Understanding the therapeutic factors of the social reintegration treatment stage in a residential treatment setting: a qualitative approach

Purpose

The purpose of this paper is to understand deeply the important elements of the reintegration phase of recovery.

Design/methodology/approach

The participants were 14 people suffering from addiction to drugs, who met the criteria for substance use disorder according to the diagnostic and statistical manual of mental disorders, fifth edition. The data obtained by semi-structured interview were qualitatively analyzed by interpretive phenomenological analysis.

Findings

The results highlight the importance of relationships in therapy, identity reshaping, a deeper understanding of the causes of substance use, the importance of boundaries, the critical parameters of the transition to regularity and the important role of emotions.

Originality/value

The results are discussed on the basis of the enhancement of the therapeutic interventions that are followed at the reintegration stage, taking into account not only the peculiarities of this phase but also social factors such as stigmatization.

Maintaining Normative Functioning Alongside Drug Use: The Recognition of Harms and Adoption of Change Strategies

The current study examined drug users' perspectives on strategies that helped them to maintain normative functioning or resolve impaired functioning. We interviewed 29 drug users who described themselves as functioning normatively while using drugs on a regular basis until they experienced harms or raised concerns of future harms. The content analysis showed that the users maintain their normative functioning through diverse strategies that can be located on a continuum. This continuum was conceptualized as "normative functioning management" based on White et al.'s concept of "recovery management." This study found an ongoing continuum through self-management and social interaction consisting of three regions: the management of normative functioning, the recognition of the harm of drug use to functioning, and the subsequent adoption of change strategies for maintaining normative functioning. This continuum may provide a more nuanced theoretical understanding of the phenomenon of drug users with normative functioning and is therefore relevant for counselors encountering such users in their practice. This study highlights inner resources such as self-awareness and social interaction that help functioning users to maintain their normative functioning and fulfill basic obligations in their normal routines, that is, preserving their professional status, family lives, and relationships.

"Drinkers Like Me": A Thematic Analysis of Comments Responding to an Online Article About Moderating Alcohol Consumption

Background

There has been media coverage surrounding the dangers of heavy drinking and benefits of moderation, with TV and radio presenter, Adrian Chiles, documenting his experience of moderating alcohol consumption in an online article for the Guardian. By analysing the comments in response to Chiles' article, this study aimed to explore (i) posters' (someone who has posted a comment in response to the article) attitudes or beliefs toward moderating alcohol and (ii) posters' experiences of moderating or abstaining from alcohol.

Method

A secondary qualitative analysis of online comments in response to an article about moderating alcohol consumption. Main outcome measures: Comments (n = 784) in response to a United Kingdom online news article about moderating alcohol consumption were extracted and inductive thematic analysis was used.

Results

For aim one, two themes were developed; "general attitudes toward drinking" and "general attitudes toward reducing consumption". These themes reflect negative perceptions of alcohol and issues around changing attitudes. For aim two, three themes were developed: "moderation vs. abstention", "reflection on past drinking behaviours", and "current drinking behaviours". These themes represent posters' experiences and implications changing their drinking habits.

Conclusion

Our analysis provides a novel insight into perceptions and experiences of moderating or abstaining from alcohol. Alcohol is embedded within United Kingdom culture, creating difficulties for those who choose to moderate or abstain from alcohol. Our analysis highlights the need for public health to focus on shifting the current drinking culture, through clearer drinking guidelines and a wider availability of alcohol-free alternatives.

Redefining recovery: Accounts of treatment experiences of dependent cannabis users in Nigeria

BACKGROUND

Research on addiction recovery describes recovery as a process leading to cessation of drug use. Few researchers have explored alternative views of recovery, and the interplay of individuals' agency and social context in the recovery process. This study explored situated understandings of recovery among cannabis users that emphasized process and contingency.

METHODS

We conducted the study in Uyo, Akwa Ibom State in Nigeria. Participants were current (street-involved) cannabis users aged 21 to 34 (n = 97), recruited through time-location sampling. The study collected data through in-depth, individual interviews, which study staff transcribed, coded, and analyzed thematically.

RESULTS

Participants' accounts indicated a quest for treatment as a means of recovery and redemption (i.e., repairing an identity damaged by dependent cannabis use). Relapse affected recovery when participants defined the latter as abstinence. Framing recovery this way showed the effects of social and structural factors on individual agency and treatment experiences. Yet some participants' accounts highlighted a redefinition of recovery as a process ("recovering"), measured by such outcomes as reduced drug use and improved overall well-being.

CONCLUSIONS

Reframing recovery, as some participants' accounts in our study capture, speaks to the need for treatment programs that are informed by the principles of harm reduction and health promotion. Instead of foisting a singular treatment goal defined as total abstinence onto drug users seeking treatment, treatment should be attuned to the experiences and life circumstances of users and support them in achieving their recovery goals.

The phenotype of recovery IV: Delay discounting predicts perceived stress and a chance locus of control in individuals in recovery from substance use disorders

OBJECTIVE

Understanding individuals who are successful in recovery from substance use disorders will help to inform treatments and preventative measures. Stress has been shown to be associated with both substance use and relapse. Delay discounting is associated with risk of substance use; it is predictive of treatment outcomes and maintained abstinence. Associations between perceived stress, beliefs about locus of control, and delay discounting have yet to be assessed in individuals in recovery from substance use disorder.

METHODS

Data from 93 individuals in recovery from substance use recruited from the International Quit and Recovery Registry (IQRR) were analyzed. Individuals completed the adjusting amount delay discounting procedure to obtain delay discounting rates. Level of perceived stress was assessed by the Perceived Stress Scale (PSS). An individual's belief about locus of control was assessed using the Internality, Powerful Others and Chance Scale (IPCS).

RESULTS

Delay discounting was a significant predictor of perceived stress and scores associated with beliefs about a Chance locus of control (i.e., belief that events that occur in an individual's life are because of chance or luck), even after controlling for demographic characteristics. Time in recovery was also predictive of levels of perceived stress; this relationship was mediated by delay discounting.

CONCLUSION

The present study indicates that delay discounting can predict perception of stress and beliefs about a chance locus of control in individuals in recovery. This information may help understand, identify, and assist individuals whomay need different, new, or more intensive interventions for their substance use disorder.

"Chasing the first high": memory sampling in drug choice

Although vivid memories of drug experiences are prevalent within clinical contexts and addiction folklore ("chasing the first high"), little is known about the relevance of cognitive processes governing memory retrieval to substance use disorder. Drawing on recent work that identifies episodic memory's influence on decisions for reward, we propose a framework in which drug choices are biased by selective sampling of individual memories during two phases of addiction: (i) downward spiral into persistent use and (ii) relapse. Consideration of how memory retrieval influences the addiction process suggests novel treatment strategies. Rather than try to break learned associations between drug cues and drug rewards, treatment should aim to strengthen existing and/or create new associations between drug cues and drug-inconsistent rewards.

Psychosomatic subjects and the agencies of addiction

Addiction science and public policy have for some time been articulated in conformity with a broader antinomy in Western thought between biological reductionism and liberal voluntarism. Hence, mainstream debates have concerned whether and how addiction might be understood as a disease in the biomedically orthodox sense of anatomical or physiological pathology or whether and how addiction might be understood as a voluntary choice of some kind. The fact that those who staff these debates have appeared either unable or unwilling to consider alternatives to this antinomy has resulted in a rather unhappy and intransigent set of intellectual anomalies both on the biomedical and the social scientific sides of this divide. Perhaps more importantly, it has also resulted in a striking isolation of scientific debates themselves from the vicissitudes of therapeutically caring for those putatively suffering from addictions both within and outside clinical settings. After briefly demonstrating the conformity of debates in addiction science with the broader antinomy between biological reductionism and liberal voluntarism and the anomalies that thereby result, this article considers the scientific and therapeutic benefits of a psychosomatic framework for the understanding of both self-governing subjects and the experience of a loss of self-control to agencies of addiction.

Research report

Processes of change during and after drug treatment, What factors are described by clients as important to initiate and maintain positive changes?

Aims

The aim is to describe and analyze how clients recovered from alcohol or drug abuse perceive change in connection with treatment interventions. The specific questions are: What factors are described as important to 1) initiate a process of change? 2) avoid returning to abuse?

Design

40 clients were interviewed according to a brief interview guide. The analysis resulted in models with factors that the clients considered important for initiating and maintaining positive changes.

Results

The result suggests that a pattern is emerging in the process of change. Although the clients often describe common factors as important, the variation of timing and severity for different factors makes the individual story unique.

Conclusions

The variation of timing and severity for different factors implies that it is very difficult to predict when a factor is important or not. This underlines the importance of treatment systems with a structure and a flexibility that enables supporting factors to be used when they are of importance for the individual client.

Narrative change, narrative stability, and structural constraint: The case of prisoner reentry narratives

Cultural sociologists and other social scientists have increasingly used the concept of narrative as a theoretical tool to understand how individuals make sense of the links between their past, present, and future, how individuals construct social identities from cultural building blocks, and how culture shapes social action and individual behavior. Despite its richness, we contend that the narratives literature has yet to grapple with narrative change and stability when structural constraints or barriers challenge personal narratives and narrative identities. Particularly for marginalized groups, the potential incompatibility of personal narratives with daily experiences raises questions about the capacity of narratives to influence behavior and decision-making. In this study we draw on prospective longitudinal data on the reentry narratives and narrative identities of former prisoners to understand how narratives do and not change when confronted with contradictory experiences and structural constraints. We identify and describe the processes generating narrative change and stability among our subjects. These findings inform a framework for studying narrative change and stability based on four factors: the content of the narrative itself, the structural circumstances experienced by the individual, the institutional contexts in which the individual is embedded, and the social networks in which the individual is embedded.

Public Perspectives on Expanding Naloxone Access to Reverse Opioid Overdoses

BACKGROUND

Opioid overdoses can often be reversed with naloxone hydrochloride. Past studies on attitudes toward expanded naloxone access have surveyed drug users, family members, and providers.

OBJECTIVES

To explore how the general public perceives take-home or nonmedical first-responder access to naloxone to reverse opioid overdoses. Additionally, little is known about how support for expanded access is related to participant's endorsement of Individualism and Just World Belief-colloquially people getting what they deserve and deserving what they get.

METHODS

Lay participants completed an online survey examining concerns with and support for expanding naloxone access. Just World Belief, Individualism, and participants' dependence history were also measured. Four different hypothetical situations were considered, varying according to type of opioid (heroin versus nonmedical prescription opioid) and recipient (suburban middle class versus recent parolee).

RESULTS

Most participants agreed with at least some degree of expanded access. Analyses of variance indicated that type of opioid or recipient did not affect attitudes toward expansion. Pearson correlations and multiple regressions revealed that endorsement of Just World Beliefs and Individualism were associated with greater concerns with and less support for expansion.

IMPORTANCE

While there is general agreement with some degree of expanding naloxone access, participants' level of endorsement was influenced by their level of individualism and belief in a just world. These factors need to be considered in how to best frame messages to maximize layperson support for expansion.

A qualitative study of self-managed change in substance dependence among women

Alcohol and drug abuse and dependence are common disorders in our society, and the vast majority of those who recover do so without formal treatment. Although this phenomenon appears to be more common among women than men, no study reported in the literature has provided information on the process of natural recovery among women. This qualitative study found that the model of natural recovery described by Biernacki appears to adequately characterize the broad categories of the process among women. There are, however, gender-specific aspects to a number of the processes and strategies described, and in the degree of salience of some of the factors in enhancing motivation to change addictive behaviors. The term “self-managed change” has been adopted to more adequately characterize this process.

[Out of addictions: Alcohol, or alcohol to alcohol]

Pathways from alcoholism to recovery are documented; less often are those from drug addiction to alcoholism. Biographical approaches allow analyzing how people change their uses and talk about their trajectories of recovery.

METHODS

Three hundred and forty-one people (34% women) in the Paris area were questioned on their trajectories with a biographical questionnaire. Some open questions were aimed to understand the connection they made between events in their lives, how recovered they felt and what they considered strengths or obstacles. All the participants had stopped at least one product. Their mean age was 43, and 26% were over 50.

STUDY OBJECTIVES

How can the differences between one substance addicts and dual abusers be explained? Can we hypothesize a better result for the patients with a single dependence to alcohol in their lives for the following two reasons? (1) They could really be taken in charge for their alcoholism whereas the dual abusers mostly receive cared for their illicit drug problems with an under estimation of their problem with alcohol. In this case, they turn to alcohol after weaning themselves from their drug dependence so as to return to a social consumption, especially when they are given an opiate treatment. (2) Conversely could we suggest that the dual substance abusers had different trajectories from their childhood (more adverse events, more social difficulties, mental health problems), and that this accumulation explains their skipping from one substance or behaviour to another without any real recovery for decades?

RESULTS

All respondents were polydrug users. Eighty-two had been dependent mainly on alcohol. One hundred and twenty-one people had been drug addicts (mostly heroin), which they had stopped on average ten years before the survey. The last group included 138 persons who had been heroin or cocaine addicts and alcoholics in their lives, a third of whom had been dependent on alcohol before their drug addiction (35%), a tenth on both at the same time (10%) and more than half of the users (55%) had turned from drug addiction to alcoholism. The group concerning alcohol dependence includes the oldest participants, on average 49.7, and 55% of them were abstinent at the survey. Conversely, the group "with no alcohol dependence" had mainly turned to opiate treatments. Their histories in dependence and in various social statuses also showed a longer duration out of employment, in sickness or invalidity, or in prison, for the drug dependents as opposed to the "mainly" alcoholics. The population with dual substance abuse experienced twice as many adverse childhood events as the others (P<0.005): it was the case for 19.5% in "mainly alcohol" dependence compared to 38.4% in dual abuse. The recovery capital gave a mean score of 7.56±2.35 (median 7). A score below 6 was considered low. The score was significantly different according to the dependence groups: while 7.3% of "mainly alcohol" dependents had a score below 6, this was the case for 30.4% of the dual group (with alcohol and drugs), and 19% for the "mainly drug dependence" group. Controlling ages, sexes and groups of dependence in a logistic regression, the risk of having a recovery capital below six was more than four times higher for the dual dependents as opposed to the "mainly alcohol" dependents.

CONCLUSION

Some people stay for decades in drug addiction centers switching from one dependence to another. Their alcohol drinking should be addressed earlier to prevent them from turning to drinking excessively in order to wean themselves from their drug addiction.

Estimating incidence of problem drug use using the Horwitz-Thompson estimator - A new approach applied to people who inject drugs in Oslo 1985-2008

BACKGROUND

The trend in the number of new problem drug users per year (incidence) is the most important measure for studying the diffusion of problem drug use. Due to sparse data sources and complicated statistical models, estimation of incidence of problem drug use is challenging. The aim of this study is to widen the palette of available methods and data types for estimating incidence of problem drug use over time, and for identifying the trends.

METHODS

This study presents a new method of incidence estimation, applied to people who inject drugs (PWID) in Oslo. The method took into account the transition between different phases of drug use progression - active use, temporary cessation, and permanent cessation. The Horwitz-Thompson estimator was applied. Data included 16 cross-sectional samples of problem drug users who reported their onset of injecting drug use. We explored variation in results for selected probable scenarios of parameter variation for disease progression, as well as the stability of the results based on fewer years of cross-sectional samples.

RESULTS

The method yielded incidence estimates of problem drug use, over time. When applied to people in Oslo who inject drugs, we found a significant reduction of incidence of 63% from 1985 to 2008. This downward trend was also present when the estimates were based on fewer surveys (five) and in the results of sensitivity analysis for likely scenarios of disease progression.

CONCLUSION

This new method, which incorporates temporarily inactive problem drug users, may become a useful tool for estimating the incidence of problem drug use over time. The method may be less data intensive than other methods based on first entry to treatment and may be generalized to other groups of substance users. Further studies on drug use progression would improve the validity of the results.

Social Identities as Pathways into and out of Addiction

There exists a predominant identity loss and "redemption" narrative in the addiction literature describing how individuals move from a "substance user" identity to a "recovery" identity. However, other identity related pathways influencing onset, treatment seeking and recovery may exist, and the process through which social identities unrelated to substance use change over time is not well understood. This study was designed to provide a richer understanding of such social identities processes. Semi-structured interviews were conducted with 21 adults residing in a drug and alcohol therapeutic community (TC) and thematic analysis revealed two distinct identity-related pathways leading into and out of addiction. Some individuals experienced a loss of valued identities during addiction onset that were later renewed during recovery (consistent with the existing redemption narrative). However, a distinct identity gain pathway emerged for socially isolated individuals, who described the onset of their addiction in terms of a new valued social identity. Almost all participants described their TC experience in terms of belonging to a recovery community. Participants on the identity loss pathway aimed to renew their pre-addiction identities after treatment while those on the identity gain pathway aimed to build aspirational new identities involving study, work, or family roles. These findings help to explain how social factors are implicated in the course of addiction, and may act as either motivations for or barriers to recovery. The qualitative analysis yielded a testable model for future research in other samples and settings.

The CHANGE Study: Methods and Sample Description for a Cross-Sectional Study of Heroin Cessation in New York City

The CHANGE (Cessation of Heroin: A Neighborhood Grounded Exploration) Study aimed to understand factors associated with the initiation and maintenance of sustained heroin cessation from the perspective of users themselves and specifically set out to document the correlates of natural recovery. The CHANGE Study was a case-control study conducted in New York City from 2009 to 2011. Cases were former heroin users, abstinent for 1-5 years in the past 5 years. Controls used heroin at least weekly during the past 5 years and were (1) continuous heroin users without a quit attempt of ≥2 weeks' duration or (2) relapsed heroin users who were currently using and had a quit attempt of ≥2 weeks' duration during the past 5 years. Recruitment and data collection methods are described along with limitations and a brief description of the study sample. In contrast to many studies of drug use and cessation, the CHANGE Study was designed to model success (i.e., initiation and maintenance of heroin cessation) and not failure.

Potential bias due to outcome-related loss to follow-up in cohort studies on incidence of drug injection: systematic review and meta-analysis

AIMS

A systematic review and meta-analysis were conducted to synthesize results from cohort studies on initiation into drug injection among vulnerable populations, to quantify heterogeneity in the estimated incidence rates of drug injection and to identify potential sources of heterogeneity and bias.

METHODS

MEDLINE, EMBASE, PsycINFO and LILACS were searched for relevant studies published between 1980 and 2012. Investigators independently reviewed studies for inclusion, retrieved information on baseline population characteristics and follow-up features and assessed study quality. Study-specific incidence rates of drug injection were calculated as the number of new injectors divided by the person-years at risk. The I(2) statistic was used to quantify heterogeneity in incidence rates across studies, and random-effects meta-regression models were used to identify determinants of heterogeneity and bias.

RESULTS

Nine cohorts totalling 1843 participants met the inclusion criteria, with individual sample sizes of 70-415 participants and follow-up lengths of 6 months-3.4 years. The incidence of drug injection varied widely, from 2.1 to 24.2 cases per 100 person-years. The strong between-study heterogeneity (I(2)  = 90%, P<0.001) was reduced significantly after accounting for the different follow-up lengths (I(2)  = 17%, P = 0.30), with a 57% (95% confidence interval 46-66%) decrease in the pooled incidence of drug injection per 1-year increase in average follow-up.

CONCLUSIONS

The incidence of drug injection decreases sharply with increasing follow-up length in cohort studies on drug injection initiation. Low retention rates and potential for downward selection bias in cohort studies on drug injection initiation are caused primarily by greater loss to follow-up among individuals at higher risk of starting injection, compared with other participants.

Trajectories of Aging Long-Term Mexican American Heroin Injectors: The "Maturing Out" Paradox

OBJECTIVE

To examine the applicability of the "maturing out" theory to a sample of aging Mexican American men who are long-term heroin injectors.

METHOD

Ethnographic data were collected as part of a cross-sectional study of aging Mexican American heroin users in Houston with 20 current heroin users.

RESULTS

Findings indicate that dysfunctions that emerge in the heroin lifestyle lead not to cessation but rather to "maturing in," a specific process of social readjustment that returns the heroin user to a stable maintenance pattern of use instead of a recovery phase. This process of paradoxical maturing out can be attributed to the unconditional social support provided to the heroin user by family, peers, and the tecato subculture embedded in Mexican American communities.

DISCUSSION

Results highlight the implications for the intersection of heroin-related conditions, natural age-related impairments, and cognitive functioning that make this population increasingly susceptible to adverse health consequences.

Long-term course of opioid addiction

Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions. Guided by a life-course framework, we review the literature on the long-term course of opioid addiction in terms of use trajectories, transitions, and turning points, as well as other factors that facilitate recovery from addiction. Most long-term follow-up studies are based on heroin addicts recruited from treatment settings (mostly methadone maintenance treatment), many of whom are referred by the criminal justice system. Cumulative evidence indicates that opioid addiction is a chronic disorder with frequent relapses. Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence. Over the long term, the mortality rate of opioid addicts (overdose being the most common cause) is about 6 to 20 times greater than that of the general population; among those who remain alive, the prevalence of stable abstinence from opioid use is low (less than 30% after 10-30 years of observation), and many continue to use alcohol and other drugs after ceasing to use opioids. Histories of sexual or physical abuse and comorbid mental disorders are associated with the persistence of opioid use, whereas family and social support, as well as employment, facilitates recovery. Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence. Recent advances in pharmacological treatment options (buprenorphine and naltrexone) include depot formulations offering longer duration of medication; their impact on the long-term course of opioid addiction remains to be assessed.

Making sense of the transition from the Detroit streets to drug treatment

In this article we consider the process of adjustment from active street sex work to life in structured substance abuse treatment among Detroit-area women who participated in a semicoercive program administered through a drug court. We examine this transition in terms of changes in daily routines and social networks, drawing on extensive qualitative data to illuminate the ways in which women defined their own situations. Using concepts from Bourdieu and Latour as analytical aids, we analyze the role of daily routines, environments, and networks in producing the shifts in identity that those who embraced the goals of recovery demonstrated. We conclude with a discussion of how the restrictive environments and redundant situations experienced by women in treatment could be paradoxically embraced as a means to achieve expanded opportunity and enhanced individual responsibility because women effectively reassembled their social networks and identities to align with the goals of recovery.

Misrepresenting the Accomplishments of Treatment

The term "chronic relapsing disorder/disease" is viewed as an unfortunate shorthand expression that does an injustice to the accomplishments of treatment patients and treatment providers, and inadequately describes the findings from treatment evaluation research. Studies are reported that make clear relapse is not an inevitable consequence of substance abuse treatment, while substantial reductions in drug use and crime are routinely obtained consequent to treatment. It is past time to retire a term whose only virtue is brevity, and whose vices risk harm to a treatment population that is already stigmatized and a treatment system that is under frequent pressure. Thus, retiring this term provides the important benefit of recognizing the real achievements in behavior change obtained by treatment clients in conjunction with their service providers.

Understanding prolonged cessation from heroin use: findings from a community-based sample

BACKGROUND

There is abundant literature describing heroin initiation, co-morbidities, and treatment. Few studies focus on cessation, examining the factors that motivate and facilitate it.

METHODS

The CHANGE study utilized mixed methods to investigate heroin cessation among low-income New York City participants. This paper describes findings from qualitative interviews with 20 former and 11 current heroin users. Interviews focused on background and current activities, supports, drug history, cessation attempts, and motivators and facilitators to cessation.

RESULTS

Participants found motivation for cessation in improved quality of life, relationships, and fear of illness, incarceration and/or death. Sustained cessation required some combination of treatment, strategic avoidance of triggers, and engagement in alternative activities, including support groups, exercise, and faith-based practice. Several reported that progress toward goals served as motivators that increased confidence and facilitated cessation. Ultimatums were key motivators for some participants. Beyond that, they could not articulate factors that distinguished successful from unsuccessful cessation attempts, although data suggest that those who were successful could describe more individualized and concrete-rather than general-motivators and strategies.

CONCLUSIONS

Our findings indicate that cessation may be facilitated by multifaceted and individualized strategies, suggesting a need for personal and comprehensive approaches to treatment.

Pharmacotherapies for treating opioid use disorder

Opioid use disorder (OUD) is a major public health problem in the United States. It has resulted in devastating consequences for people with this condition, including psychosocial and legal problems, in addition to contraction of infectious diseases such as HIV and hepatitis B and C. Furthermore, this disease can cause fatalities from drug overdoses and drug-drug interactions. OUD shatters families and destroys relationships. Effective treatment is crucial in order to curtail the consequences of this condition. The objective of this article is to provide a review of the pharmacotherapies currently being used to treat OUD.

Remission from substance dependence: differences between individuals in a general population longitudinal survey who do and do not seek help

BACKGROUND

Only a minority of individuals who have substance use disorders receives treatment, and those who do typically have more severe disorders. The current study examines the relationship of help-seeking with remission from alcohol and/or drug dependence and other outcomes.

METHODS

Data from the Wave 1 (2001-2002) and Wave 2 (2004-2005) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to examine remission at Wave 2 among respondents who had past-year substance dependence disorders at Wave 1 (N=1262). Multi-group structural equation modeling was used to compare individuals with (n=356) and without (n=906) prior help-seeking at Wave 1 on subsequent help-seeking and other factors that influence outcomes.

RESULTS

Baseline help-seekers sought help at higher levels over the follow-up period (31% vs. 8%) and had lower rates of remission (50% vs. 68%), as compared with those without prior help-seeking, respectively. Among baseline help-seekers, there were stronger relationships between baseline stress and mental disorders and having sought help since baseline; age and past-year level of stress at follow-up; level of stress and health status at follow-up; and social support and mental disorders at follow-up. Among baseline non-help-seekers, there were stronger relationships between being female and past-year stress at follow-up, and between having sought help since baseline and physical health status at follow-up.

CONCLUSIONS

Findings extend our understanding of the factors associated with recovery from substance dependence, including "natural recovery", use of services outside of addiction treatment, and gender differences in help-seeking and remission.

Trajectories of injection drug use over 20 years (1988-2008) in Baltimore, Maryland

The objective of this study was to identify longitudinal patterns of injection drug use over 20 years in the AIDS Linked to the Intravenous Experience (ALIVE) Study, a community-based cohort of injection drug users (IDUs) in Baltimore, Maryland, with a focus on injection cessation. Starting in 1988, persons over 18 years of age with a history of injection drug use were recruited into the study. Participants provided information on their injection drug use semiannually through 2008. The analysis was restricted to 1,716 IDUs with at least 8 study visits. Finite mixture models were used to identify trajectories and predictors of injection patterns over time. The mean age of participants was 35 years; 75% were male, and 95% were African-American. Five distinct patterns were identified: 2 usage patterns (32% engaged in persistent injection and 16% had frequent relapse) and 3 cessation patterns (early cessation (19%), delayed cessation (16%), and late cessation (18%)). A history of drug treatment, no recent use of multiple substances, and less frequent injection distinguished the early cessation group from the other groups. This study demonstrated multiple trajectories of drug injection behaviors, with a substantial proportion of IDUs stopping injection over extended time frames. For maximum effectiveness, public health programs for IDUs should be long-term, comprehensive, and targeted toward individual patterns of use.

Heroin use, dependence, and attitudes to treatment in non-treatment-seeking heroin users: a pilot study

Much research examining heroin users utilizes treatment samples; non-treatment-seeking heroin users are not well understood. It is unclear whether this group can avoid impaired control or negative sequelae commonly observed in treatment-seeking populations. During 2000 and 2001, we recruited 69 non-treatment-seeking heroin users with no treatment history. Heroin use, management strategies, treatment attitudes, and risk behaviors were assessed; the DSM-IV checklist and severity of dependence scale were completed. Study limitations and implications for heroin use and its treatment are discussed.

Does taking steps to control one's drug use predict entry into treatment?

BACKGROUND

Treatment readiness has been shown to predict entry and success in drug treatment programs.

OBJECTIVE

To examine the association between treatment readiness (defined as engaging in activities to control one's drug use) and enrolling in drug treatment.

METHODS

Longitudinal data collected through face-to-face interviews (March 2004-February 2007, NIDA-funded) from 585 injectors in Baltimore were analyzed.

RESULTS

Avoiding buying drugs and drug-related people and places were associated with entering treatment at follow-up. Also, the more activities one engaged in, the greater likelihood of entering drug treatment.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

These findings suggest that practicing behaviors to control one's drug use may be a beneficial strategy for getting ready for treatment.

Becoming an ex-user: insights into the process and implications for treatment and policy

Studies of the processes by which people give up dependent heroin use are useful in helping services evaluate their treatment practices and in informing drug policy debates. In this exploratory investigation, a diverse group of 18 Canberra-based ex-users was interviewed about stopping, the role of treatment and their views on a proposal to make heroin available in a controlled manner as a new treatment option. Factors involved in stopping dependent heroin use included 'hitting rock bottom' or a less intense crisis such as the death by overdose of someone close, falling in love, wanting to be a good parent, geographical relocation, wanting to avoid becoming caught up with the police or going to jail, maturing out or becoming sick of the lifestyle, finding a new purpose in life or developing a new lifestyle, dealing with past hurts and the support of family, friends, other ex-users and professionals. Many respondents had been in methadone treatments and in therapeutic communities and their advantages and disadvantages in stopping use are discussed. The respondents were evenly divided in their support for the controlled availability of heroin and the potential benefits and problems of such treatment are also discussed.

Abstinence and acceptance? The problematic relationship between the German abstinence paradigm, low-threshold oriented drug work, and methadone

It is hardly surprising that, compared to international standards, the Federal Republic of Germany holds an exceptional position in the area of drug policy. For decades, the majority of so-called 'drug experts' in Germany have deliberately ignored the findings of international research and, often despite their better knowledge, pursued a policy of misinformation which has remained unaffected by international research findings and standards of practice. This policy is essentially characterised by a rigid adherence to the abstinence paradigm.

The effectiveness of a mutual-help group activity for drug users and family members in Japan

AIMS

To understand the efficacy of a mutual-help group activity for drug users and family members in terms of: (a) family members' behavioral changes (b) treatment engagement rate of the drug users, and (c) life satisfaction of family members.

METHODS

A total of 186 family members answered questionnaires.

RESULTS

Attending the group changed the family members' behaviors. The treatment engagement rates within 1, 6, and 12 months for untreated drug users were 23.2%, 39.2%, and 52.3%, respectively. The well-being (Subjective Well-Being Inventory [SUBI]) of long-term group members is higher than that of short-term group members.

Is Ricoeur's Notion of Narrative Identity Useful in Understanding Recovery in Drug Addicts?

From Ricoeur's narrative theory, we argue that drug addicts may particularly need the help of literature, in a broad sense- fiction, history, and also specialized literature on addiction-to make their lives intelligible, to construct their identities, and to be able to change. Their need for this popular and professional literature concerns the numerous theories in the field of addiction. This literature is encountered indirectly by patients via interaction with professionals. It reflects attempts on the part of practitioners to find turning points in their patients' life stories, as in the mimesis circle described by Ricoeur. Our hypothesis is therefore explored in the light of certain sociological and psychiatric models that plot patients' lives, especially in the recovery period. The risks of a noncritical appropriation of this literature are discussed. Indeed, patients may hesitate between several identification models, loss of identity, and identity withdrawal.

Factors influencing the course of opiate addiction

AIMS

To describe important non-biological factors which influence the course of opiate addiction.

METHOD

Studies were reviewed that present empirical results on the long-term course of opiate addiction, progress of opiate addicts during and after treatment, variables that predict remission and abstinence, comparisons of treated and untreated samples, and recovery from opiate addiction without formal help.

RESULTS

Opiate addiction is a chronic disorder with high mortality risk. The course of opiate addiction often consists of recurring sequences of addictive opiate use and abstinence. Treatment for opiate addiction, especially maintenance treatment, reduces opiate use; however, it is unclear how long after treatment the effects last. In treated samples, long-term opiate use can be moderately predicted from psychosocial factors, such as peer-group relationships, family problems, employment, and social support. Little is known about addicts who do not participate in treatment or who recover without treatment. Common factors that both treated and untreated addicts view as most important to their success are the social environment and their social life and daily activities.

CONCLUSIONS

In view of the chronic course of opiate addiction and the phenomenon of spontaneous recovery without treatment, the role of drug-abuse treatment as an influencing factor would seem to require further clarification. Current treatment programmes may leave unaddressed important factors that contribute to the recovery of drug addicts.

Addiction recovery: Its definition and conceptual boundaries

The addiction field's failure to achieve consensus on a definition of "recovery" from severe and persistent alcohol and other drug problems undermines clinical research, compromises clinical practice, and muddles the field's communications to service constituents, allied service professionals, the public, and policymakers. This essay discusses 10 questions critical to the achievement of such a definition and offers a working definition of recovery that attempts to meet the criteria of precision, inclusiveness, exclusiveness, measurability, acceptability, and simplicity. The key questions explore who has professional and cultural authority to define recovery, the defining ingredients of recovery, the boundaries (scope and depth) of recovery, and temporal benchmarks of recovery (when recovery begins and ends). The process of defining recovery touches on some of the most controversial issues within the addictions field.

Migrating identities: the relational constitution of drug use and addiction

This paper aims to develop a properly social conceptualisation of addiction through drawing on analyses of rich, in-depth data from ex/users of heroin. Practices of addiction are considered as in and of themselves constitutive of particular identities, ways of being, and ways of being with and for others. The discussion seeks to demonstrate how heroin use is predicated upon, and productive of, purposeful drug-using relationships in which users produce and reproduce the conditions for continued use (e.g. scoring, grafting, using). Accordingly, the concept of 'dependence' is here reconfigured to encompass both dependence on the provision (and ingestion) of drugs and, simultaneously, dependence upon diverse configurations of users, clinicians, support workers, and so on. The paper makes a critical departure from existing debates in which addiction, even if conceived as a social practice, is nonetheless understood at the level of 'the individual'. It is argued that this tendency towards ontological individualism leads towards conceiving the problem of addiction as residing predominantly in the individual negotiation and, ultimately, resolution of identity narratives. The analyses presented here explore how the migration from addict to non-addict involves more than identity work. Theorisations of the level of 'field' or 'configuration' are developed, and considered as both a level of analysis and a conceptual lens for understanding changes in the ongoing, relational, practices involved in such identity migration. Finally, the consequences of intersecting, relational, dimensions of time horizons, place and space in the talk of ex/users are considered for strategies for successful recovery, identified during the research.

Investigating how decisions to use marijuana change over time

This article examines illicit drug use from a decision-making perspective using data collected during 2000-2002 from 51 current and ex-users of marijuana in a large urban city in the central/southwest United States. A qualitative inductive approach based on grounded theory guided the analyses. We find that prior to experimentation and use, decision-making processes are general and nonspecific. In the later stages of drug involvement, decision-making processes become drug-specific. Individuals consider a number of different types of factors when making decisions about illicit drug use involvement. The study's implications and limitations are discussed and future research suggested.