How effective is continuing care for substance use disorders? A meta-analytic review

Observations of substance use treatment engagement during the period of community re-entry following residential treatment

BACKGROUND

The period of community re-entry following residential substance use treatment is associated with elevated risk for return to substance use. Although continuity of care is best practice, many individuals do not engage in follow-up treatment, struggle to engage in follow-up treatment, or continue to use substances while participating in follow-up treatment. There is a need to both characterize treatment engagement during community re-entry following residential substance use treatment as well as understand how treatment impacts substance use during this high-risk period.

METHOD

This observational study used retrospective self-report to examine treatment engagement and substance use among individuals who had exited residential substance use treatment. Participants completed a Timeline Follow-back interview reporting substance use and treatment engagement in the 30 days following residential treatment.

RESULTS

Most participants (83.1 %) reported engaging in substance use treatment following discharge. The most common treatments were Alcoholics Anonymous/Narcotics Anonymous (61.1 %), medication for addiction treatment (40 %), and outpatient therapy (29.2 %). Participants were less likely to use substances on a day in which they engaged in outpatient therapy (OR = 0.32, 95 % CI [0.12, 0.90], p = 0.030) and more likely on days they engaged in medication treatment (OR = 21.49, 95 % CI [1.46, 316.74], p = 0.025).

CONCLUSION

Findings characterize engagement in substance use treatment in the month following residential treatment. Treatment engagement was common during community re-entry; however, only outpatient therapy was found to reduce substance use during this high-risk period. Findings may inform intervention efforts during the high-risk period of community re-entry.

Impact of continuous care on cardiac function in patients with lung cancer complicated by coronary heart disease

BACKGROUND

Despite sharing similar pathogenic factors, cancer and coronary heart disease (CHD) occur in comparable populations at similar ages and possess similar susceptibility factors. Consequently, it is increasingly commonplace for patients to experience the simultaneous occurrence of cancer and CHD, a trend that is steadily rising.

AIM

To determine the impacts of continuing care on lung cancer patients with CHD following percutaneous coronary intervention (PCI).

METHODS

There were 94 lung cancer patients with CHD following PCI who were randomly assigned to the intervention group (n = 38) and the control group (n = 41). In the intervention group, continuing care was provided, while in the control group, routine care was provided. An evaluation of cardiac and pulmonary function, medication compliance, a 6-min walk test, and patient quality of life was performed.

RESULTS

Differences between the two groups were significant in left ventricular ejection fraction, 6-min walk test, oxygen uptake, quality of life and medication compliance (P < 0.05). In comparison with the control group, the enhancement in the intervention group was more significant. The intervention group had more patients with high medication compliance than the control group, with a statistically significant difference (P < 0.05).

CONCLUSION

After undergoing PCI, lung patients with CHD could benefit from continued care in terms of cardiac and pulmonary function, medications compliance, and quality of life.

Feasibility and preliminary results of a call centre delivered continuing care intervention following residential alcohol and other drug treatment

INTRODUCTION

To help reduce relapse rates following alcohol and other drug (AOD) treatment, continuing care interventions have been recommended. Previous continuing care interventions have incorporated telephone and face-to-face sessions to help promote participant engagement. The study was conducted as a randomised controlled feasibility study and examined a call centre delivered continuing care intervention for people leaving residential rehabilitation services.

METHODS

Participants were attending AOD residential treatment services in NSW, Australia (N = 154). Participants were randomised to either 12- or 4-sessions of continuing care. Follow up assessments were completed at 6-months. The primary outcomes were demand and implementation. Secondary outcomes were AOD use, mental health and physical health at 6-months.

RESULTS

Interest in continuing care was high, with 93% of participants approached reporting an interest in being involved. Of the participants who completed the consent and baseline procedures, 29% of people were contacted post residential treatment and randomised. For those people randomised, the average number of sessions completed was 2.78 (SD = 1.65) for the 4-session arm and 4.81 (SD = 4.46) for the 12-session arm. Fidelity to the treatment manual was high. Both treatment arms showed higher complete abstinence at 6-months compared to baseline (12-session OR 28.57 [2.3, 353.8]; 4-session OR 28.11 [3.6, 221.2]).

DISCUSSION AND CONCLUSIONS

A major challenge associated with the call centre approach was re-engaging participants once they left the residential facility and delivering the planned dose of treatment. Further work is required to promote greater uptake of these protocols once people leave residential treatment.

Relative and Interactive Associations of Psychosocial Intervention and Alcoholics Anonymous Attendance With Alcohol Use Disorder Outcomes

OBJECTIVE

Psychosocial intervention and Alcoholics Anonymous (AA)/mutual help organization attendance are both associated with alcohol use disorder (AUD) outcomes. However, no research has explored the relative or interactive associations of psychosocial intervention and AA attendance with AUD outcomes.

METHOD

This was a secondary analysis of data from the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) outpatient arm participants (N = 952), who were randomly assigned to complete 12-session cognitive-behavioral therapy (CBT, n = 301), 12-session 12-step facilitation (TSF, n = 335), or 4-session motivational enhancement therapy (MET, n = 316). Regression analyses tested the association of psychosocial intervention attendance only, AA attendance only (measured as past-90-day attendance immediately after psychosocial intervention, as well as 1 and 3 years after intervention), and their interaction with the percentage of drinking days and percentage of heavy drinking days after intervention, 1 year after intervention, and 3 years after intervention.

RESULTS

When accounting for AA attendance and other variables, attending more psychosocial intervention sessions was consistently associated with fewer drinking days and heavy drinking days after intervention. AA attendance was consistently associated with a lower percentage of drinking days at 1 and 3 years after intervention, when accounting for psychosocial intervention attendance and other variables. Analyses failed to identify an interaction between psychosocial intervention attendance and AA attendance with AUD outcomes.

CONCLUSIONS

Psychosocial intervention and AA attendance are robustly associated with better AUD outcomes. Replication studies comprising samples of individuals who attend AA more than once per week are needed to further test the interactive association of psychosocial intervention attendance and AA attendance with AUD outcomes.

Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders

BACKGROUND

This study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes.

METHODS

A cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively.

RESULTS

Profile 1 patients (47% of the sample), labeled "Low outpatient service users", received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled "Moderate outpatient service users", received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they  were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled "High outpatient service users", received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles.

CONCLUSIONS

Frequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.

Individual factors predict substance use treatment course patterns among patients in community-based substance use disorder treatment

BACKGROUND AND OBJECTIVES

Substance use disorders (SUDs) usually involve a complex natural trajectory of recovery alternating with symptom reoccurrence. This study examined treatment course patterns over time in a community SUD clinic. We examined depressive symptoms level, primary SUD assigned at each admission, and lifetime misuse of multiple substances as potential risk factors for premature treatment termination and subsequent treatment readmission.

METHODS

De-identified longitudinal data were extracted from charts of 542 patients from an SUD treatment center. Survival analysis methods were applied to predict two time-to-event outcomes: premature treatment termination and treatment readmission.

RESULTS

Primary opioid (vs alcohol) use disorder diagnosis at admission was associated with higher hazard of premature termination (HR = 1.91, p<0.001). The interaction between depressive symptoms level and substance use status (multiple vs single use) on treatment readmission was significant (p = 0.024), such that higher depressive symptoms level was predictive of readmission only among those with a history of single substance use (marginally significant effect). Lifetime use of multiple (vs single) substances (HR = 1.55, p = 0.002) and age (HR = 1.01, p = 0.019) predicted increased hazard of readmission.

CONCLUSIONS

Findings did not support a universal role for depressive symptoms level in treatment course patterns. Primary SUD diagnosis, age, and history of substance misuse can be easily assessed and incorporated into treatment planning to support SUD patients and families. This study is the first to our knowledge that afforded a stringent test of these relationships and their interactions in a time-dependent, recurrent event, competing risks survival analysis examining both termination and readmission patterns utilizing a real-world clinic-based sample.

Digital approaches to continuing care

PURPOSE OF REVIEW

To provide an update of studies on the effectiveness of digital and telephonic approaches to providing remote continuing care for substance use disorders.

RECENT FINDINGS

Effective continuing care can be provided via smartphone apps, text messaging, interactive voice response, and structured telephone counseling. The remote continuing care interventions with the strongest evidence of efficacy are the Addiction Comprehensive Health Enhancement Support System app and Telephone Monitoring and Counseling. Positive effects for these intervention on drinking outcomes in patients with alcohol use disorders were replicated in a recent randomized controlled study.

SUMMARY

Continuing care is widely believed to be an important component of treatment for substance use disorders, especially for sustaining positive outcomes. However, many individuals do not attend clinic-based continuing care, due to a variety of reasons, including competing work and family responsibilities, disabilities, transportation challenges, and recently the COVID-19 pandemic. Remote continuing care, provided via smartphone apps, text messaging, and various telephonic approaches, has been shown to be effective, and could be used to provide continuing care to patients who would otherwise not receive it. Further work is needed to determine how to effectively combine more traditional continuing care with newer digitized and telephonic approaches.

Efficacy and comparative effectiveness of telephone and smartphone remote continuing care interventions for alcohol use disorder: a randomized controlled trial

BACKGROUND AND AIMS

Management of alcohol use disorder (AUD) could be enhanced by effective remote treatments. This study tested whether supplementing intensive outpatient programs (IOPs) with continuing care delivered via (1) telephone, (2) smartphone or (3) their combination improves outcomes relative to (4) IOP only. Continuing care conditions were also compared.

DESIGN

Randomized controlled trial of four groups with 3-, 6-, 9-, 12- and 18-month follow-ups.

SETTING

University research center in Philadelphia, PA, USA.

PARTICIPANTS

Participants (n = 262) met DSM-V criteria for AUD, were largely male (71%) and African American (82%).

INTERVENTIONS AND COMPARATOR

Telephone monitoring and counseling (TMC; n = 59), addiction comprehensive health enhancement support system (ACHESS; n = 68) and TMC + ACHESS (n = 70) provided for 12 months. The control condition received IOP only (TAU; n = 65).

MEASUREMENT

The primary outcome was percentage of days heavy drinking (PDHD) in months 1-12. Secondary outcomes were any drinking, any drug use, drinking consequences and quality of life.

FINDINGS

Mean PDHD in months 1-12 was 10.29 in TAU, 5.41 in TMC, 6.80 in ACHESS and 5.99 in TMC + ACHESS. PDHD was lower in TMC [Cohen's d = 0.35, P = 0.018, 95% confidence interval (CI) = (-1.42, -0.20)], ACHESS [d = 0.31, P = 0.031, 95% CI = (-1.27, -0.06)] and TMC + ACHESS [d = 0.36, P = 0.009, 95% CI = (-1.40, -0.20)] than in TAU. Differences between TMC + ACHESS, TMC and ACHESS were small (d ≤ 0.06) and non-significant. Findings were inconclusive as to whether or not the treatment conditions differed on PDHD at 18 months. A significant effect was obtained on any drinking, which was higher in months 1-12 in TAU than in TMC [odds ratio (OR) = 3.02, standard error (SE) = 0.43, 95% CI = (1.30, 6.99), P = 0.01] and TMC + ACHESS [OR = 2.43, SE = 0.39, 95% CI = (1.12, 5.27), P = 0.025). No other significant effects were obtained on other secondary outcomes during or after treatment.

CONCLUSIONS

A telephone-delivered intervention and a smartphone-delivered intervention, alone and in combination, provided effective remote continuing care for alcohol use disorder. The combination of both interventions was not superior to either alone and effects did not persist post-treatment.

How do individuals with alcohol problems use social and healthcare services in Finland? Comparison of service use patterns between two high-need patient groups

Aims:

Alcohol use disorders (AUDs) are associated with high risk of comorbidities and excess use of social and healthcare services. We examined health service use (HSU) frequencies of patients with AUD in comparison to those with type 2 diabetes mellitus (T2DM).

Design:

A random sample of individuals with AUD (n = 396) were identified based on ICD-10 codes and HSU patterns, morbidity and mortality were compared with age- and gender-matched T2DM controls (n = 792) using logistic regression analysis. Six years (2011–2016) of electronic health record (EHR) data from the North Karelia district in Finland were used.

Results:

Similarities in comorbidity patterns existed, although mental health comorbidity (odds ratio [OR] 1.86) was more prevalent in the AUD group. The average annual HSU varied according to the groups: T2DM patients had more continuous contact with public health nurses in primary care, whereas AUD patients were more likely to experience somatic specialised care hospitalisations (OR 11.30) and have frequent somatic primary healthcare doctor visits (OR 3.30) and frequent emergency room doctor visits in specialised care (OR 8.89). Furthermore, patients with AUD had a 7.5 times higher risk of death compared with T2DM patients.

Conclusions:

This study identified rather similar comorbidity status for the AUD and T2DM patients, but their HSU patterns differed noticeably. AUD patients had higher frequencies of hospitalisation periods and emergency service use and were at a higher risk of death compared with T2DM patients, indicating greater challenges in the organisation of care for AUD patients compared with those having T2DM.

Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background

This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables.

Methods

Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16).

Results

Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization.

Conclusion

Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00421-7.

Methamphetamine use and technology-mediated psychosocial interventions: A mini-review

Engagement with face-to-face psychosocial interventions is often compromised in people using methamphetamine (MA), in the context of high rates of polysubstance use, mental health disorders, cognitive impairment and geographic isolation. Technology-mediated interventions offer flexible ways of engaging with treatment and are readily accessible. This mini-review evaluates evidence from eight studies for the effectiveness of telephone, mHealth (text-messaging and apps) and computer-based interventions for MA use. Two papers from one telephone counselling study showed a small improvement in MA-related outcomes, particularly for individuals in active use. However, a directive counselling style was associated with a higher likelihood of MA use during recovery for those higher in resistance to authority. Text-messaging interventions generally showed small but significant reductions in MA use in non-treatment seekers. When compared, there was no significant difference in level of MA use reduction between interactive, automated and self-monitoring text messages. Studies in other modalities (smartphone app, one trial; computer-based interventions, two trials) did not confer statistically significant reductions in MA use, though were likely impacted by app design and participant characteristics. Preliminary findings hint at the potential effectiveness of telephone counselling in aftercare and the capacity for text-messaging to reach those who are not in treatment. Given the small amount of existing literature, this review discusses the potential value of emerging interventions, the importance of adapting interventions to the characteristics of people who use MA and suggests specific directions for research in each technology modality.

Using conventional and machine learning propensity score methods to examine the effectiveness of 12-step group involvement following inpatient addiction treatment

BACKGROUND

Continuing care following inpatient addiction treatment is an important component in the continuum of clinical services. Mutual help, including 12-step groups like Alcoholics Anonymous, is often recommended as a form of continuing care. However, the effectiveness of 12-step groups is difficult to establish using observational studies due to the risks of selection bias (or confounding).

OBJECTIVE

To address this limitation, we used both conventional and machine learning-based propensity score (PS) methods to examine the effectiveness of 12-step group involvement following inpatient treatment on substance use over a 12-month period.

METHODS

Using data from the Recovery Journey Project - a longitudinal, observational study - we followed an inpatient sample over 12-months post-treatment to assess the effect of 12-step involvement on substance use at 12-months (n = 254). Specifically, PS models were constructed based on 34 unbalanced confounders and four PS-based methods were applied: matching, inverse probability weighting (IPW), doubly robust (DR) with matching, and DR with IPW.

RESULTS

Each PS-based method minimized the potential of confounding from unbalanced variables and demonstrated a significant effect (p <  0.001) between high 12-step involvement (i.e., defined as having a home group; having a sponsor; attending at least one meeting per week; and, being involved in service work) and a reduced likelihood of using substances over the 12-month period (odds ratios 0.11 to 0.32).

CONCLUSIONS

PS-based methods effectively reduced potential confounding influences and provided robust evidence of a significant effect. Nonetheless, results should be considered in light of the relatively high attrition rate, potentially limiting their generalizability.

A systematic review and meta-analysis of the efficacy of the long-term treatment and support of substance use disorders

RATIONALE

The reconceptualization of substance use disorders (SUD) as a chronic phenomenon calls for a paradigm shift in service provision, particularly by way of long-term treatment and support. Studies that have evaluated the efficacy of long-term treatment models seem to indicate that they are an improvement on more standard short-term treatments, even though these studies do not take the durations into consideration.

OBJECTIVE

Measure the efficacy of SUD treatments and support lasting 18 months or more regarding their ability to decrease substance use as compared to shorter treatments.

METHODS

A meta-analysis based on a systematic literature review was conducted. Eight databases were consulted for peer-reviewed studies. Certain variables were coded as moderators: intervention length, participant characteristics, and treatment characteristics.

RESULTS

The main results suggest that the people who received a planned long-term treatment or support had a 23.9 % greater chance of abstaining or consuming moderately than did people who received a shorter standard treatment (OR = 1.347 [CI 95 % = 1.087-1.668], p < .006, adjusted OR = 1.460 [CI 95 % = 1.145-1.861]). None of the moderation analyses revealed any variation in the efficacy of the long-term treatments and support.

CONCLUSIONS

The reconceptualization of the SUD as a chronic disorder among people with this problem leads us to reconsider both the length of the services provided and the paradigms underlying their organization.

Continuing care following residential alcohol and other drug treatment: Continuing care worker perceptions

INTRODUCTION

Little is known about the experiences of continuing care workers (CCW) in the implementation of continuing care programs. The current study sought to understand CCWs and supervisor perceptions of the successes and challenges of implementing a telephone-based continuing care intervention following residential alcohol and other drug treatment services. It also aimed to provide recommendations for treatment providers wishing to integrate continuing care into their treatment model, including the resources, training and supervision needs of CCWs.

METHODS

The participants were eight CCWs and two independent supervisors who completed semi-structured interviews. Interview coding and analysis was guided by Iterative Categorisation procedures and an implementation framework. The Consolidated Framework for Implementation Research was used.

RESULTS

Telephone delivery was advantageous, but even more enhanced, when there was a face-to-face session first to build rapport. Other key successes included CCWs who were confident and competent, as well as a match between the organisation's values and the philosophy of the continuing care program. Key challenges faced by CCWs related to a perceived lack of support from managers, difficulties accessing quiet office spaces and participant disengagement.

DISCUSSION AND CONCLUSIONS

Interviews revealed several factors that may influence successful delivery of continuing care as part of alcohol and other drug treatment. These included features of the intervention (e.g. telephone delivery, evidence-based content), characteristics of the individual CCWs (e.g. flexibility in delivery of the intervention while maintaining fidelity), organisational culture (e.g. alignment of organisational values with continuing care) and resources (e.g. office space, flexible work schedules).

Predictors of consent and engagement to participate in telephone delivered continuing care following specialist residential alcohol and other drug treatment

INTRODUCTION AND AIMS

Although continuing care programs have been shown to improve alcohol and other drug (AOD) treatment outcomes, uptake of continuing care has been low. The current study aimed to determine predictors of participants' who both re-confirmed consent to engage in telephone-based continuing care and commenced continuing care once they left residential AOD treatment. These participants had initially consented to partake in continuing care during the course of their residential stay.

METHODS

Participants were 391 individuals (232 males, 59% and 158 females, 40%) accessing therapeutic communities for AOD treatment provided by The Australian Salvation Army and We Help Ourselves (WHOS). Measures at baseline, collected during residential treatment, included demographics, primary substance of concern, abstinence goal, refusal self-efficacy, cravings for substances, mental health diagnoses, psychological distress, quality of life and feelings of loneliness. All measures were used as predictor variables to determine characteristics of participants who re-confirmed consent to engage in continuing care and commenced continuing care following residential AOD treatment.

RESULTS

Completing residential treatment, being unmarried, and higher levels of loneliness predicted re-confirmation of consent to participate in continuing care following discharge from residential treatment. Participants who were Aboriginal and/or Torres Strait Islander were less likely to provide re-confirmation of consent. Participants were more likely to commence continuing care if they completed residential treatment, were older, and had longer years of substance use.

CONCLUSIONS

Tailoring continuing care programs to reach a broader array of individuals such as Indigenous populations and persons who exit treatment services early is needed to ensure these programs can reach all individuals who might need them.

Why we stopped using the term 'aftercare'

The words we choose to describe alcohol and other drug (AOD) treatments and interventions reveal assumptions about how we understand AOD use. Moreover, they have important implications for how the treatment is imagined, implemented and funded. Service provision which follows engagement in an intensive (usually residential) program is often called 'aftercare' in the international AOD field. In this commentary, we argue that the term 'aftercare' fails to articulate the nature of ongoing care required by people who are managing AOD use. We maintain that 'aftercare' positions post-residential care as being less important than other treatment modalities, rather than as integral to a continuum of care. It is a term that implies that care should be acute, like much treatment delivered through a medical model, and assumes that people follow linear pathways in managing their AOD use. Assumptions embedded in the term 'aftercare' such as these may disincline governments from funding ongoing services for people exiting intensive programs. Alternative terms including 'continuing coordinated care' more aptly signal the integrated and ongoing service provision that should be available to support people in sustaining changes initiated through other AOD interventions.

Conceptual framework for telehealth strategies to increase family involvement in treatment and recovery for youth opioid use disorder

With opioid use at crisis levels, it is imperative to support youth ages with opioid use disorders (OUD) in taking medication and accessing behavioral services over long periods. This article presents a conceptual framework for telehealth strategies that can be adopted to increase family involvement across a four-stage continuum of youth OUD treatment and recovery: Treatment Preparation, Treatment Initiation, Treatment Stabilization, OUD Recovery. It first identifies provider-delivered tele-interventions that can enhance OUD services in each of the four stages, including family outreach, family engagement, family-focused intervention, and family-focused recovery maintenance. It then introduces several types of direct-to-family tele-supports that can be used to supplement provider-delivered interventions. These include both synchronous tele-supports (remote interactions that occur in real time) such as helplines, peer-to-peer coaching, and online support groups; and asynchronous tele-supports (communications that occur without participants being simultaneously present) such as automated text messaging, self-directed internet-based courses, and digital web support.

Impact of Continuing Care on Recovery From Substance Use Disorder

Continuing care is widely believed to be an important component of effective treatment for substance use disorder, particularly for those individuals with greater problem severity. The purpose of this review was to examine the research literature on continuing care for alcohol and drug use disorders, including studies that addressed efficacy, moderators, mechanisms of action, and economic impact. This narrative review first considered findings from prior reviews (published through 2014), followed by a more detailed examination of studies published more recently. The review found that research has generally supported the efficacy of continuing care for both adolescents and adults, but the picture is complex. Reviews find relatively small effects when results from individual studies are combined. However, continuing care of longer duration that includes more active efforts to keep patients engaged may produce more consistently positive results. Moreover, patients at higher risk for relapse may benefit to a greater degree from continuing care. Several newer approaches for the provision of continuing care show promise. These include incentives for abstinence and automated mobile health interventions to augment more conventional counselor-delivered interventions. Primary care can be used to provide medications for opioid and alcohol use disorders over extended periods, although more research is needed to determine the optimal mix of behavioral treatments and other psychosocial services in this setting. Regardless of the intervention selected for use, the status of most patients will change and evolve over time, and interventions need to include provisions to assess patients on a regular basis and to change or adapt treatment when warranted.

Success Rates of Monitoring for Healthcare Professionals with a Substance Use Disorder: A Meta-Analysis

In the past decades, monitoring programs have been developed for healthcare professionals with substance use disorders. We aimed to explore estimates of abstinence and work retention rates after participation in such monitoring programs. A literature search was performed using PubMed, Embase, PsycINFO, and CINAHL. Twenty-nine observational studies reporting on success rates (abstinence and work retention) of monitoring for healthcare professionals with a substance use disorder were included in the meta-analysis. Quality-effects models calculated pooled success rates and corresponding 95%-Confidence Intervals (CI), with subgroup analyses on monitoring elements and patient characteristics. Pooled success rates were 72% for abstinence (95%-CI = 63–80%) and 77% for work retention (95%-CI = 61–90%). Heterogeneity across studies was partly explained by the starting moment of monitoring, showing higher abstinence rates for studies that started monitoring after treatment completion (79%; 95%-CI = 72–85%) compared to studies that started monitoring with treatment initiation (61%; 95%-CI = 50–72%). About three-quarters of healthcare professionals with substance use disorders participating in monitoring programs are abstinent during follow-up and working at the end of the follow-up period. Due to selection and publication bias, no firm conclusions can be drawn about the effectiveness of monitoring for healthcare professionals with SUD.

More behavioral recommendations produce more change: A meta-analysis of efficacy of multibehavior recommendations to reduce nonmedical substance use

Death and morbidity associated with substance use have risen continuously over the last few decades, increasing the need for rigorous examination of promising programs. Interventions attempting to change multiple behaviors have been designed to address interconnected problems such as use of both alcohol and drugs. This meta-analysis aimed to examine the efficacy of multibehavior interventions to curb nonmedical substance use in relation to the theoretical relation among different substance use behaviors. Specifically, our synthesis aimed to estimate the optimal number of recommendations for intervention efficacy and evaluate the impact of different combinations of recommendations on intervention efficacy. A synthesis of multibehavior interventions addressing nonmedical substance use was conducted to measure behavioral changes between the pretest and the follow-up. These changes were then compared across different numbers of recommendations. Sixty-nine reports and 233 effect sizes (k of conditions = 155, n = 28,295) were included. A positive linear relation was found between the number of targeted behaviors and intervention efficacy, which was stronger for drug use than alcohol use. Furthermore, recommendations on drug use worked better when paired with recommendations targeting other behaviors, whereas recommendations on alcohol use worked more independently. Lastly, multibehavior interventions were especially efficacious when delivered by experts. Overall, our synthesis indicated that targeting multiple substances is beneficial for changing drug use outcomes, but less so for alcohol use outcomes. Therefore, in the current substance use epidemic, innovative multibehavior programs appear to hold promise, especially to combat nonmedical drug use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Outpatient care for opioid use disorder among the commercially insured: Use of medication and psychosocial treatment

BACKGROUND

Evidence-based outpatient treatment for opioid use disorder (OUD) consists of medications that treat OUD (MOUD) and psychosocial treatments (e.g., psychotherapy or counseling, case management). Prior studies have not examined the use of these components of care in a commercially insured population.

METHODS

We analyzed claims data from a large national commercial insurer of enrollees age 17-64 identified with OUD (2008-2016, N = 87,877 persons and 122,708 person-years). Multinomial logistic regression models identified factors associated with receiving in a given year: 1) both MOUD and psychosocial visits, 2) MOUD without psychosocial visits, 3) psychosocial visits without MOUD, or 4) neither. We estimated predicted probabilities for key variables of interest.

RESULTS

Identification of OUD nearly tripled during the observation period (0.17% in 2008, 0.45% in 2016). Among person-years identified as having OUD, 36.3% included MOUD (8.1% both MOUD and psychosocial visits and 28.2% MOUD without psychosocial visits). In adjusted analyses, women had a lower probability of receiving either treatment alone or in combination (e.g.,MOUD plus psychosocial visits: women = 6.7% [6.5%-6.9%] vs. men = 9.2% [9.0%-9.4%]). Moderate/severe vs. mild OUD was associated with a higher probability of receiving MOUD (e.g., MOUD plus psychosocial visits: 8.7% [8.6%-8.9%] vs. 0.9% [0.7%-1.0%]). In contrast, an OUD overdose was associated with a greater probability of receiving neither treatment (78.2% [77.4%-79.0%] vs. 55.5% [55.2%-55.8%]). Over time, the probability of receiving each MOUD and psychosocial treatment category increased relative to 2008, but reached a peak and then plateaued or declined, by the end of the study period.

CONCLUSIONS

A significant treatment gap exists among individuals identified with OUD in this commercially insured population, with greater risks of receiving no treatment for women and for individuals with mild versus moderate or severe OUD. Overdose is associated with receiving neither MOUD nor psychosocial treatment. While treated prevalence initially increased relative to 2008, rates of treatment subsequently plateaued. Additional study and monitoring to elucidate barriers to OUD treatment in commercially insured populations are warranted.

The Lived Experience of Inpatients With Acute Recurrent Pancreatitis: A Qualitative Research Study From West China

The incidence of acute pancreatitis (AP) has increased year by year. Approximately 20%-30% of these patients will have further subsequent attacks, described as acute recurrent pancreatitis (ARP). Patients who are repeatedly admitted to hospitals suffer significant psychological problems and mental hardships. In the current study, we aimed to illuminate the lived experience of inpatients with ARP from Chongqing, China. A purposive sample of 13 ARP patients was recruited from the First Affiliated Hospital of Chongqing Medical University. Semistructured and in-depth qualitative interviews were adopted in this phenomenological research. Data were analyzed by Colaizzi's Method of descriptive phenomenology and feedback on early findings from the participants. All interviews were audio-recorded and transcribed with the permission of the participants. Five themes presented in the study: anxiety and fear, lack of related knowledge, inevitability and helplessness, guilt and shame, hope, and perseverance. Overall, the ARP inpatients showed complexed experience, both active and positive. They also performed poor compliance during their hospitalization but wished for professional knowledge. Nurses should pay attention to their psychological changes to take effective interventions for them.

Study protocol the Continuing Care Project: a randomised controlled trial of a continuing care telephone intervention following residential substance dependence treatment

BACKGROUND

A priority area in the field of substance dependence treatment is reducing the rates of relapse. Previous research has demonstrated that telephone delivered continuing care interventions are both clinically and cost effective when delivered as a component of outpatient treatment. This protocol describes a NSW Health funded study that assesses the effectiveness of delivering a telephone delivered continuing care intervention for people leaving residential substance treatment in Australia.

METHODS/DESIGN

All participants will be attending residential alcohol and other drug treatment provided by The Salvation Army or We Help Ourselves. The study will be conducted as a randomised controlled trial, where participants will be randomised to one of three treatment arms. The treatment arms will be: (i) 12-session continuing care telephone intervention; (ii) 4-session continuing care telephone intervention, or (iii) continuing care plan only. Baseline assessment batteries and development of the participants' continuing care plan will be completed prior to participants being randomised to a treatment condition. Research staff blind to the treatment condition will complete follow-up assessments with participants at 3-months and 6-months after they have been discharged from their residential service.

DISCUSSION

This study will provide comprehensive data on the effect of delivering the continuing care intervention for people exiting residential alcohol and other drug treatment. If shown to be effective, this intervention can be disseminated to improve the rates of relapse among people leaving residential alcohol and other drug treatment.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001231235. Registered on 23rd July 2018. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375621&isReview=true.

"Becoming myself": how participants in a longitudinal substance use disorder recovery study experienced receiving continuous feedback on their results

BACKGROUND

Being a participant in longitudinal follow-up studies is not commonly a factor considered when investigating useful self-change aspects for individuals attempting recovery from substance use disorder (SUD). This study reports on how ongoing monitoring, and feedback on data results in a longitudinal follow-up study of SUD recovery were perceived by individuals who had achieved long-term abstinence and social recovery.

METHODS

Interviewers with first-hand experience with the topic conducted interviews with 30 participants and analysed the data using a thematic analytic approach within an interpretative-phenomenological framework.

RESULTS

Analyses resulted in the following themes. 1) Ongoing short text messaging (SMS) monitoring: helped participants by offering recovery milestones and reminders of the past. 2) Feedback on data results helped participants track physical and cognitive recovery: "I am more like myself". 3) Using feedback in treatment: understanding the importance of a functional brain to participants may help with long-term retention in treatment.

CONCLUSIONS

Self-changes that were challenging to detect on a day-to-day basis were available for reflection through longitudinal study participation, including ongoing monitoring and feedback on the results, allowing personal consolidation of change processes. Clinical services could benefit from continuing development and implementation of such technology for ongoing monitoring and feedback on assessments to motivate self-change in SUD recovery. The development of guidelines for providing the results of research assessments to individuals could help reduce attrition in research projects and support recovery and healthy choices for study participants.

Effects of 12-step mutual support and professional outpatient services on short-term substance use outcomes among adults who received inpatient treatment

BACKGROUND

Continuing care is increasingly prioritized in the treatment of substance use disorders (SUDs). Ongoing engagement in continuing care, including mutual support (e.g., 12-step groups) and/or professional outpatient services, may enhance treatment outcomes and facilitate recovery.

OBJECTIVE

This study investigates how engagement in 12-step mutual support and professional outpatient services is associated with short-term substance use outcomes in a sample of patients who completed inpatient SUDs treatment.

METHODS

As part of the Recovery Journey Project - a longitudinal cohort study - participants completed questionnaires upon admission to an inpatient SUDs treatment program, and at 1- and/or 3-months post-discharge (n = 379). Baseline data were collected by self-administered, electronic questionnaires. Follow up data were collected by phone or email. Analyses involved multivariate Generalized Estimating Equations separately modelling self-reported abstinence and percent days abstinent (PDA) over the three time periods.

RESULTS

Overall, rates of self-reported abstinence and PDA increased significantly from baseline to 1- and 3-months follow up. Engagement in 12-step activities (i.e., attended 30 meetings in 30 days, had a home group, had a sponsor, did service work) and professional outpatient substance use support were each significantly associated with abstinence and PDA. Participants who reported a higher degree of 12-step involvement (defined as engagement in more 12-step activities) were also more likely to report being abstinence and greater PDA.

CONCLUSIONS

Engagement in continuing care, including 12-step activities and professional outpatient substance use support, was highly associated with substance use. Clinical teams should encourage participation in such activities to optimize treatment outcomes.

Opioids and the hormone oxytocin

The neuropeptide Oxytocin (ΟΤ) is involved as a neurohormone, a neurotransmitter, or a neuromodulator in an extensive range of central and peripheral effects, complex emotional and social human behaviors, memory and learning processes. It is implicated in homeostatic, neuroadaptive processes associated with stress responses and substance use via interactions with the hypothalamic-pituitary-adrenal (HPA) axis and the dopamine mesolimbic reward stress system. This chapter reviews the preclinical and clinical literature on the complicated relationships between endogenous and exogenous opioids and ΟΤ systems and attempts to highlight key findings to date on the effectiveness of intranasal OT administration to treat opioid use disorders. OΤ seems to attenuate, even inhibit, the development of opioid use disorders in preclinical models but is still under clinical research as a promising pharmacological agent in the treatment of opioid use related behaviors. Evidence suggests a role for OT as an adjunctive or stand-alone treatment of behavioral, cognitive and emotional deficits associated with substance use, which may be responsible for seeking behavior and relapse. The mechanisms by which oxytocin acts to reverse the neural substrates of these deficits, partially due to substance induced alterations of the endogenous OT system, and thus modify the behavioral response to substance use are discussed. Other clinically relevant issues are also discussed.

The alumni club: interpersonal contact and the exchange of recovery oriented helping in a sample of former residents of a therapeutic community for women

Purpose

Aftercare is an important predictor of outcomes following treatment for substance abuse. Despite this, there is evidence that the great majority of substance abusing clients choose not to participate in aftercare. Aftercare programs that are tied to specific residential treatment facilities, sometimes known as alumni groups or alumni clubs, might increase participation by offering former residents the opportunity to maintain treatment oriented social networks. Therapeutic communities (TCs), which emphasize mutual aid between residents, are ideal candidates for such programs. The paper aims to discuss these issues.

Design/methodology/approach

In total, 100 randomly chosen former TC residents were randomly surveyed regarding their contact with fellow alumni and their exchange of recovery oriented helping behaviors. A thirty day timeline follow-back methodology was used.

Findings

Contact was primarily through electronic means, particularly phone calls, texts and the alumni club Facebook page. Participants who reported more electronic contact also reported more days in which they offered and received recovery oriented help. Participants who were African American or had spent more time in TC treatment offered and received recovery oriented help on more days.

Research limitations/implications

While this is an exploratory study limited to one TC, this alumni club allows for the maintenance of a mutual aid network after termination. That network primarily consists of electronic forms of contact. A longer time spent in TC treatment may allow for the internalization of the practice of mutual aid. Further research on alumni clubs is warranted.

Originality/value

This is the first survey of TC alumni club members.

Change in psychosocial factors connected to coping after inpatient treatment for substance use disorder: a systematic review

BACKGROUND

Among the adult population worldwide, about 0.5% has illicit drug use disorder (DUD) and about 5% has alcohol use disorder (AUD). Dependency on alcohol, medication or illicit drugs are recognised as risk factors for disabling disease and early death. Treatment for substance use disorders (SUD) is important in promoting persistent abstinence and may be perceived as a valuable public health measure. The current systematic review aims at exploring how psychosocial factors connected to recovery capital and coping behaviour, change after inpatient SUD treatment.

METHODS

A systematic search was conducted in Campbell Collaboration Library, Cochrane Library, EMBASE, Epistemonikos, Medline, PsychINFO, Social Sciences Citation Index and SocINDEX. Cohort studies on psychosocial outcomes for adults who had attended to inpatient SUD treatment that exceeds 3 months, were included. The outcome of interest was change in psychosocial factors. The search results were identified as include, exclude or unclear by one author and then screened by the second author with a specific focus on studies recognised as unclear. Diverging evaluations of eligibility among the unclear studies were resolved by discussion. In case of disagreement, the third author decided the eligibility of the studies in question.

RESULTS

Findings imply an overall progress in mental health, and a potential improvement in employment status and perceived social support after inpatient SUD treatment. Additionally, findings indicate a decrease in substance use from admission to follow-up after discharge from inpatient SUD treatment. These findings are consistent with earlier research on important factors in recovering from SUD. Findings on change in self-efficacy, housing, education and Quality of Life (QoL) however, were scantly researched and were expected to be more prominent outcomes of interest among the included studies.

CONCLUSION

Due to the substantial resources used to provide SUD treatment, knowledge about recovery capital, like psychosocial factors that facilitate coping behaviour and reintegration to society, should be standardised and used by SUD treatment providers.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42018087408.

Psychosocial factors associated with coping behaviour after inpatient treatment for substance use disorder: a systematic review study protocol

INTRODUCTION

Much is known about factors associated with coping with abstinence from substance use. The planned systematic review aims to summarise available studies exploring the change in psychosocial factors associated with coping after long-term (≥3 months) inpatient treatment for substance use disorder (SUD). Examples of psychosocial factors of interest are social support, housing, activity (eg, employment and education) mental health and quality of life. Coping behaviour can be understood as responses or actions taken in a stressful situation, particularly how psychosocial factors affect a person's coping behaviour with abstinence from substances in everyday life (characterised as a stressful situation).

METHODS AND ANALYSIS

A set of text words were developed based on the population (people with SUD), exposure (long-term inpatient SUD treatment), outcome (psychosocial factors) and study design (prospective cohort studies) of interest. A systematic search will be conducted in eight electronic databases: Campbell Collaboration Library, Cochrane Library, EMBASE, Epistemonikos, Medline, PsychINFO, Social Sciences Citation Index and SocINDEX. The titles and abstracts will be screened for relevance before a pre-piloted data collection form will be used to evaluate eligibility and extract data from the search results. The planned review will include peer-reviewed study reports published in English or Scandinavian language.

ETHICS AND DISSEMINATION

The target group, people with SUD, might be considered as vulnerable. Based on this, the population will be the group of interest in the planned systematic review of studies that have already been conducted. Patients and the general public will not be involved in the development of this systematic review. The results will be summarised in a study report and submitted to a peer-reviewed international journal. Additionally, results will be disseminated in the mass media and at international research conferences.

PROSPERO REGISTRATION NUMBER

CRD42018087408.

A Meta-Analysis of the Efficacy of Case Management for Substance Use Disorders: A Recovery Perspective

Background: Case management is a client-centered approach to improve the coordination and continuity of service delivery, especially for persons with substance use disorders (SUD) and multiple and complex support needs. This intervention supports individuals by helping them identify needed services, facilitate linkage with services, and promote participation and retention in services. However, it is questionable whether case management is equally effective in promoting recovery and aspects of personal functioning. The objective was to conduct an updated meta-analysis and to assess whether case management was more effective than treatment as usual (TAU) among persons with SUD for improving treatment-related (e.g., successful linkage with and retention in treatment) as well as personal functioning outcomes (e.g., substance use). Methods: This meta-analysis focuses on randomized controlled trials (RCTs) that included persons with alcohol or drug use disorders and compared case management with TAU. To be eligible, interventions had to meet core case management functions as defined in the literature. We conducted searches of the following databases to May 2017: the Cochrane Drugs and Alcohol Specialized Register, CENTRAL, PubMed, Embase, CINAHL, and Web of Science. Also, reference lists of retrieved publications were scanned for relevant (un)published studies. Results: The overall effect size for case management compared to TAU across all outcome categories and moments was small and positive (SMD = 0.18, 95% CI 0.07-0.28), but statistically significant. Effects were considerably larger for treatment tasks (SMD = 0.33, 95% CI 0.18-0.48) than for personal functioning outcomes (SMD = 0.06, 95% CI -0.02 to 0.15). The largest effect sizes were found for retention in substance abuse treatment and linkage with substance abuse services. Moderator effects of case management models and conditions were assessed, but no significant differences were observed. Conclusions: The primary results from earlier meta-analyses were supported: case management is more effective than TAU conditions for improving outcomes, but this effect is significantly larger for treatment-related tasks than for personal functioning outcomes. Case management can be an important supplement to available services for improving linkage and retention, although further research is needed to assess its potential for supporting recovery from a longitudinal perspective.

Feasibility and Effects of Digital Interventions to Support People in Recovery From Substance Use Disorders: Systematic Review

Background

The development and evaluation of digital interventions aimed at preventing or treating substance use–related problems and disorders is a rapidly growing field. Previous reviews of such interventions reveal a large and complex picture with regard to targeted users, use, and efficacy.

Objective

The objective of this review was to investigate the feasibility and effects of interventions developed specifically for digital platforms. These interventions are focused on supporting people in recovery from substance use disorders by helping them achieve their substance use goals and develop a more satisfying life situation.

Methods

The review is based on a systematic search in MEDLINE, Embase, PsycInfo, and Cochrane Library databases. Of the 1149 identified articles, 722 were excluded as obviously not relevant. Of the remaining articles, 21 were found to be previous reviews, 269 were on interventions aimed at reducing hazardous alcohol or cannabis use, and 94 were on digitized versions of standard treatment methods. The remaining 43 articles were all read in full and systematically scored by both authors.

Results

The 43 articles cover 28 unique interventions, of which 33 have been published after 2013. The interventions are aimed at different target groups (defined by age, substance, or comorbidity). Based on the number of features or modules, the interventions can be categorized as simple or complex. Fourteen of the 18 simple interventions and 9 of the 10 complex interventions have been studied with quantitative controlled methodologies. Thirteen of the 18 simple interventions are integrated in other treatment or support systems, mainly delivered as mobile phone apps, while 6 of the 10 complex interventions are designed as stand-alone interventions, most often delivered on a platform combining desktop/Web and mobile phone technologies. The interventions were generally easy to implement, but in most cases the implementation of the complex interventions was found to be dependent on sustained organizational support. Between 70% and 90% of the participants found the interventions to be useful and easy to use. The rates of sustained use were also generally high, except for simple interventions with an open internet-based recruitment and some information and education modules of the complex interventions. Across all interventions, slightly more than half (55%) of the studies with control groups generated positive findings on 1 or more substance use outcomes, with 57% of the interventions also found to be efficacious in 1 or more studies. In the positive studies, effects were typically in the small to moderate range, with a few studies yielding larger effects. Largely due to the inclusion of stronger control conditions, studies of simple interventions were less likely to produce positive effects.

Conclusions

The digital interventions included in this review are in general feasible but are not consistently effective in helping people in recovery from substance use disorder reduce their substance use or achieving other recovery goals.

Agency-level financial incentives and electronic reminders to improve continuity of care after discharge from residential treatment and detoxification

BACKGROUND

Despite the importance of continuity of care after detoxification and residential treatment, many clients do not receive further treatment services after discharged. This study examined whether offering financial incentives and providing client-specific electronic reminders to treatment agencies lead to improved continuity of care after detoxification or residential treatment.

METHODS

Residential (N = 33) and detoxification agencies (N = 12) receiving public funding in Washington State were randomized into receiving one, both, or none (control group) of the interventions. Agencies assigned to incentives arms could earn financial rewards based on their continuity of care rates relative to a benchmark or based on improvement. Agencies assigned to electronic reminders arms received weekly information on recently discharged clients who had not yet received follow-up treatment. Difference-in-difference regressions controlling for client and agency characteristics tested the effectiveness of these interventions on continuity of care.

RESULTS

During the intervention period, 24,347 clients received detoxification services and 20,685 received residential treatment. Overall, neither financial incentives nor electronic reminders had an effect on the likelihood of continuity of care. The interventions did have an effect among residential treatment agencies which had higher continuity of care rates at baseline.

CONCLUSIONS

Implementation of agency-level financial incentives and electronic reminders did not result in improvements in continuity of care, except among higher performing agencies. Alternative strategies at the facility and systems levels should be explored to identify ways to increase continuity of care rates in specialty settings, especially for low performing agencies.

Effects of automated smartphone mobile recovery support and telephone continuing care in the treatment of alcohol use disorder: study protocol for a randomized controlled trial

Background

New smartphone communication technology provides a novel way to provide personalized continuing care support following alcohol treatment. One such system is the Addiction version of the Comprehensive Health Enhancement Support System (A-CHESS), which provides a range of automated functions that support patients. A-CHESS improved drinking outcomes over standard continuing care when provided to patients leaving inpatient treatment. Effective continuing care can also be delivered via telephone calls with a counselor. Telephone Monitoring and Counseling (TMC) has demonstrated efficacy in two randomized trials with alcohol-dependent patients. A-CHESS and TMC have complementary strengths. A-CHESS provides automated 24/7 recovery support services and frequent assessment of symptoms and status, but does not involve regular contact with a counselor. TMC provides regular and sustained contact with the same counselor, but no ongoing support between calls. The future of continuing care for alcohol use disorders is likely to involve automated mobile technology and counselor contact, but little is known about how best to integrate these services.

Methods/Design

To address this question, the study will feature a 2 × 2 design (A-CHESS for 12 months [yes/no] × TMC for 12 months [yes/no]), in which 280 alcohol-dependent patients in intensive outpatient programs (IOPs) will be randomized to one of the four conditions and followed for 18 months. We will determine whether adding TMC to A-CHESS produces fewer heavy drinking days than TMC or A-CHESS alone and test for TMC and A-CHESS main effects. We will determine the costs of each of the four conditions and the incremental cost-effectiveness of the three active conditions. Analyses will also examine secondary outcomes, including a biological measure of alcohol use, and hypothesized moderation and mediation effects.

Discussion

The results of the study will yield important information on improving patient alcohol use outcomes by integrating mobile automated recovery support and counselor contact.

Trial registration

ClinicalTrials.gov, NCT02681406. Registered on 2 September 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2466-1) contains supplementary material, which is available to authorized users.

"I just feel comfortable out here, there's something about the place": staff and client perceptions of a remote Australian Aboriginal drug and alcohol rehabilitation service

BACKGROUND

The need for effective, culturally safe residential rehabilitation services for Aboriginal people is widely acknowledged, however the combination of treatment components that is optimally effective, is not well defined. Most existing Aboriginal residential rehabilitation research has focused on describing client characteristics, and largely ignored the impact of treatment and service factors, such as the nature and quality of therapeutic components and relationships with staff.

METHODS

This qualitative study was undertaken as part of a three-year mixed methods community-based participatory research (CBPR) project that aimed to empirically describe a remote Aboriginal drug and alcohol rehabilitation service. Researchers utilised purposive sampling to conduct 21 in-depth, semi-structured interviews. The interviews used a 'research yarning' approach, a form of culturally appropriate conversation that is relaxed and narrative-based. The interview transcripts were thematically coded using iterative categorization. The emerging themes were then analysed from an Interpretative Phenomenological Analysis, focusing on how participants' lived experiences before and during their admission to the service shaped their perceptions of the program.

RESULTS

A total of 12 clients (mean age 35 years, SD 9.07, 91% Aboriginal) and 9 staff (2 female, 7 male, mean age 48 years, SD 8.54, 67% Aboriginal) were interviewed. Five themes about specific program components were identified in the interview data: healing through culture and country; emotional safety and relationships; strengthening life skills; improved wellbeing; and perceived areas for improvement. This research found that Aboriginal drug and alcohol residential rehabilitation is not just about length of time in treatment, but also about the culture, activities and relationships that are part of the treatment process.

CONCLUSION

This study highlights that cultural elements were highly valued by both clients and staff of a remote Aboriginal residential rehabilitation service, with the country or location being fundamental to the daily practice of, and access to, culture. Developing reliable and valid assessments of the program components of culture and treatment alliance would be valuable, given this study has reinforced their perceived importance in achieving positive treatment outcomes. Further, strengthening the aftercare program, as part of an integrated model of care, would likely provide greater support to clients after discharge.

Duration of therapy - Does it matter?: A systematic review and meta-regression of the duration of psychosocial treatments for alcohol use disorder

BACKGROUND

The recommendations in clinical guidelines for duration of therapy for alcohol use disorder (AUD) are based on consensus decisions. In reality, we do not know the optimal duration of an alcohol treatment course.

METHODS

A systematic review and meta-regression of randomized controlled trials of psychosocial treatment in alcohol outpatient treatment centers. The population consisted of adults suffering from AUD, treated in an outpatient facility with at least two sessions of therapy. Meta-regression analysis was performed with treatment outcome as a function of duration of therapy across studies. Treatment outcome was defined as long-term alcohol use measured in percentage of days abstinent (PDA), percentage of heavy days drinking (PHD), and/or proportion of participants abstinent (ABS).

RESULTS

48 studies encompassing 8984 participants. Mean planned duration of therapy: 18 (8-82) weeks and 14 (2-36) sessions. Mean actual attended sessions: 9 (1-26). Mean follow-up time: 43 (8-104) weeks with a mean of 6 (2-18) research assessments. Neither planned weeks, duration of sessions, frequency of sessions per week, nor actual attended sessions were associated with long-term alcohol use outcomes. However, frequency of research assessments was positively associated with PDA and PHD.

CONCLUSION

No associations between long-term alcohol use outcomes and planned or actual attended duration of psychosocial treatment in outpatient care. Research assessments and, accordingly, the research project in itself may influence outcome in studies of psychosocial treatment for alcohol use disorder.

Predischarge Injectable Versus Oral Naltrexone to Improve Postdischarge Treatment Engagement Among Hospitalized Veterans with Alcohol Use Disorder: A Randomized Pilot Proof-of-Concept Study

BACKGROUND

Injectable naltrexone for alcohol use disorders (AUDs) has been efficacious in several studies. It has not been (i) compared head-to-head with oral naltrexone or (ii) examined in the hospital setting as an intervention that might facilitate treatment attendance after hospital discharge.

METHODS

Fifty-four hospitalized veterans identified as having DSM-IV-TR alcohol dependence were randomized to receive (i) a 50 mg oral naltrexone plus a 30-day prescription or (ii) a 380 mg intramuscular naltrexone injection prior to discharge. Of 113 veteran inpatients deemed eligible based on screening criteria, 54 met final eligibility criteria and were enrolled and randomized. Baseline data included demographics, alcohol consumption, and comorbidity. Measures of treatment initiation and engagement and alcohol consumption were reassessed at 14- and 45-day follow-ups.

RESULTS

Thirty-five participants (64.8%) completed the entire study protocol (received a study medication and completed 14- and 45-day follow-ups). Among those who received a study medication (n = 45), 77.8% completed all follow-up interviews. This pilot study was not designed to have sufficient statistical power for hypothesis testing, and thus, as expected, there were no significant differences between groups in medication adherence (self-report of >80% of daily doses taken in oral group; receipt of second injection in the injection group), treatment engagement (at least treatment 3 visits in the 30 days postdischarge, and 2 or more visits per month in each of the 3 months following discharge) or alcohol consumption at 14 or at 45 days (p > 0.05). The median number of drinks among the entire cohort in the 2 weeks prior to hospitalization (128 drinks) was significantly higher than at day 14 (0 drinks, p < 0.001) or day 45 (0 drinks, p < 0.001). Rates of medication adherence were 62% in the oral group and 61% in the injection group.

CONCLUSIONS

Results indicate feasibility for larger, more definitive study. Both groups had significant reductions in alcohol consumption over time and high-treatment engagement rates. Both oral and injectable formulations are feasible to initiate prior to discharge for hospital inpatients identified as having an AUD.

Making the hard work of recovery more attractive for those with substance use disorders

BACKGROUND

Research has led to improvements in the effectiveness of interventions for substance use disorders (SUD), but for the most part progress has been modest, particularly with regard to longer-term outcomes. Moreover, most individuals with SUD do not seek out treatment.

ARGUMENT/ANALYSIS

This paper presents two recommendations on how to improve treatment engagement and long-term outcomes for those with SUD. First, treatments should go beyond a focus on reducing or eliminating substance use to target greater access to and more time spent in experiences that will be enjoyable or otherwise rewarding to clients. Secondly, there must be sufficient incentives in the environment to justify the effort needed to sustain long-term abstinence for individuals who often have limited access to such incentives.

CONCLUSIONS

To increase rates of long-term recovery from substance misuse, treatments should link clients to reinforcers that will make continued abstinence more appealing. This work needs to extend beyond interventions focused on the individual or family to include the local community and national policy in an effort to incentivize longer-term recoveries more strongly.

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.

Treatment seeking as a mechanism of change in a randomized controlled trial of a mobile health intervention to support recovery from alcohol use disorders

BACKGROUND

We estimated the efficacy of the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) in increasing the use of services for addiction and examined the extent to which this use of services mediated the effects of A-CHESS on risky drinking days and abstinence from drinking.

METHODS

We conducted secondary data analyses of the A-CHESS randomized controlled trial. Recruitment occurred in five residential treatment programs operated by two addiction treatment organizations. Participants were 349 adults with alcohol use disorders recruited two weeks before discharge from residential treatment. We provided intervention arm participants with a smartphone, the A-CHESS application, and an 8-month service plan. Control arm participants received treatment as usual. Telephone interviews at 4, 8, and 12-month follow-ups assessed past-month risky drinking days, past-month abstinence, and post-discharge service utilization (past-month outpatient addiction treatment and past-week mutual help including Alcoholics Anonymous and Narcotics Anonymous). Using mixed effects latent variable models, we estimated the indirect effects of A-CHESS on drinking outcomes, as mediated by post-discharge service utilization.

RESULTS

Approximately 50.5% of participants reported outpatient addiction treatment and 75.5% reported mutual help at any follow-up interview in the year following randomization. Assignment to the A-CHESS intervention was associated with an increased odds of outpatient addiction treatment across follow-ups, but not mutual help. This use of outpatient addiction treatment mediated the effect of A-CHESS on risky drinking days, but not abstinence. The effect of A-CHESS through outpatient addiction treatment appeared to reduce the expected number of risky drinking days across follow-ups by 11%.

CONCLUSIONS

The mobile health (mHealth) intervention promoted the use of outpatient addiction treatment, which appeared to contribute to its efficacy in reducing risky drinking. Future research should investigate how mHealth interventions could link patients to needed treatment services and promote the sustained use of these services.

Post-Discharge Treatment Engagement Among Patients with an Opioid-Use Disorder

INTRODUCTION

Opioid misuse is a growing public health problem, and estimates show a 150% increase in opioid-related hospital stays over the last two decades. This study examined factors associated with substance use treatment engagement following a hospitalization for opioid use disorder or overdose.

METHODS

This study analyzed the Truven Health Analytics MarketScan® Commercial Claims and Encounters (CCAE) database for 2010 through 2014 to study post-hospitalization substance use disorder (SUD) treatment of individuals aged 18-64 who had an inpatient admission for an opioid-use disorder or opioid overdose. Engagement in post-discharge SUD treatment was defined as having at least two unique outpatient visits within 30 days of a hospitalization. Generalized estimating equations (GEEs) with a binomial link were used to determine the factors associated with SUD treatment engagement.

RESULTS

Only 17% of patients engaged in SUD treatment within 30 days of hospital discharge. A behavioral health outpatient visit prior to the SUD admission increased the odds of engaging in SUD treatment by 1.34 (CI: 1.25-1.45), an antidepressant prescription drug fill prior to the SUD admission increased the odds by 1.14 (CI: 1.07-1.21), a benzodiazepine fill prior to the SUD admission increased the odds by 1.14 (CI: 1.07-1.21), a principal diagnosis for an SUD at index admission increased the odds by 2.13 (CI: 1.97-2.30), an alcohol-related disorder diagnosis at index admission increased the odds by 3.13 (CI: 2.87-3.42), and an additional SUD diagnosis at the index admission increased the odds by 2.72 (CI: 2.48-2.98).

CONCLUSIONS

We found low rates of SUD treatment engagement following hospitalizations for opioid use disorders and overdoses. Patients with prior engagements with behavioral health providers were more likely to engage in follow-up care; therefore, providers may need to focus additional efforts on patients admitted to the hospital with opioid-use disorders who do not have an existing provider relationship.

An Initial Evaluation of a Comprehensive Continuing Care Intervention for Clients with Substance Use Disorders: My First Year of Recovery (MyFYR)

INTRODUCTION

Physician health programs (PHPs) generate high rates of sustained abstinence in addicted physicians, through a combination of formal treatment, self-help involvement, regular monitoring via random urine toxicology tests, and powerful incentives generated by the threat of losing one's medical license. Recently, Caron Treatment Centers developed a new continuing care intervention, "My First Year of Recovery" (MyFYR), which is modeled after PHPs but provides extended recovery support to a broader segment of those with substance use disorders. This paper presents initial outcome data from MyFYR.

METHODS

MyFYR features frequent outcomes monitoring via urine toxicology tests, and also includes a web-based social platform to coordinate efforts of recovery coaches, family members, and others (e.g., employers, probation officers). Participants were the first 198 clients who enrolled in MyFYR after participating in residential treatment at Caron. Substance use outcomes were determined by a combination of urine toxicology tests, client self-report, and information from family members obtained during a 12-month period following entry into MyFYR.

RESULTS

Clients in MyFYR provided 70% of scheduled urine samples, for an average of 16.4 urine samples per client. Only 4.1% of the samples tested positive for alcohol or any drug. As determined by urine toxicology and client and family reports, 54% of the participants had some use of alcohol or drugs during the follow-up. Of these relapsed clients, 70.1% were retained or re-engaged in MyFYR, and of these, half were able to re-establish abstinence of two months duration or more, as documented by urine toxicology.

DISCUSSION

These initial results are extremely promising, as they document high rates of sustained participation in urine drug test monitoring and positive outcome in clients not under the threat of losing a professional license or incarceration.

Cost-effectiveness analysis of a continuing care intervention for cocaine-dependent adults

INTRODUCTION

The study conducts a cost-effectiveness analysis (CEA) of a continuing care Telephone Monitoring and Counseling (TMC) intervention for adults diagnosed with cocaine dependence. Participants were randomly assigned to a control condition of intensive outpatient treatment only (treatment-as-usual, or TAU; N=108), or to one of two treatment conditions featuring TMC (N=106) and TMC plus incentives (TMC-plus; N=107). Follow-up assessments were conducted over a 2-year period.

METHODS

Intervention and client costs were collected with the program and client versions of the Drug Abuse Treatment Cost Analysis Program (DATCAP). Effectiveness was measured as the number of days abstinent during follow-up. Secondary analyses consider alternative measures of effectiveness and the reduced societal costs of physical and mental health problems and criminal justice involvement.

RESULTS

From the societal perspective, TMC dominates both TAU and TMC-plus as a cost-effective and cost-saving intervention. Results varied by substance-using status, however, with the subgroup of participants in TMC-plus that were using drugs at intake and early in treatment having the greatest number of days of abstinence and generating similar savings during follow-up than the TMC subgroup using drugs at intake.

CONCLUSIONS

Telephone monitoring and counseling appears to be a cost-effective and potentially cost-saving strategy for reducing substance use among chronic substance users. Providing client incentives added to total intervention costs but did not improve overall effectiveness.

CLINICAL TRIAL REGISTRATION

Clinical Trials.gov Number: NCT00685659.

The effects of continuing care on emerging adult outcomes following residential addiction treatment

BACKGROUND

Professional continuing care services enhance recovery rates among adults and adolescents, though less is known about emerging adults (18-25 years old). Despite benefit shown from emerging adults' participation in 12-step mutual-help organizations (MHOs), it is unclear whether participation offers benefit independent of professional continuing care services. Greater knowledge in this area would inform clinical referral and linkage efforts.

METHODS

Emerging adults (N=284; 74% male; 95% Caucasian) were assessed during the year after residential treatment on outpatient sessions per week, percent days in residential treatment and residing in a sober living environment, substance use disorder (SUD) medication use, active 12-step MHO involvement (e.g., having a sponsor, completing step work, contact with members outside meetings), and continuous abstinence (dichotomized yes/no). One generalized estimating equation (GEE) model tested the unique effect of each professional service on abstinence, and, in a separate GEE model, the unique effect of 12-step MHO involvement on abstinence over and above professional services, independent of individual covariates.

RESULTS

Apart from SUD medication, all professional continuing care services were significantly associated with abstinence over and above individual factors. In the more comprehensive model, relative to zero 12-step MHO activities, odds of abstinence were 1.3 times greater if patients were involved in one activity, and 3.2 times greater if involved in five activities (lowest mean number of activities in the sample across all follow-ups).

CONCLUSIONS

Both active involvement in 12-step MHOs and recovery-supportive, professional services that link patients with these community-based resources may enhance outcomes for emerging adults after residential treatment.