Prompted to treatment by the criminal justice system: Relationships with treatment retention and outcome among cocaine users

Identifying gender differences in risk profiles and in opioid treatment outcomes in Los Angeles County

Policies and programs that aim to minimize wait time to enter opioid use disorder (OUD) treatment and maximize retention respond to potential differences in female and male clients' risk profiles. We conducted multigroup latent class analysis using significant individual risk factors. Our sample included 13,453 opioid treatment episodes from 135 unique substance use disorder treatment programs in Los Angeles County, California, in four waves: 2011 (66 programs, 1035 clients), 2013 (77 programs, 3671 clients), 2015 (75 programs, 4625 clients), and 2017 (69 programs, 4106 clients). Groups at risk of waiting longer included clients who were female, had mental health issues, received medication for OUD, had criminal justice involvement, received mandated referrals, had children in child protective services, and had caretaker responsibilities. All clients with children in protective services were likely to wait longer than those not in protective services, but women waited longer. Findings highlight that: (a) women and men in OUD treatment have significant health and social problems; (b) female and male clients have distinct risk profiles; and (c) targeted services responding to risk profiles may improve treatment access and engagement. Findings have implications for health policy and program evaluation and planning in the delivery of treatment services considering gendered risk factors.

Review and inventory of 911 Good Samaritan Law Provisions in the United States

BACKGROUND

911 Good Samaritan Laws (GSLs) confer limited legal immunity to bystanders in possession of controlled substances who report emergency overdoses. While these laws may decrease opioid overdose mortality, current literature reduces GSLs to a small number of variables, overlooking substantial differences in implementation and statutory context which dramatically alter their applicability.

METHODS

We identified all state GSLs and their legislative history, characterizing features into four categories using a novel framework: breadth of protected activities, burden placed on Good Samaritans, strength of protection, and exemption in coverage. When protections depended on the nature of the controlled substance, heroin served as a common point of comparison.

RESULTS

GSLs vary substantially across states and time. Protections depend on the quantity of substances involved and may extend to the person experiencing the overdose or persons reporting their own overdose. Protected offenses range from possession of controlled substances to drug-induced homicide. In some states, Good Samaritans must complete substance use treatment or administer naloxone to retain protections. Immunity ranges from protection from arrest to merely procedural protections at trial, and may even exclude persons in possession of opioids. Exemptions target persons engaging in chronic substance use, such as persons invoking protection multiple times or previously reporting an overdose.

CONCLUSION

States offer Good Samaritans substantially different protections even when the statutes confer nominally comparable immunities. Accommodating this heterogeneity will enhance the validity of future studies into these laws and their efficacy.

Factor Structure of the Brief Addiction Monitor in a Non-Veteran Substance Use Disorder Outpatient Treatment Sample

Background

The Brief Addiction Monitor (BAM) was developed as a comprehensive substance use disorder (SUD) outcome metric to fill a gap in quality measurement. Research to date has only examined the psychometric performance of this measure in veteran SUD populations. The purpose of the current research is to examine the factor structure and validity in a non-veteran SUD population.

Methods

Non-veteran patients admitted to a SUD treatment program (N = 2,227) completed BAM at intake. After confirmatory factor analysis (CFA) was performed to evaluate the measurement model validity of previously defined latent structures, exploratory factor analysis (EFA) was used to assess the factor structure and psychometric properties of the BAM within the full sample and within subgroups, specifically racial, referral source (mandated vs. not), and primary SUD diagnosis.

Results

Exploratory factor analyses in the full sample supported a 4-factor model (representing Stressors, Alcohol Use, Risk Factors, and Protective Factors) derived from 13 items. Subsequent EFAs conducted separately in each subgroup revealed variability in the number of resulting factors and pattern matrices. The internal consistency also varied among factors and between subgroups; in general, reliability was greatest for the Alcohol Use scale and either poor or questionable for pattern matrices resulting in scales reflecting Risk or Protective Factors.

Conclusion

Findings from our study suggest that the BAM might not be a reliable and valid instrument for all populations. More research is needed to develop and validate tools that are clinically meaningful and allow clinicians to track recovery progress over time.

Court-Mandated Treatment Outcomes for Prescribed Opioid Use Disorder: A Gender Based Study

This study provides empirical information suggesting court-mandated treatment may be a more effective treatment pathway for opioid use disorder (OUD). To examine the effects of mandated treatment for prescription opioid users, we consider the differences in discharge completion rates for court-mandated and non-mandated treatment for both males and females. We use the Treatment Episode Data Set-Discharges (TEDS-D) from 2015 to 2017 with 13,239, 14,765, and 15,433 cases, respectively, to study successful completion rates for males and females with OUD. Logistic regression analysis confirms a greater completion rate for mandated treatment episodes. Of all mandated females, 59% completed treatment in each of the 3 years as compared to the 59%, 65%, and 64% of successful completion for mandated males, respectively, from 2015 to 2017. Our results suggest court-mandated treatment pathways are more effective on treatment completion for individuals with OUD, yet treatment completion disparity between sexes increases even when females are mandated.

The effect of cannabis policies on treatment outcomes for cannabis use among U.S. adults

BACKGROUND

Research has explored the impact of various medical cannabis policies on substance use treatment admission in recent years, but we know little about factors related to participants' treatment engagement and outcome. To fill this gap in the existing literature, this study used national data to examine the influence of cannabis policies (decriminalized, medical, and recreational) and referral sources (criminal justice vs. voluntary) on treatment completion and length of stay.

METHODS

Data came from the Treatment Episode Data Set-Discharge (2006-2017) on adults 18+ whose primary drug at treatment admission was cannabis. Difference-in-difference analyses using logistic regression examined the effect of cannabis policies on outpatient treatment completion (yes/no; n = 2,192,807) and length of stay (more/fewer than 90 days; n = 1,863,585) in those with a criminal justice or voluntary referral source.

RESULTS

Cannabis policy was not associated with treatment completion in either those with a criminal justice or voluntary referral source. Compared to individuals in states where cannabis use was strictly illegal, those in states with a decriminalization policy were less likely to stay in treatment for 91+ days regardless of the referral source.

CONCLUSIONS

Cannabis policy appears to have a differential effect on treatment completion versus length of stay, with policy having no impact on successful treatment completion. Specifically, we found that decriminalization policies hinder treatment engagement past 90 days. In this sense, length of stay may be a more useful measure of treatment outcome for research than treatment completion moving forward. Furthermore, our study found that neither medical nor recreational policies affected length of stay or treatment completion, regardless of referral source.

Demographic Predictors of Dropping Out of Treatment (DOT) in Substance Use Disorder Treatment

BACKGROUND

Researchers have not studied or used novel methods for identifying potential disparities for sexual minorities, those with criminal pasts, and veterans in (DOT).

METHODS

We used Bayesian logistic regression to identify factors associated with DOT, tested interaction effects, and used machine learning to classify qualitative responses.

FINDINGS

With 2,772 clients from two inpatient clinics in the Southwest United States, we found sexual minorities and females had 52% and 61%, increases and African Americans had 54% decreases in the odds of DOT. Additionally, those with a criminal past and 34.5 and older were less likely to DOT by 5% relative to clients with no prior involvement in the criminal justice system.

CONCLUSIONS

This study illustrated the disparities for women and sexual minorities in DOT as well as demonstrated novel methodological approaches to addressing previously unanswered questions.

Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning

OBJECTIVE

Abstinence outcomes are typically prioritized in the treatment of cocaine use disorder while ignoring patterns of low-frequency cocaine use. This study examined patterns of cocaine use frequency during treatment and evaluated how these patterns related to baseline characteristics and functioning outcomes 6 and 12 months after treatment.

METHOD

We used a pooled dataset (N = 720) from seven randomized clinical trials for cocaine use disorder. The Addiction Severity Index (ASI) was used to assess functioning. Repeated-measures latent class analysis was used to derive patterns of cocaine use.

RESULTS

Three patterns were identified: abstinence (10.6%), low-frequency use (approximately 1 day/week; 66.3%), and persistent frequent use (approximately 4 days/week; 23.1%). The low-frequency group was associated with male gender, younger age, and a criminal justice referral. The abstinent group had the highest alcohol problem severity score at baseline. At Month 6, the low-frequency group reported lower problem severity than the persistent frequent use group across multiple ASI areas, including the cocaine use as well as psychological, family, employment, and legal domains. At Month 12, the low-frequency group did not differ from the abstinent group in problem severity on any ASI domain and, relative to the persistent frequent use group, had lower cocaine use and employment problem severity.

CONCLUSIONS

These findings highlight the importance of adopting a harm reduction approach and recognizing the potential clinical benefits associated with nonabstinent outcomes.

The effect of legal mandates on substance use disorder treatment completion among older adults

Objective: This study seeks to determine the relationship between referral type (legally mandated versus non-mandated) and substance use disorder (SUD) treatment completion among older adults and by primary substance used.Method: We used data from the Treatment Episode Data Set - Discharges (TEDS-D) from 2011. Using data for persons age 55 and over (n = 104,747), we used propensity score matching (PSM) to address selection bias and attenuate the likelihood of a type I error. Logistic regression models estimated the effect of referral type on treatment completion based on treatment for a primary substance for five categories of substances.Results: In the matched sample, those who faced treatment mandates had 71% greater odds of completing treatment compared with those who entered treatment voluntarily (OR =1.71, 95% CI [1.64, 1.79]). Based on the primary drug used, odds of treatment completion were highest for alcohol, with 86% greater treatment completion for the mandated individuals compared with those entering treatment without a legal mandate (OR =1.86, 95% CI [1.75, 1.97]).Conclusion: These findings suggest that the motivating influence of treatment mandates may encourage completion of SUD treatment among older adults. Although the legal mandates for treatment are punitive, they may act to keep older adults with SUD engaged in treatment, an important factor as treatment completion is inversely related to relapse of a SUD.

Clinical validation of reduction in cocaine frequency level as an endpoint in clinical trials for cocaine use disorder

BACKGROUND

Despite calls for non-abstinence endpoints in randomized clinical trials (RCTs) for cocaine use disorder, there is a lack of data validating non-abstinence endpoints. We conducted a clinical validation of reduction in cocaine frequency level as a non-abstinence endpoint in RCTs for cocaine use disorder (CUD).

METHODS

We utilized a pooled dataset (n = 716; 63.6 % male, 51.4 % non-Hispanic white) from seven RCTs for CUD. We specified three cocaine frequency levels at baseline and end of treatment (EOT): abstinence, low frequency (1-4 days/month), and high frequency (5+ days/month). Multiple regression analyses were conducted.

RESULTS

Among the sample, 38.3 % had at least a one-level reduction from baseline to EOT, whereas 61.7 % did not change/increased frequency level. At least a one-level reduction in cocaine frequency level from baseline to EOT versus no change/increase was significantly associated with better functioning up to one year following treatment on measures of cocaine use, as well as psychological, employment, legal, and other drug use problem severity domains of the Addiction Severity Index (ASI). We also conducted analyses only among those at the high frequency level at baseline and found those who reduced to low frequency use at EOT had similar outcomes at follow-up as those who reduced to abstinence.

CONCLUSIONS

At least a one-level reduction in cocaine frequency level from pretreatment to EOT can be a clinically meaningful endpoint given its relation to sustained clinical benefit up to one-year following treatment. These data parallel recent findings regarding reduction in drinking risk level among individuals with alcohol use disorder.

Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning

OBJECTIVE

Abstinence outcomes are typically prioritized in the treatment of cocaine use disorder while ignoring patterns of low-frequency cocaine use. This study examined patterns of cocaine use frequency during treatment and evaluated how these patterns related to baseline characteristics and functioning outcomes 6 and 12 months after treatment.

METHOD

We used a pooled dataset (N = 720) from seven randomized clinical trials for cocaine use disorder. The Addiction Severity Index (ASI) was used to assess functioning. Repeated-measures latent class analysis was used to derive patterns of cocaine use.

RESULTS

Three patterns were identified: abstinence (10.6%), low-frequency use (approximately 1 day/week; 66.3%), and persistent frequent use (approximately 4 days/week; 23.1%). The low-frequency group was associated with male gender, younger age, and a criminal justice referral. The abstinent group had the highest alcohol problem severity score at baseline. At Month 6, the low-frequency group reported lower problem severity than the persistent frequent use group across multiple ASI areas, including the cocaine use as well as psychological, family, employment, and legal domains. At Month 12, the low-frequency group did not differ from the abstinent group in problem severity on any ASI domain and, relative to the persistent frequent use group, had lower cocaine use and employment problem severity.

CONCLUSIONS

These findings highlight the importance of adopting a harm reduction approach and recognizing the potential clinical benefits associated with nonabstinent outcomes.

Motivation and substance use outcomes among adolescents in a school-based intervention

The stages of change (Precontemplation, Contemplation, Preparation, Action, and Maintenance) have been well studied in adult populations. However, fewer studies have examined how the stages of change are related to adolescent substance use. Furthermore, there have been no studies that have examined how the stages of change relate to outcomes in a school-based intervention. To better capture adolescent motivation, we added an additional group to the Transtheoretical Model of Change, which we titled Coerced Action, to represent adolescents that made changes to their substance use despite low problem recognition (representing the internal motivation of Precontemplation and the change behaviors of the Action group). We then examined how the stages of change were related to a thorough assessment of substance use at baseline and corresponding treatment outcomes. Our sample consisted of 264 adolescents (mean age: 16.1, 44.5% Caucasian, 37.5% female) who participated in an 8-week, school-based Motivational Enhancement intervention. Results indicated significant group differences across the stages of change in substance use patterns (alcohol use, negative consequences, affective dysregulation), as well as treatment outcomes (alcohol use and negative consequences). For instance, adolescents in the Action group demonstrated more negative consequences at 16weeks follow-up than those in Precontemplation and Coerced Action, F(1, 3)=8.23, p<.001. The Coerced Action group reported the most alcohol use at 16weeks follow-up, although the finding was not significant when post-hoc tests were conducted. This study provides meaningful support for the assessment of motivation among adolescent substance users within school-based settings.