to specialty substance use disorder care: a review of the literature

AIM

This article presents a conceptual model to help facilitate the transition from primary care to specialty substance use disorder (SUD) care for appropriate patients.

BACKGROUND

Substance misuse is a common health condition among patients presenting to primary care settings and may complicate the treatment of chronic health conditions such as diabetes and hypertension. It is therefore critical that primary care providers be prepared to identify and determine appropriate treatment options for patients presenting with substance misuse.

METHODS

We conducted a narrative review that occurred in three stages: literature review of health care transition models, identification of conceptual domains common across care transition models, and identification of SUD-specific model elements. Findings The conceptual model presented describes patient, provider, and system-level facilitators and barriers to the transition process, and includes intervention strategies that can be utilized by primary care clinics to potentially improve the process of transitioning patients from primary care to SUD care. Recognizing that primary care clinics vary in available resources, we present three examples of care practices along an intensity continuum from low (counseling and referral) to moderate (telephone monitoring) to high (intensive case management) resource demands for adoption. We also provide a list of common outcomes clinics might consider when evaluating the impact of care transition practices in this patient population; these include process outcomes such as patients' increased knowledge of available treatment resources, and health outcomes such as patients' reduced substance use and better quality of life.

A qualitative study of the perceived impact of a community mobilisation intervention to reduce alcohol consumption among amateur sportsmen

Aim The aim of this study was to examine the perceived impact of a community mobilisation intervention programme to reduce alcohol consumption among amateur sportsmen aged 16-34 years.

METHOD

A qualitative focus group format was used to identify potentially important themes or concepts relating to players' and coaches' experiences of the intervention. Six focus groups were conducted (five with four to seven players per focus group and one with six coaches) to elicit participants' experiences of the intervention.

RESULTS

Three major themes emerged from the analyses: patterns of alcohol consumption and associated factors; perceived impact of the intervention; and suggested changes to the community mobilisation intervention. Excessive binge drinking (i.e. the consumption of six or more standard drinks on any one occasion) was common among players. The perceived impact of the intervention programme among players was low; players and coaches believed that if future programmes were to succeed, a 'bottom-up' rather than a 'top-down' approach should be adopted.

CONCLUSIONS

The findings suggest that players perceived the community mobilisation programme to have had only limited success in changing attitudes or behaviour towards alcohol consumption in this amateur sports setting.

The combination very low-dose naltrexone-clonidine in the management of opioid withdrawal

BACKGROUND

The management of withdrawal absorbs substantial clinical efforts in opioid dependence (OD). The real challenge lies in improving current pharmacotherapies. Although widely used, clonidine causes problematic adverse effects and does not alleviate important symptoms of opioid withdrawal, alone or in combination with the opioid antagonist naltrexone. Very low-dose naltrexone (VLNTX) has been shown to attenuate withdrawal intensity and noradrenaline release following opioid agonist taper, suggesting a combination with clonidine may result in improved safety and efficacy.

OBJECTIVES

We investigated the effects of a VLNTX-clonidine combination in a secondary analysis of data from a double-blind, randomized opioid detoxification trial.

METHODS

Withdrawal symptoms and treatment completion were compared following VLNTX (.125 or .25 mg/day) and clonidine (.1-.2 mg q6h) in 127 individuals with OD undergoing 6-day methadone inpatient taper at a community program.

RESULTS

VLNTX was more effective than placebo or clonidine in reducing symptoms and signs of withdrawal. The use of VLNTX in combination with clonidine was associated with attenuated subjective withdrawal compared with each medication alone, favoring detoxification completion in comparison with clonidine or naltrexone placebo. VLNTX/clonidine was effective in reducing symptoms that are both undertreated and well controlled with clonidine treatment and was not associated with significant adverse events compared with other treatments.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Preliminary results elucidate neurobiological mechanisms of OD and support the utility of controlled studies on a novel VLNTX + low-dose clonidine combination for the management of opioid withdrawal.

Computerized assessment facilitates disclosure of sensitive HIV risk behaviors among African Americans entering substance abuse treatment

BACKGROUND

Individuals entering substance abuse treatment are at elevated risk for HIV infection, and clinicians must generally rely on patient self-report to gauge their involvement in risk behaviors. Strategies to improve accurate reporting of personally sensitive or stigmatizing risk behaviors are needed.

OBJECTIVE

This study compared computerized and face-to-face interview methods in eliciting self-disclosure of HIV risk behaviors among a high-risk sample of urban African Americans entering substance abuse treatment (N = 146).

METHODS

Participants completed a standardized HIV risk behavior screening as a face-to-face interview. Several days later, the same participants completed a computerized self-interview with the same measure, covering the same time frame.

RESULTS

Disclosure rates for many sensitive risk behaviors were considerably higher on the computerized interview. Participants had significantly higher odds of disclosure on the computerized interview compared to the face-to-face interview on 2 of 6 drug risk behaviors examined (ORs between 2.75 and 3.15) and 9 of 13 sex risk behaviors examined (ORs between 1.60 and 6.45). The advantage of the computerized interview was most evident for highly stigmatized behaviors, such as unprotected sex with someone other than a spouse or main partner (OR = 3.93; p < .001), unprotected sex during a commercial sex transaction (OR = 5.63; p < .001), unprotected anal sex (OR = 6.45; p < .001), and using unsterilized syringes (OR = 3.15; p < .05).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Findings support the utility of computerized risk behavior assessment with African Americans entering substance abuse treatment. Computerized assessment of HIV risk behaviors may be clinically useful in substance abuse treatment and other healthcare venues serving high-risk populations.

Reducing dropout among traumatized alcohol patients in detoxification treatment: a pilot intervention study

Dropout rates from detoxification treatment are high. We tested whether high trauma event load was related to a higher dropout from alcohol detoxification. Furthermore, we studied the feasibility and effects of a short psychoeducational tool to increase retention among traumatized alcohol in-patients. Retention and treatment length were compared between treatment as usual (TAU) and standard therapy plus a psychoeducational group intervention on alcohol drinking related to stress and trauma (PAST). Patients with high trauma load were identified with the Trauma History Questionnaire. Of the 159 in-patients treated during the study period, 66 were included in the analysis: 33 in TAU and 33 in PAST. Sociodemographic characteristics did not differ between the groups. During TAU, patients with high trauma load tended to drop out more often (p = 0.056). Among patients with high trauma load, retention level increased from 29 to 80% (p = 0.006), and among those with low trauma load from 63 to 83% (p = 0.250). Treatment length only tendentially improved among patients with lower burden (p = 0.056). The pilot study supports the idea that detoxification treatment dropout occurs more often among alcohol patients with high trauma load and that their retention can be increased by a psychoeducational group intervention.