Streamlining admissions to outpatient substance use treatment using lean methods

The study investigated patient- and program-level variables associated with attrition from intensive outpatient (IOP) substance use treatment in a national VA sample. National databases were used to identify a recent cohort of veterans receiving intensive IOP substance use treatment. Attrition was defined as receiving less than five visits of IOP treatment. Patient-level variables examined included age, gender, race, and psychiatric and medical comorbidities. Program-level variables examined included the number of hours of treatment offered, the percentage of patients living on-campus, and extent of staff cuts in the past year. Twenty-seven percent of veterans left treatment early. Being older, female, and having a psychotic disorder was associated with attrition. Program-level factors associated with attrition were the number of hours the program offered treatment, in that more treatment offered was associated with higher attrition. Focus on individual and program level factors associated with attrition is crucial to retaining individuals in treatment.

Despite evidence showing that readiness to change substance use predicts reductions in substance use among treated adolescents, there is little research on changes in thoughts about abstinence and marijuana use during and after treatment. The current study tested whether time-varying changes in adolescents' motivation to abstain and perceived difficulty to abstain from marijuana use hinder the return of regular marijuana use during and after treatment. Monthly data on thoughts about abstinence, marijuana use, and treatment utilization were collected over 6 months from 142 adolescents recruited from intensive outpatient substance use treatment. Results indicated that higher motivation to abstain (but not perceived difficulty) predicted fewer days of marijuana use, over and above the individual's average trajectory of marijuana use, the initial severity of marijuana involvement, and the effects of treatment utilization. Moreover, past-month marijuana use influenced both motivation to abstain and perceived difficulty to abstain. Findings highlight the importance of abstinence-related cognitions as a target of intervention during and after treatment and underscore the importance of considering recovery from substance use disorders as a dynamic process of change over time.

Successful outcomes of outpatient substance use disorder treatment result from many factors for clients—including intersections between individual characteristics, choices made, and social determinants. However, prioritizing which of these and in what combination, to address and provide support for remains an open and complex question. Therefore, we ask: What factors are associated with outpatient substance use disorder clients remaining in treatment for > 90 days and successfully completing treatment? To answer this question, we apply a virtual twins machine learning (ML) model to de-identified data for a census of clients who received outpatient substance use disorder treatment services from 2018 to 2021 from one treatment program in the Southeast U.S. We find that primary predictors of outcome success are: (1) attending self-help groups while in treatment, and (2) setting goals for treatment. Secondary predictors are: (1) being linked to a primary care provider (PCP) during treatment, (2) being linked to supplemental nutrition assistance program (SNAP), and (3) attending 6 or more self-help group sessions during treatment. These findings can help treatment programs guide client choice making and help set priorities for social determinant support. Further, the ML method applied can explain intersections between individual and social predictors, as well as outcome heterogeneity associated with subgroup differences.

abstractStudies have shown that motivation to change is related to better substance use outcomes among treatment-seeking adolescents. Goal setting, which may be related to motivation, also has been shown to be associated with positive treatment outcomes. However, relationships between motivation and goal setting as mediators of change in cannabis use over time among treated youths have not been investigated. This study tested direct and indirect associations of motivation and goal setting with cannabis use frequency over 12-month follow-up among treated adolescents. A longitudinal study of 163 adolescents enrolled in intensive outpatient substance use treatment (mean age = 16.69, 34% female, 87% Caucasian) provided repeated assessment of motivation, goal setting, and cannabis use. Path analysis tested direct and indirect effects of motivation and goal setting on cannabis use. A comparison of two path models that tested motivation and goal setting independently showed that goal setting had better model fit and accounted for more of the variance in six-month (R2 = .35) and 12-month (R2 = .46) cannabis use frequency than motivation (R2 = .28, .44, respectively). When both mediators were included in the same model, better model fit was found for motivation preceding goal setting in the context of double mediation. Overall, results suggest that goal setting, or the combination of motivation preceding goal setting in a double mediation model, predicted lower cannabis use in treated adolescents.

A pilot study comparing in-person and remote outpatient substance use treatment services on quality-of-life outcomes

Post–residential treatment outpatient care preferences: Perspectives of youth with opioid use disorder

Racial and Ethnic Disparities in Outpatient Substance Use Disorder Treatment Episode Completion for Different Substances

IntroductionBuprenorphine benefits patients with opioid use disorder (OUD) in the emergency department (ED), but its efficacy for OUD patients with suicidal ideation (SI) in the ED is unknown.Case SeriesWe present a case series of 14 OUD patients with SI who were given buprenorphine and a referral to outpatient substance use treatment in the ED. All experienced SI resolution, engaged with outpatient services, and remained in outpatient substance use treatment 30 days after ED discharge.ConclusionOur data provide evidence for the feasibility of starting buprenorphine in OUD patients with SI in the ED, and suggest that buprenorphine may be useful in helping to resolve SI for these patients. Future research with larger samples is needed.

How long does it take to complete outpatient substance use disorder treatment? Disparities among Blacks, Hispanics, and Whites in the US

To evaluate the impact of concurrent treatments for substance use disorder and nicotine-dependence for stimulant-dependent patients. A randomized, 10-week trial with follow-up at 3 and 6 months after smoking quit date conducted at 12 substance use disorder treatment programs between February 2010 and July 2012. Adults meeting DSM-IV-TR criteria for cocaine and/or methamphetamine dependence and interested in quitting smoking were randomized to treatment as usual (n = 271) or treatment as usual with smoking-cessation treatment (n = 267). All participants received treatment as usual for substance use disorder treatment. Participants assigned to treatment as usual with concurrent smoking-cessation treatment received weekly individual smoking cessation counseling and extended-release bupropion (300 mg/d) during weeks 1-10. During post-quit treatment (weeks 4-10), participants assigned to treatment as usual with smoking-cessation treatment received a nicotine inhaler and contingency management for smoking abstinence. Weekly proportion of stimulant-abstinent participants during the treatment phase, as assessed by urine drug screens and self-report, was the primary outcome. Secondary measures included other substance/nicotine use outcomes and treatment attendance. There were no significant treatment effects on stimulant-use outcomes, as measured by the primary outcome and stimulant-free days, on drug-abstinence, or on attendance. Participants assigned to treatment as usual with smoking-cessation treatment, relative to those assigned to treatment as usual, had significantly better outcomes for drug-free days at 6-month follow-up (χ(2)(1) = 4.09, P <.05), with a decrease in drug-free days from baseline of -1.3% in treatment as usual with smoking-cessation treatment and of -7.6% in treatment as usual. Participants receiving treatment as usual with smoking-cessation treatment, relative to those receiving treatment as usual, had significantly better outcomes on smoking point-prevalence abstinence (25.5% vs 2.2%; χ(2)(1) = 44.69, P < .001; OR =18.2). These results suggest that providing smoking-cessation treatment to illicit stimulant-dependent patients in outpatient substance use disorder treatment will not worsen, and may enhance, abstinence from nonnicotine substance use. ClinicalTrials.gov identifier: NCT01077024.

BackgroundRates of substance use disorders (SUDs) continue to rise in the USA with parallel rises in admissions to outpatient SUD treatment programs. Insomnia symptoms reduce treatment adherence, trigger relapse, and generally undermine SUD recovery efforts. Cognitive-behavioral therapy for insomnia (CBT-I) is the first-line treatment recommended for chronic insomnia. No study has examined the effectiveness of CBT-I for individuals who recently entered an outpatient SUD treatment program embedded within a therapeutic community (i.e., long-term drug-free residential setting).MethodsA randomized controlled trial conducted at a SUD program embedded in a therapeutic community aimed to compare group-based CBT-I (gCBT-I) (N = 10) with the standard of care (SOC) (N = 11) among individuals who have SUDs and comorbid insomnia. We present a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework evaluation to provide empirical data on gCBT-I feasibility and facilitators and barriers of conducting an insomnia-focused clinical effectiveness study within a therapeutic community.ResultsParticipants in both study arms reported moderately severe insomnia symptoms at admission and reductions in insomnia symptoms over time. Among participants who completed the Insomnia Severity Index (ISI) beyond admission, ISI decreased to ≤ 8 (the clinical cutoff for mild insomnia) in 80% of individuals in the gCBT-I group compared with 25% of individuals in the SOC group. A RE-AIM framework evaluation showed initial success with Reach and Adoption while Implementation, and Maintenance were limited. Effectiveness was inconclusive because of challenges with recruitment, intervention integrity, and missing data that precluded meeting the planned recruitment and study aims and led to study termination. Coordination and communication with staff and leadership facilitated gCBT-I implementation, yet well-known CBT-I barriers including time- and resource-intensive sleep medicine training for interventionalists and maintenance of treatment integrity during an 8-week intervention limited gCBT-I sustainability.ConclusionsThis analysis supports the feasibility of conducting behavioral sleep medicine research in outpatient SUD treatment programs embedded within therapeutic communities. Implementation of an insomnia-focused intervention was widely accepted by patients and providers and has potential to address insomnia symptoms in early SUD recovery. Addressing patient- and organizational-level implementation barriers may enhance the sustainability and scalability of sleep interventions and provide new hope to effectively treat insomnia among people living with SUDs.Trial registrationClinicaltrials.gov: NCT03208855. Registered July 6, 2017https://clinicaltrials.gov/ct2/show/NCT03208855?term=NCT03208855&draw=2&rank=1

At the American Association for the Treatment of Opioid Dependence (AATOD) meeting in Las Vegas last week, Allegra Schorr, M.S., delegate to the AATOD borad from New York, presented highlights from key initiatives for her state. Schorr is President of the Coalition of Medication Assisted Treatment Providers and Advocates (COMPA) and owner and vice president of West Midtown Medical Group, and opioid treatment program (OTP), outpatient substance use disorder treatment program, and primary care provider.

This study examined interest in computerized psychotherapies (CPTs) and its relation to use of information technology among individuals receiving Veterans Health Administration (VHA) outpatient treatment. Veterans receiving treatment in a VHA substance use disorder outpatient clinic completed a self-report questionnaire. The survey addressed recent experience using information technology and potential interest in using CPTs for symptoms/functional problems associated with substance use and mental health disorders. Demographic, diagnostic, and information technology use data were compared between those expressing interest in CPT and those not expressing an interest, as well as with nationally representative veteran data from the 2010 National Survey of Veterans (NSV). Of 151 respondents, 82% were interested in CPT for at least one problem, and 60% were interested for more than one. The most commonly selected CPTs were for substance use (46%), depression (45%), problem solving (43%), and insomnia (42%). None of the 23 measures of information technology use was associated with interest in CPTs. Compared with respondents not interested in any CPTs, those interested in CPT were older (t150=2.1, p=0.042) and more likely to be African American [χ(2)(1)=8.8, p=0.032], to have reported a drug use disorder [χ(2)(1)=4.2, p=0.041], and to have reported more than one substance use or psychiatric disorder [χ(2)(1)=8.5, p=0.014]. The majority of respondents reported use of Internet and e-mail (65% and 64%, respectively), proportions comparable to respondents to the NSV. Among veterans receiving outpatient substance use treatment, interest in CPT is high and unrelated to information technology use. Efforts to implement CPTs may interest this population.

BackgroundAppointment no-show and early dropout from treatment represent major challenges in outpatient substance use disorder treatment, adversely affecting clinical outcomes and health care productivity. In this quasi-experimental study, we examined how a brief reminder intervention for new patients before their first appointment affected treatment participation and retention. No-shows (not attending any sessions) and dropouts (discontinuation of initiated treatment because of three consecutively missed appointments) were compared between a period with pre-admission telephone calls (intervention) and a period without such reminders (non-intervention).MethodsParticipants were all eligible patients (N = 262) admitted to a Norwegian specialist clinic for substance use disorder treatment. We used the Chi-square test for the no-show analysis. Of the eligible patients, 147 were included in a subsequent dropout analysis. We used the number of visits up to 10 appointments as a measure for time to event. Group differences were analyzed using a Kaplan–Meier plot and the log-rank test. To control for relevant sociodemographic variables, as well as substance use and mental distress severity, we used Cox regression.ResultsNo-show rates did not differ between the two periods (12% for non-intervention vs. 14% for intervention; χ2 = 0.20, p = 0.653). Of those consenting to participate in the dropout analysis (n = 147), 28 (19%) discontinued treatment within the time frame of 10 appointments, with no differences between the two periods (log-rank test = 0.328, p = 0.567). Controlling for baseline characteristics did not alter this finding. In fact, of the registered covariates at baseline, only higher education level was associated with attrition, linked to a reduced risk for dropout (hazard ratio = 0.85, 95% CI = 0.74–0.98, p = 0.025).ConclusionThese findings do not provide support for the systematic use of a brief pre-admission telephone reminder in the current treatment setting.Trial registrationThe study was retrospectively registered 13 Jan 2021 at ClinicalTrials.gov, NCT04707599.

The present study assessed possible predictors of relapse while in treatment and treatment completion among marijuana-dependent adolescents (N = 59) in an intensive outpatient substance abuse treatment program. Comorbid depression was associated with an increased likelihood of relapse and a higher total number of relapses. As expected, relapse while in treatment was associated with a reduced likelihood of successfully completing the treatment program. Comorbid attention deficit hyperactivity disorder (ADHD) was also associated with a lower likelihood of successful program completion. These findings add to a slowly growing literature regarding adolescent substance abuse treatment, and may help clinicians identify marijuana-dependent adolescents at greater risk of relapse or noncompliance.