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

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

The Personality Assessment Inventory (PAI): Treatment Scales and Interpersonal Characteristics in a Sample of Men Charged with or Convicted of a Sexual Offense

An individual's interpersonal features are pertinent to treatment within clinical populations. The Personality Assessment Inventory (PAI) contains two scales that assess the interpersonal features of warmth (WRM) and dominance (DOM), as well as two additional measures to assess to treatment prediction, process, and rejection (RXR; TPI). The current study examined associations between these PAI scales in a sample of 92 men who underwent comprehensive evaluations of sexual behavior after being charged with or convicted of a sexual offense. Analyses indicated that RXR was positively associated with WRM and DOM, TPI was negatively associated with WRM, and the two interpersonal scales of WRM and DOM were positively correlated with each other. A significant inverse relationship was found between the two treatment scales RXR and TPI indicating that motivation for treatment may have a limited relationship with the treatment process. WRM significantly predicted scores on the TPI, and both WRM and DOM predicted individual scores on RXR. Higher scores on positive impression management (PIM) were predictive of lower TPI and higher RXR, as individuals with higher stakes cases may score higher on PIM and underreport obstacles within treatment or be unwilling to accept the need for treatment. Overall, findings suggest that interpersonal characteristics identified by the PAI scales may be advantageous in approaching treatment within this population.

Associations between drug use patterns and viral load suppression among HIV-positive individuals who use support services in New York City

BACKGROUND

Drug use (DU) represents a significant barrier to maintaining physical health among people living with HIV (PLWH). Few studies, however, have examined the relationship between DU over time and HIV treatment outcomes. Such studies are needed because an individual's risk of poor health outcomes may vary with their DU behaviors. We examined associations between DU patterns over time and unsuppressed viral load (VL).

METHODS

The sample included 7896 PLWH in New York City who completed ≥3 substance use assessments over a 24-month period. DU was defined as crystal methamphetamine, crack/cocaine, heroin, and/or recreational prescription medication use in the last three months. Four behavior patterns were constructed: (1) persistent use (DU reported on each assessment); (2) intermittent use-active (DU reported on the third, but not all previous assessments); (3) intermittent use-inactive (DU reported previously with no DU reported on the third assessment); (4) persistent non-use (no DU reported on any assessment). Unsuppressed VL (>200 copies/mL) was assessed based on the last VL value in the New York City HIV Surveillance Registry in the 12 months following an individual's third DU assessment.

RESULTS

Compared with persistent non-users, individuals with intermittent use-inactive (aOR = 1.24, 95% CI = 1.03-1.49), intermittent use-active (aOR = 1.68, 95% CI = 1.36-2.06), and persistent use (aOR = 2.21, 95% CI = 1.69-2.89) were significantly more likely to have unsuppressed VL.

CONCLUSIONS

While providers may be more likely to intervene with persistent or active drug users, our findings suggest the importance of addressing the risk of poor HIV treatment outcomes among those with any DU behavior.

Stage-Based Mobile Intervention for Substance Use Disorders in Primary Care: Development and Test of Acceptability

Background

In 2016, 21 million Americans aged 12 years and older needed treatment for a substance use disorder (SUD). However, only 10% to 11% of individuals requiring SUD treatment received it. Given their access to patients, primary care providers are in a unique position to perform universal Screening, Brief Intervention, and Referral to Treatment (SBIRT) to identify individuals at risk, fill gaps in services, and make referrals to specialty treatment when indicated. Major barriers to SBIRT include limited time among providers and low motivation to change among many patients.

Objective

The objective of this study was to develop and test the acceptability of a prototype of a mobile-delivered substance use risk intervention (SURI) for primary care patients and a clinical dashboard for providers that can address major barriers to SBIRT for risky drug use. The SURI delivers screening and feedback on SUD risk via mobile tools to patients at home or in the waiting room; for patients at risk, it also delivers a brief intervention based on the transtheoretical model of behavior change (TTM) to facilitate progress through the stages of change for quitting the most problematic drug and for seeking treatment if indicated. The prototype also delivers 30 days of stage-matched text messages and 4 Web-based activities addressing key topics. For providers, the clinical dashboard summarizes the patient’s SUD risk scores and stage of change data, and provides stage-matched scripts to guide in-person sessions.

Methods

A total of 4 providers from 2 federally qualified health centers (FQHCs) were recruited for the pilot test, and they in turn recruited 5 patients with a known SUD. Furthermore, 3 providers delivered dashboard-guided SBIRT sessions and completed a brief acceptability survey. A total of 4 patients completed a Web-based SURI session and in-person SBIRT session, accessed other program components, and completed 3 acceptability surveys over 30 days. Questions in the surveys were adapted from the National Cancer Institute’s Education Materials Review Form. Response options ranged from 1=strongly disagree to 5=strongly agree. The criterion for establishing acceptability was an overall rating of 4.0 or higher across items.

Results

For providers, the overall mean acceptability rating was 4.4 (standard deviation [SD] 0.4). Notably, all providers gave a rating of 5.0 for the item, “The program can give me helpful information about my patient.” For patients, the overall mean acceptability rating was 4.5 (SD 0.3) for the mobile- and provider-delivered SBIRT sessions and 4.0 (SD 0.4) for the text messages and Web-based activities. One highly rated item was “The program could help me make some positive changes” (4.5).

Conclusions

The SURI program and clinical dashboard, developed to reduce barriers to SBIRT in primary care, were well received by providers and patients.

The Effect of Drug Use, Drug Treatment Participation, and Treatment Completion on Probationer Recidivism

The prevalence of drug use among probationers, and the entire offender population, has been well documented. Numerous drug treatment modalities have been shown to reduce recidivism among this population; however, analyses of programmatic success are often based on a subset of offenders who complete treatment. Less is known about individuals who fail to complete treatment. The goal of the current study is to consider the interaction of drug use, drug treatment provision, and treatment completion on recidivism using data from the 2000 Illinois Probation Outcome Study. Findings from a series of proportional hazard models indicate that probationers who failed to complete treatment were more likely to be rearrested in the four years following discharge from probation, even when compared to individuals who needed treatment but did not enroll. Moreover, probationers who failed to complete treatment had more serious criminal histories and fewer ties to society. The research has important implications for the measurement of treatment provision in studies of recidivism, in specific, and more generally for the need to engage and retain probationers in drug treatment.

Recidivism Among Drug Offenders Following Exposure to Treatment

The contemporary debate about punishment versus treatment for drug-using criminal offenders often revolves around the pragmatic issue of the extent to which treatment is more effective than punishment at reducing the probability of subsequent criminal behavior. Although there is growing evidence that treatment works, it is equally apparent that the effects of exposure to treatment vary by offender characteristics, offense characteristics, and the degree of program involvement. Using data on 3,328 drug-using offenders eligible for diversion from prosecution to a community treatment program, multivariate survival models indicate significant differences in the time of rearrest during a 5-year follow-up period, suggesting that the act of entering treatment is a signal of the offender’s readiness for treatment and that the time to rearrest is affected by exposure to treatment. The findings are discussed in terms of current efforts to use the threat of legal sanction to motivate criminal offenders into drug treatment.

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.

Impact of jail sanctions during drug court participation upon substance abuse treatment completion

AIMS

This study of participants in a US drug treatment court describes the relationship between the imposition of short-term jail sanctions and substance abuse treatment dropout, and examines offender characteristics moderating or modifying the impact of jail sanctions on treatment dropout.

METHODS

Data were derived from administrative information collected by the Dane County Wisconsin Drug Treatment Court from 1996-2004 on all 573 participants achieving a final disposition of treatment completion or failure during those program years. Iterative Cox proportional hazards models of time to treatment failure were created; jail sanctions during drug court participation were framed as time-dependent covariates. A theoretical framework and specific statistical criteria guided construction of a final parsimonious model of time to treatment drop-out.

FINDINGS

Treatment failure was associated with unemployment [hazard ratio (HR) in unemployed versus employed = 1.41, P-value 0.0079], lower educational attainment (HR in high school non-graduate versus graduate = 1.41, P = 0.02) and application of the first jail sanction (HR 2.71, P < 0.001). The association between treatment failure and a first sanction was considerably stronger for sanctions administered earlier in participation (HR for sanction 1 at <30 days 11.34, P-value 0.0002). Conclusions  An initial jail sanction for non-adherence may be more likely to foster treatment compliance in less refractory individuals (i.e. those not already acclimated or socialized to incarceration or other corrections interventions). More stringent supervisory conditions and individualized services may be required to reintegrate such offenders and promote longer-term public safety.

Understanding treatment readiness in recently assessed, pre-treatment substance abusers

The goal of this study was to more fully understand readiness for treatment in a pre-treatment sample of 446 substance abusers. Structural Equation Modeling (SEM) was used to: (1) examine the relationships between readiness factors identified in the Pre-Treatment Readiness Scale; and (2) identify the effects of predisposing, illness, and inhibiting determinants on the factors. As with in-treatment samples, Problem Recognition was found to influence Treatment Readiness, although through a different intervening factor, Desire for Change rather than Desire for Help. A fourth factor, Treatment Reluctance, was also influenced by the Desire for Change factor. Fixed characteristics such as age and gender had minimal influences on readiness factors, as did inhibiting characteristics that reflected recent functioning. Illness characteristics including drug severity and perceived treatment barriers had a more robust influence on readiness factors. This study provides an increased understanding of readiness for treatment among pre-treatment substance abusers and also supported the construct validity of the Pre-Treatment Readiness Scale.

Will and skill - an exploratory study of substance abusers' attitudes towards lifestyle change

BACKGROUND/AIMS

This exploratory study focuses on attitudes towards lifestyle change among untreated, voluntarily and compulsorily treated Swedish substance abusers (n = 97).

METHODS

Attitudes were measured with scales on e.g. problem recognition, treatment readiness and the time perspective of future orientation. Subjects were categorised into 4 'addict types' according to their viewpoint on changing substance use habits, i.e. 'less change-willing': non-addicts (n = 16) and consonant addicts (n = 32); 'more change-willing': dissonant (n = 13) and transient addicts (n = 36).

RESULTS

It was shown that 'less change-willing' subjects had experienced less dependence disorders and expressed less treatment demand and motivation than 'more change-willing' subjects. A general measure of willingness to lifestyle change correlated with future orientation among 'more change-willing' subjects.

CONCLUSIONS

The study suggests that individuals' time perspectives ought to be considered when trying to illuminate the process of change and understand what attitudes exercise a positive influence on and are associated with successful lifestyle change efforts. The consistency of substance abusers' motivational structures over time and in different social contexts is discussed.

'Treatment experienced' and 'treatment naïve' drug agency clients compared

BACKGROUND

Research on the prevalence and significance of previous treatment is limited, but indicates that many drug agency clients have had prior drug treatment experiences. Furthermore, treatment experienced drug users have different characteristics from treatment novices at treatment entry and poorer outcomes at follow up.

METHODS

Data from a national longitudinal study of drug users entering treatment in Scotland were analysed using univariate and multivariate techniques to provide the first systematic comparison of treatment experienced and treatment naïve drug users in the UK. Respondents (n=653) were interviewed on four separate occasions (treatment intake, 8 months, 16 months, and 33 months) using structured questionnaires.

RESULTS

Five hundred and fifty-eight individuals (85.5%) had had some form of previous treatment and many reported multiple previous treatments, most commonly substitute drugs. At treatment intake, treatment experienced respondents had worse drug use and life problems than treatment novices. Very high levels of illicit drug use (>85%) were reported by both treatment experienced and treatment naïve drug users at all follow-ups, with no significant differences between the two groups at any time point.

CONCLUSIONS

Drug users entering treatment in Scotland have routinely had multiple earlier treatments and report high levels of illicit drug use at follow up. Contrary to some earlier research, there is no evidence that those who are treatment experienced have worse drug use outcomes than those who are treatment naïve. Findings add to the international literature on prior treatment experiences and new treatment clients' needs.

Severity of Drug Use, Initiation of Prenatal Care, and Maternal‐Fetal Attachment in Pregnant Marijuana and Cocaine/Heroin Users

OBJECTIVE

To compare the severity of drug use, initiation of prenatal care, and maternal-fetal attachment between pregnant marijuana and cocaine/heroin users.

DESIGN

A cross-sectional design.

SETTING

A prenatal clinic of a medical center in the northeast of the United States.

PARTICIPANTS

19 marijuana, 17 cocaine, and 4 heroin users. Cocaine and heroin users were combined in one group.

MAIN OUTCOME MEASURES

The Severity of Drug Use Questionnaire containing 11 questions of withdrawal, dependence, and medical, legal, and interpersonal issues was used to assess the severity of drug use. Initiation of prenatal care was obtained from the chart and was calculated by weeks of gestation when care began. Cranley's Maternal-Fetal Attachment Scale measured maternal-fetal attachment.

RESULTS

Pregnant cocaine/heroin users were 6 years older, had experienced more pregnancies, had higher drug severity scores, and initiated prenatal care later than marijuana users. No significant difference in maternal-fetal attachment was found.

CONCLUSION

Interventions to help especially cocaine/heroin users initiate early prenatal care and reduce severity of drug use are indicated.

Predicting sex offender treatment entry among individuals convicted of sexual offense crimes

This study examined what factors were predictive of who volunteers for sex offender treatment (self-selection) as well as who enters treatment after volunteering (administration selection). Research participants included 404 treatment volunteers and 387 nonvolunteers to treatment who were convicted of a sexual offense involving minors within the federal prison system. Maximum likelihood probit estimation procedures indicated that when compared with nonvolunteers, treatment volunteers were more likely to be recommended by a judge to receive treatment at the time of sentencing, had received prior treatment for sexually deviant behavior, reported higher levels of motivation to change their sexually deviant behavior, and had lower rates of a substance use disorder in the year prior to incarceration. Of those persons who initially volunteered, 62% were accepted and entered treatment, 16% were denied entry to treatment by program staff, and 22% refused treatment after being accepted to the waiting list. When compared with those who were accepted and entered treatment, motivation was the only predictor of being denied admission into treatment by program staff and for refusal of treatment once accepted. The findings emphasize the need to control for selection bias in treatment outcome studies and the importance of examining the role of motivation in treatment volunteerism and treatment entry for sexual offenders.

A conceptual framework for drug treatment process and outcomes

Evidence from specialized treatment evaluations and large-scale natural studies of treatment effectiveness is organized conceptually into a "treatment model" for summarizing how drug treatment works. Sequential relationships between patient and treatment program attributes, early patient engagement, recovery stages, retention, and favorable outcomes are discussed--along with behavioral, cognitive, and skills training interventions that have been shown to be effective for enhancing specific stages of the patient recovery process. Applications of the treatment model for incorporating science-based innovations into clinical practice for improving early engagement and retention, performance measurements of patient progress, program monitoring and management using aggregated patient records, and organizational functioning and systems change also are addressed.

Gender differences in substance use treatment entry and retention among prisoners with substance use histories

OBJECTIVES

We examined gender similarities and differences in the predictors of substance use treatment entry and of the combination of treatment entry and completion.

METHODS

The sample consisted of 2219 male and female program participants. Maximum likelihood probit estimation was used to identify background and attitudinal characteristics predictive of substance use treatment entry and retention.

RESULTS

We observed gender similarities and differences in predictors of treatment entry and the combination of treatment entry and completion. Many of the factors that attract individuals to treatment are the same ones that keep individuals in treatment.

CONCLUSIONS

Attitudinal predictors-namely, motivation to change-showed the greatest consistency between genders and between predictors of treatment entry and predictors of treatment entry and completion.

Treatment readiness among out-of-treatment African-American crack users

Crack cocaine use is linked to high rates of HIV and other sexually transmitted infections, as well as violence and criminal activity. Substance abuse treatment can play an important role in reducing drug use and related problems. However, many crack users do not want treatment, and those who do often encounter significant obstacles to access. This study compares 216 out-of-treatment African-American crack users who reported wanting to enter treatment with 129 who did not want treatment. In bivariate analyses, participants wanting treatment in the next 30 days were more likely to report needing help with medical care, daily crack use, physical abuse, transportation issues, and legal pressure to enter treatment. Predictors of treatment readiness in multiple logistic regression analysis included gender, daily crack use, legal pressure, depression, and problem recognition. Fear of physical abuse and previous treatment admissions were associated with decreased odds of wanting treatment. The many unmet needs reported by crack users motivated for treatment suggest that treatment entry and retention could be facilitated by pretreatment and more comprehensive and ancillary treatment services.

Factors that predict adolescent motivation for substance abuse treatment

Many adolescent substance abusers enter treatment because of external pressures and thus lack motivation to change their behavior and engage in treatment. Because an understanding of adolescent motivation may contribute to improved treatment, an investigation of factors that predict motivation was undertaken with youth admitted to an adolescent outpatient substance abuse treatment program (N=196). At admission, these subjects received a comprehensive biopsychosocial assessment. Using multiple regression analysis, factors considered to potentially predict motivation were assessed. Of the factors examined, those that involved experiencing various negative consequences of substance use emerged as important predictors of motivation, whereas severity of substance use did not. Diminished awareness of negative consequences of use was consonant with lower motivation, suggesting the importance of interventions to help youth recognize negative consequences of their substance use. Interventions to enhance motivation are likely to become more important as the juvenile justice system increasingly refers troubled youth to treatment.

Technology trauma: barriers to increasing technology utilization

While most social workers might agree that increasing the use of technology in agencies may be important for developing efficiency and effectiveness, little is known about the obstacles of doing so. In an NIDA-funded demonstration project to increase technology in agencies that serve drug abusing populations, researchers logged all email and memorandum communication for a two and a half year period. These communications documented the progress of the intervention from inception to implementation. Using a qualitative methodology, researchers for this analysis examined the communication documents, noting themes. A core theme focusing on barriers to implementing technology emerged from the data. These barriers included: agency personnel's lack of computer proficiency, lack of motivation for agency personnel to participate in the intervention, and agency personnel not following intervention protocols, having computer hardware and networking problems, the agency's physical structure (lack of space/computers), and the researchers/interventionists having restricted access to agency personnel.

Arrestees' perceived needs for substance-specific treatment: exploring urban-rural differences

An interview study among a group of arrestees in seven county jails was conducted in the state of Ohio between June 1999 and September 2001, examining the prevalence of alcohol and drug dependence within the group and assessing the need for substance-abuse treatment. Four of the county jails where interviews were conducted are in urban areas, and three are in rural areas. The present study focused on demographic variables, situation-related factors, current drug dependence diagnoses, past treatment experience, and jail location-rural or urban. It sought to assess whether these factors predicted arrestees' perceived needs for substance-specific treatment (for alcohol, marijuana, cocaine, and/or opiate addiction); and, further, whether any predictors of a perceived need for treatment would be identical for arrestees housed in rural jails and those housed in urban jails. The results show that some of the factors assessed do exert differential effects on rural and urban arrestees' perceived needs for substance-specific treatment. Future treatment policy within the criminal justice system should perhaps take into account inmates' individual characteristics and the rural or urban location of the jail initiating their processing. It may be possible, by paying attention to these variables, to enhance inmates' motivation to enter treatment programs, leading ultimately to drug-use cessation.