Characteristics of life stressors predictive of substance treatment outcomes

Alcohol use disorder relapse factors: A systematic review

A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.

Absolute Abstinence as a Treatment Outcome in Servicemen with Alcohol Dependence: A Retrospective Cohort Study

Background: Within India's military medical framework, alcohol dependence syndrome (ADS) is deemed a treatable medical illness incompatible with military service, and complete abstinence is the only acceptable successful treatment outcome. Objective: This study was designed to identify factors which were able to differentiate treatment outcomes of abstinence and relapse among ADS patients in a military framework. Method: Recognizing personal incentives to misrepresent alcohol consumption, abstinence, and relapse outcomes were established using official reports from a patient's parent unit, in combination with biochemical parameters and clinical examination. Patients serially admitted for ADS treatment or follow-up review were surveyed, and their socio-demographic and alcohol consumption profiles, coping styles, life events and specific relapse precipitants were recorded and compared as contributory variables in a cognitive-behavioral model of ADS. From this survey of 140 patients, membership to abstainer or relapser groups was then predicted using a discriminant analysis. Results: 34% of patients achieved early absolute abstinence. No baseline socio-demographic or drinking profile distinctions existed between abstainers and relapsers. Differences were forthcoming on coping styles, life-event, and relapse-precipitant exposure measures. Stepwise discriminant analysis produced a final equation comprising 10 independent variables (including two positive life event measures), which predicted an abstinence/relapse outcome with an 86% and 79% hit-rate (original and cross-validated). Conclusion: Using prevailing cognitive-behavioral constructs, early absolute abstinence emerged as an actionable objective and an achievable goal without any contributory socio-demographic predilections. This preliminary evaluation suggests it is a tenable and realistic target of current ADS treatment programs.

Life events and alcohol use disorder clinical course: Modeling the dynamic association

BACKGROUND

Despite over 35 years of study, the relationship between life events (LEs) and alcohol use disorder (AUD) treatment outcome lacks consistent empirical support, which may be due to a lack of theoretically driven designs and corresponding statistical analyses. The purpose of this study was to elucidate the LEs-AUD treatment outcome relationship by statistically modeling the dynamic relationship between negative LEs and alcohol use post-treatment, as it is conceptualized within the dynamic model of relapse.

METHODS

Existing longitudinal data from 417 AUD treatment-seeking adults were randomly assigned to two demographically comparable samples. One sample (N=208) was used to estimate a series of dynamic bivariate latent change score models that differentially relate latent indicators of distal and proximal negative LEs (i.e., events subjectively rated as negative) and percent heavy drinking days across 12 months. Cross-validation was conducted on the second sample (N=209).

RESULTS

Findings indicated that distal negative LEs were positively associated with a greater increase in negative LEs, but not heavy drinking, over the subsequent 12 months. Proximal negative LEs were significantly associated with subsequent increases in heavy drinking, though heavy drinking was not a determinant of change in negative LEs. These findings were cross-validated with the second sample.

CONCLUSIONS

This study provides initial justification for the further study of the LEs-alcohol use relationship as it is described in the dynamic model of relapse.

Persistent adaptation by chronic alcohol is facilitated by neuroimmune activation linked to stress and CRF

This review updates the conceptual basis for the association of alcohol abuse with an insidious adaptation that facilitates negative affect during withdrawal from chronic intermittent alcohol (CIA) exposure - a change that later supports sensitization of stress-induced anxiety following alcohol abstinence. The finding that a CRF1-receptor antagonist (CRF1RA) minimized CIA withdrawal-induced negative affect supported an association of alcohol withdrawal with a stress mechanism. The finding that repeated stresses or multiple CRF injections into selected brain sites prior to a single 5-day chronic alcohol (CA) exposure induced anxiety during withdrawal provided critical support for a linkage of CIA withdrawal with stress. The determination that CRF1RA injection into positive CRF-sensitive brain sites prevented CIA withdrawal-induced anxiety provided support that neural path integration maintains the persistent CIA adaptation. Based upon reports that stress increases neuroimmune function, an effort was undertaken to test whether cytokines would support the adaptation induced by stress/CA exposure. Twenty-four hours after withdrawal from CIA, cytokine mRNAs were found to be increased in cortex as well as other sites in brain. Further, repeated cytokine injections into previously identified brain sites substituted for stress and CRF induction of anxiety during CA withdrawal. Discovery that a CRF1RA prevented the brain cytokine mRNA increase induced by CA withdrawal provided critical evidence for CRF involvement in this neuroimmune induction after CA withdrawal. However, the CRF1RA did not block the stress increase in cytokine mRNA increases in controls. The latter data supported the hypothesis that distinct mechanisms linked to stress and CA withdrawal can support common neuroimmune functions within a brain site. As evidence evolves concerning neural involvement in brain neuroimmune function, a better understanding of the progressive adaptation associated with CIA exposure will advance new knowledge that could possibly lead to strategies to combat alcohol abuse.

Associations between childhood adversity, adult stressful life events, and past-year drug use disorders in the National Epidemiological Study of Alcohol and Related Conditions (NESARC)

Stress sensitization, whereby CA lowers tolerance to later stressors, has been proposed as a potential mechanism explaining the association between exposure to childhood adversities (CA) and drug use disorders in adulthood. However, this mechanism remains untested. This paper begins to address this gap through exploring associations between CA exposure and stressful events in adulthood for predicting drug use disorders. We used data drawn from Wave 2 of the U.S. National Epidemiological Survey of Alcohol and Related Conditions (n = 34,653) to explore whether the association between past-year stressful life events and the 12-month prevalence of disordered cannabis, stimulant, and opiate use varied by the number of types of CA that an individual was exposed to. Past-year stressful life events were associated with an increased risk of cannabis, stimulant, and opiate use disorders among men and women. Exposure to CA was associated with increased risk for disordered cannabis use among men and women and opiate use among men only. Finally, we found significant associations between exposure to CA and past-year stressful life events in predicting disordered drug use, but only for women in relation to disordered stimulant and opiate use. Findings are suggestive of possible stress sensitization effects in predicting disordered stimulant and opiate use among women. Implications of these findings for the prevention and treatment of drug use disorders and for future research are discussed.

Changes in emotional reactivity and distress tolerance among heavy drinking adolescents during sustained abstinence

BACKGROUND

Negative affect and low distress tolerance have been associated with increased likelihood of alcohol consumption and relapse. This study utilized the Paced Auditory Serial Attention Test - Computerized Version (PASAT-C) to examine affective reactivity, cognitive performance, and distress tolerance during early abstinence among heavy drinking adolescents.

METHODS

Participants, ages 16 to 18 (50% female), were 23 heavy episodic drinking youth (HED) and 23 demographically matched, nondrinking teens (CON). Both groups were drawn from the same schools and assessed at 3 time points: HED was first studied within 10 days (M = 4.26, SD = 4.4) of heavy episodic drinking and then at two 2-week intervals over 4 subsequent weeks of abstinence from alcohol and drugs. CON were studied at the same 2-week intervals.

RESULTS

From the findings, it was observed that HED responded with greater emotional response to the PASAT-C (i.e., greater increases in frustration and irritability and greater decreases in happiness) at the initial assessment, but their affective responses diminished with sustained abstinence. CON and HED task performance did not differ at the initial assessment or across time. HED showed faster task discontinuation times to the PASAT-C at the first assessment, and both groups reduced task persistence across testings. Among HED, greater lifetime and recent alcohol consumption, alcohol-induced blackouts, and withdrawal symptoms were associated with increases in negative affect with PASAT-C exposure. Earlier age of onset of alcohol use was linked to poorer performance.

CONCLUSIONS

Heavy episodic drinking adolescents demonstrated heightened emotional reactivity and poorer distress tolerance to a cognitively challenging task during early abstinence. The combination of elevated negative affect and low distress tolerance may place adolescents at a heightened risk of escalations in or return to alcohol involvement.

Mediated and moderated effects of neurocognitive impairment on outcomes of treatment for substance dependence and major depression

OBJECTIVE

Neurocognitive impairment has not consistently predicted substance use treatment outcomes but has been linked to proximal mediators of outcome. These indirect effects have not been examined in adults with substance dependence and co-occurring psychiatric disorders. We examined mediators and moderators of the effects of neurocognitive impairment on substance use among adults in treatment for alcohol or drug dependence and major depression (MDD).

METHOD

Participants were veterans (N = 197, mean age = 49.3 years, 90% male, 75% Caucasian) in a trial of 2 group interventions for alcohol/drug dependence and MDD. Measures examined here included intake neurocognitive assessments and percent days drinking (PDD), percent days using drugs (PDDRG), self-efficacy, 12-step affiliation, and depressive symptoms measured every 3 months from intake to the 18-month follow-up.

RESULTS

Greater intake neurocognitive impairment predicted lower self-efficacy, lower 12-step affiliation, and greater depression severity, and these time-varying variables mediated the effects of impairment on future PDD and PDDRG. The prospective effects of 12-step affiliation on future PDD were greater for those with greater neurocognitive impairment. Impairment also interacted with depression to moderate the effects of 12-step affiliation and self-efficacy on PDD. Adults with greater impairment and currently severe depression had the strongest associations between 12-step affiliation/self-efficacy and future drinking.

CONCLUSIONS

Greater neurocognitive impairment may lead to poorer outcomes from group therapy for alcohol/drug dependence and MDD due to compromised change in therapeutic processes. Distal factors such as neurocognitive impairment can interact with dynamic risk factors to modulate the association between therapeutic processes and future drinking outcomes.

Life events and treatment outcomes among individuals with substance use disorders: a narrative review

Substance use disorders are characterized by a variable course, in which multiple treatment attempts and relapses are typical. Consistent with conceptualizations of substance use and relapse, life events have been implicated in contributing to poor substance use disorders treatment outcomes. However, inconsistencies in empirical findings regarding the life events-substance use disorders outcome literature have been previously observed. This review provides an updated critique of the literature since the previous review published in 1987 (O'Doherty & Davies, 1987), examining the relationship between life events and substance use disorders treatment outcome among clinical samples of individuals. Review of 18 peer-reviewed articles suggested that data on the life events-outcome relationship continue to be inconclusive. Inconsistencies across studies in the operationalization of life events and substance use treatment outcomes and lack of theoretically driven designs may be contributing to differences in findings. Recommendations for future research that will increase the clinical utility of the life events construct are provided.

Impact of Physical Health on Treatment for Co-occurring Depression and Substance Dependence

OBJECTIVE

There is a high rate of comorbidity among substance dependence, depression, and physical health problems. This study aimed to examine the impact of pre-treatment physical health stressors (acute and chronic conditions) on outcomes of treatment in a sample of veterans with dual disorders (depression and substance dependence) who were randomized to integrated cognitive behavioral therapy versus 12-Step interventions.

METHODS

This study included 205 veterans (89.8% male, mean age = 49.5 years) enrolled in a clinical treatment outcomes trial. Chronic health problems (persistent, ongoing conditions lasting 2 weeks or more; e.g., arthritis, diabetes) and acute health events (occurring on a discrete date; e.g., injury, surgery, myocardial infarction) were coded dichotomously (presence versus absence) and evaluated separately. The impact of physical health stressors on abstinence (defined dichotomously), percentage of days abstinent, and depression symptoms were analyzed at the end of 12 and 24 weeks of treatment. Additionally, associations between intake motivation to change, health stressors, and substance use were examined.

RESULTS

Analyses revealed that participants who had experienced a pretreatment acute health event had higher rates of abstinence at 12-weeks, higher percentage of days abstinent at 24-weeks, and higher depression symptoms at intake. Participants with chronic health difficulties had more severe depression at intake and those participants with severe chronic difficulties had greater depression symptoms across all time points. Chronic health difficulties were related to the Taking Steps factor of motivation to change substance use, but acute health events were not related to motivation to change. Motivation to change was also not related to substance outcomes in our sample.

CONCLUSIONS

Physical health appears to have a complex relationship with co-occurring depression and substance dependence. Acute health problems predicted lower substance use, whereas chronic health problems were associated with higher depression levels. Explicitly addressing the connection between substance use and health events during treatment may improve addiction treatment outcomes. However, individuals with chronic health problems may benefit from extending treatment or adjunct strategies focused on addressing chronic health concerns. This is an analysis of data collected as part of a clinical trial registered at www.ClinicalTrials.gov as NCT00108407.

Predictors of treatment retention for substance-dependent adults with co-occurring depression

Low attendance in addiction treatment, particularly in cases of comorbidity, has been identified as a pervasive challenge. We examine predictors of treatment retention in a sample of veterans (N = 253) participating in a clinical trial comparing two types of psychotherapy for co-occurring depression and substance use disorders. The study protocol included 24 weeks of outpatient group psychotherapy in either a newly developed Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation Therapy (TSF). Using a model of treatment utilization developed by Aday and Anderson, we analyzed predictors categorized into predisposing factors, enabling resources, need for treatment, and type of treatment received. Outcome included total number of sessions attended (maximum of 36 sessions). Treatment retention did not differ between the two study interventions. Bivariate analyses indicated that predisposing factors were most predictive, with older participants, Caucasians, and those using only alcohol in the month before treatment attending more sessions, and individuals who had recently experienced a health event remained in treatment longer. Importantly, several factors were not related to treatment retention: marital status, education, neuropsychological functioning, financial stress, chronic health problems, treatment motivation, and psychiatric severity. In the combined model of predisposing, enabling and need factors, age and ethnicity were the only significant predictors.

Incorporating a Healthy Living Curriculum within Family Behavior Therapy: A Clinical Case Example in a Woman with a History of Domestic Violence, Child Neglect, Drug Abuse, and Obesity

Women reported to child protective service agencies frequently report problems that significantly interfere with the health and well-being of their children and themselves. Behavioral treatment programs appear to be effective in managing these co-existing problems, such as domestic violence and substance abuse. However, evidence-supported interventions are rarely exemplified in complicated clinical cases, especially within child welfare settings. Therefore, in this case example, we describe the process of adapting an evidence-supported treatment to assist in managing significant co-existing health-related problems in a mother who was referred due to child neglect and drug abuse. At the conclusion of therapy, the participant reported improvements in perceived family relationships, illicit drug use, child maltreatment potential, whereas other health-related outcomes were mixed. Most improvements were maintained at 4-month follow-up. Issues relevant to implementing evidence-based treatments within community contexts are discussed, including methods of increasing the likelihood of valid outcome assessment, managing treatment integrity, and adjusting standardized treatments to accommodate co-occurring problems.

Smoker characteristics and smoking-cessation milestones

BACKGROUND

Contextual variables often predict long-term abstinence, but little is known about how these variables exert their effects. These variables could influence abstinence by affecting the ability to quit at all, or by altering risk of lapsing, or progressing from a lapse to relapse.

PURPOSE

To examine the effect of common predictors of smoking-cessation failure on smoking-cessation processes.

METHODS

The current study (N=1504, 58% female, 84% Caucasian; recruited from January 2005 to June 2007; data analyzed in 2009) uses the approach advocated by Shiffman et al. (2006), which measures cessation outcomes on three different cessation milestones (achieving initial abstinence, lapse risk, and the lapse-relapse transition) to examine relationships of smoker characteristics (dependence, contextual and demographic factors) with smoking-cessation process.

RESULTS

High nicotine dependence strongly predicted all milestones: not achieving initial abstinence, and a higher risk of both lapse and transitioning from lapse to complete relapse. Numerous contextual and demographic variables were associated with higher initial cessation rates and/or decreased lapse risk at 6 months post-quit (e.g., ethnicity, gender, marital status, education, smoking in the workplace, number of smokers in the social network, and number of supportive others). However, aside from nicotine dependence, only gender significantly predicted the risk of transition from lapse to relapse.

CONCLUSIONS

These findings demonstrate that (1) higher nicotine dependence predicted worse outcomes across every cessation milestone; (2) demographic and contextual variables are generally associated with initial abstinence rates and lapse risk and not the lapse-relapse transition. These results identify groups who are at risk for failure at specific stages of the smoking-cessation process, and this may have implications for treatment.

Chronic alcohol neuroadaptation and stress contribute to susceptibility for alcohol craving and relapse

Alcoholism is a chronic relapsing disorder. Major characteristics observed in alcoholics during an initial period of alcohol abstinence are altered physiological functions and a negative emotional state. Evidence suggests that a persistent, cumulative adaptation involving a kindling/allostasis-like process occurs during the course of repeated chronic alcohol exposures that is critical for the negative symptoms observed during alcohol withdrawal. Basic studies have provided evidence for specific neurotransmitters within identified brain sites being responsible for the negative emotion induced by the persistent cumulative adaptation following intermittent-alcohol exposures. After an extended period of abstinence, the cumulative alcohol adaptation increases susceptibility to stress- and alcohol cue-induced negative symptoms and alcohol seeking, both of which can facilitate excessive ingestion of alcohol. In the alcoholic, stressful imagery and alcohol cues alter physiological responses, enhance negative emotion, and induce craving. Brain fMRI imaging following stress and alcohol cues has documented neural changes in specific brain regions of alcoholics not observed in social drinkers. Such altered activity in brain of abstinent alcoholics to stress and alcohol cues is consistent with a continuing ethanol adaptation being responsible. Therapies in alcoholics found to block responses to stress and alcohol cues would presumably be potential treatments by which susceptibility for continued alcohol abuse can be reduced. By continuing to define the neurobiological basis of the sustained alcohol adaptation critical for the increased susceptibility of alcoholics to stress and alcohol cues that facilitate craving, a new era is expected to evolve in which the high rate of relapse in alcoholism is minimized.

Life events and sexual risk among HIV-negative, heterosexual, methamphetamine users

Identifying psychosocial factors associated with sexual risk behavior among methamphetamine users is essential to enhancing HIV and sexually transmitted infection prevention. This study examined the relationship between positive and negative life events and sexual risk behavior in a sample of 100 HIV-negative, heterosexually identified, methamphetamine-using men and women. Negative life event categories included death of a significant other, negative health event involving self or significant other, and child custody or visitation issues. Categories of positive life events included birth or pregnancy involving self or significant other, a positive relationship event, and a positive life change. Multivariate analyses demonstrated that negative life events were positively associated with total number of unprotected sex acts, whereas positive life events were not associated with sexual risk taking. Also, amount of methamphetamine used did not moderate the relationship between life events and sexual risk behavior. These data support future research to identify underlying mechanisms that link negative life events to sexual risk taking in this high-risk population.

The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients

INTRODUCTION

Health problems are prevalent in chemical dependency (CD) treatment populations, and often precede reductions in substance use among untreated populations. Few studies have examined whether medical problems predict better long-term outcomes in treated individuals, or how primary care utilization and CD/primary care service integration affects long-term outcomes among those with health problems.

METHOD

In a sample of 598 CD patients in a private health plan, logistic regression models examined whether substance abuse-related medical conditions (SAMCs), integrated medical and CD care, and on-going primary care predicted remission of CD problems at 5 years.

RESULTS

Those with SAMCs were no more likely than others to be remitted at 5 years except among young adults and those with medical, but not psychiatric SAMCs. Higher levels of medical problem severity at intake and receiving integrated CD and primary care in the index treatment episode predicted remission in the full sample and among those with SAMCs. Among those with SAMCs, individuals with ongoing medical care - 2-10 primary care visits - in the 5 years following intake were more likely to be remitted at 5 years than those with fewer visits.

CONCLUSIONS

This study highlights the potentially important role of medical services in the long-term treatment of CD disorders. CD treatment may benefit from a disease management approach similar to that recommended for other chronic medical problems: specialty care when the condition is severe followed by services in primary care when the condition is stabilized.

Early life trauma and sensitivity to current life stressors in individuals with and without cocaine dependence

This study investigated the link between exposure to early life trauma, sensitivity to current daily stressors, and cocaine dependence. Individuals with (n = 105) or without (n = 53) cocaine dependence completed the Early Trauma Inventory and the Daily Hassles Scale. In comparison to controls, cocaine-dependent individuals reported almost twice as many daily hassles and perceived those hassles more negatively (p < .001). For participants with cocaine dependence, a significant relationship between exposure to early life trauma and negative perception of current daily hassles was observed (p < .01), whereas no such relationship was observed for participants without cocaine dependence. Adverse childhood events may lead to an altered view of the environment that contributes to increased irritability with daily life events among cocaine-dependent individuals.

Health problems of substance-dependent veterans with and those without trauma history

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are associated with an increased risk for health problems. We examined whether trauma history and PTSD were related to physical health in patients with an SUD. We compared health stressors, health service utilization, and self-rated health status in three groups of male veterans receiving SUD treatment: (1) no trauma exposure (SUD-only group), n = 55; (2) with PTSD (SUD-PTSD group), n = 32; and (3) trauma exposure without PTSD (SUD-trauma group), n = 34. The veterans were assessed quarterly for 1 year. Groups differed in their likelihood of experiencing chronic health stressors at all time points. The SUD-only group consistently had the lowest rates of chronic health stressors, the SUD-PTSD group had the highest rates, and the SUD-trauma group fell in between. In contrast, groups did not differ in rates of acute health problems. Chronic health stressors appear to be associated with trauma exposure and psychologic response to the trauma. Substance use disorder interventions may benefit from incorporation of primary care services.