Research roundup: Substance use

This month's roundup presents recent research and practical considerations related to substance use

By Practice Research and Policy Staff

September 15, 2011 — Based on a number of recent epidemiological studies, it is estimated that more than 50 percent of individuals with a severe mental disorder may also have problems with substance use. Without proper screening, it is difficult to recognize when a person with a mental disorder also has a substance use disorder. Thus, substance use disorders frequently go unrecognized and untreated. Psychologists have the skills to provide comprehensive, integrated treatment that can enable stabilization and recovery for those with a dual diagnosis.

Brown, C. H., Bennett, M. E., Li, L., & Bellack, A. S. (2011). Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders. Addictive Behaviors, 36(5), 439-447.

Summary

Limited research has assessed the predictors of treatment initiation and subsequent engagement in treatment among individuals with co-occurring serious mental illness (SMI) and substance use disorders (SUDs). This study analyzed data from a randomized trial of a behavioral intervention for people with co-occurring SUD and SMI in order to identify these predictors. Two hundred and fifty one (N=251) participants met all the screening criteria and consented to participate. Treatment initiation was defined as completing the pre-treatment intake assessment phase consisting of two 2.5 hour visits about a week apart and prediction variables for initiating treatment consisted of demographic, mental health diagnosis and substance use information collected during eligibility screening. Treatment engagement was defined as attending at least three treatment sessions and treatment engagement prediction variables included the prediction variables for treatment initiation, as well as psychiatric, family/social, substance abuse, legal trouble, and motivation to change characteristics assessed in the intake assessment. Males and those suffering from a schizophrenia spectrum diagnosis were less likely to initiate treatment and individuals with current drug dependence (versus recent drug dependence) and a recent arrest were associated with a decreased likelihood to engage in treatment. Positive feelings about family relationships were related to greater odds of engaging in treatment.

Practical Considerations

In order for an individual with dual SMI and SUDs to receive stable and effective care, he or she must first initiate and engage in substance abuse treatment. It is important to note that the variables identified as significant predictors of non-engagement were not associated with the SMI diagnosis. (Variables associated with the SMI diagnosis include negative symptoms, positive symptoms, past hospitalization and living independently.) These findings raise the possibility that substance abusers with SMI may be similar to other groups of substance abusers in terms of the factors that promote or inhibit engagement in substance abuse treatment. Incentives such as assistance with legal problems or housing and homelessness may increase the likelihood that these individuals, in particular males with schizophrenia, initiate and engage in substance abuse treatment. In addition, connecting to supportive family members at the start of treatment may help individuals with SMI engage in substance abuse treatment.

Khoury, L.; Tang, Y., Bradley, B., Cubells, J., Ressler, K. (2010.) Substance use, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. Depression and Anxiety, 27(12), 1077-1086.

Summary

This study assessed a sample of 587 primary care patients, predominantly African American, to examine the relationships among childhood trauma, adult trauma, substance use and Post-traumatic Stress Disorder (PTSD) symptoms. Participants completed a battery of self-report assessments and follow-up interviews to measure PTSD symptoms, lifetime and childhood trauma, substance use and depression. The use of alcohol, cocaine and marijuana significantly increased for participants reporting childhood trauma across all types of abuse. More specifically, physical abuse was positively correlated with substance use among all participants and all substances. Childhood sexual abuse, on the other hand, correlated with the use of cocaine and marijuana among women only. Positive associations were found among PTSD symptoms, cocaine and childhood trauma. While childhood trauma correlated with increased alcohol and marijuana use regardless of the presence of adult trauma, childhood trauma did not correlate with cocaine use after controlling for adult trauma. Childhood trauma also influenced the severity of PTSD symptoms independent of adult trauma.

Practical Considerations

Current substance users, especially cocaine users, have a higher likelihood of histories of childhood physical, sexual and emotional abuse that may result in the presentation of PTSD symptoms. Careful assessment of individuals who appear to be at higher risk for having experienced childhood trauma may more quickly uncover problematic interrelationships, resulting in more comprehensive and appropriate treatment. Additionally, because women report a higher rate of childhood sexual abuse, which is then linked to cocaine and marijuana use, psychologists may want to routinely include substance use assessment and histories when evaluating women who have reported childhood sexual abuse.

Lash, S., Timko, C., Curran, G., McKay, J., Burden, J. (2011.) Implementation of evidence-based substance use disorder continuing care interventions. Psychology of Addictive Behaviors, 25(2), 238-251.

Summary

The authors conducted a literature review to better understand whether and why evidence-based interventions (EBIs) are used in continuing care for substance use disorder (SUD) treatment. Factors correlated with successful recovery were also reported. Research revealed that both treatment-based and mutual-help group-based (MHG) continuing care positively correlate with improved treatment outcome. Clients are most successful when continuing care lasts a minimum of 12 months, is accessible and the intervention is matched specifically to meet client needs and current levels of functioning. African-Americans, women and clients with more severe SUDs are more likely to engage and remain in continuing care. Those clients with resources for recovery, spiritual beliefs and little or no experience with 12-step groups also were more likely to engage in continuing care. Accessibility, convenience, and affordability are strong factors in a client’s decision to seek further care. Strong therapeutic alliances, support and spirituality are highlighted as key factors for client success in MHGs. A clinician’s limited knowledge of the effectiveness of interventions and which EBI options are available can be a major barrier for continuing care. Clinicians better facilitate 12-step MHG involvement if they are less concerned about spirituality in treatment, hold no allegiance to a specific 12-step approach and require abstinence during treatment.

Practical Considerations

Further research is needed to develop substance abuse EBIs and understand what best facilitates client success in continuing care treatment. Understanding the factors that are correlated with engaging in care and those that are barriers to care will enable clinicians to tailor care more appropriately for the individual. Clinicians may be able to make changes within their practices that better facilitate client success and long-term substance use recovery.

Laudet, A. B., & Stanick, V. (2010).  Predictors of motivation for abstinence at the end of outpatient substance abuse treatment. Journal of Substance Abuse Treatment, 38(4), 317-327.

Summary

Based on a sample of 250 inner-city polysubstance users, this study endeavored to identify predictors of motivation to remain abstinent at end of treatment (EOT). In a previous assessment of this sample, EOT commitment to abstinence significantly enhanced the odds of sustained abstinence over the subsequent year. Using a number of standardized instruments administered at the EOT, the authors found that four domains contributed over 25 percent of the variance in the outcome and, when combined with demographic variables, a total of 49.6 percent of the variance in outcome was explained. Perceived harm of future drug use, abstinence self-efficacy, quality of life (QOL) satisfaction and the number of 12-step members in one's social network were among the four major predictors of motivation.

Practical Consideration

Sustained abstinence is frequently a goal of substance use disorder treatment. Strategies such as motivational interviewing that effectively promote behavior change can be used to solidify a goal of abstinence. In terms of increasing abstinence self-efficacy, clinicians can build on clients' success in resisting temptations to use drugs and on success in other challenging situations. This should enable clients to further develop confidence in their ability to make healthy decisions. The finding that QOL satisfaction contributes to commitment to abstinence emphasizes the importance of addressing clients' needs in areas other than substance use, for example education, employment and housing. Furthermore, as social support from non-using peers becomes known as a key factor in substance abuse recovery, clients should be encouraged to build a support network consisting of those with similar goals of abstinence, as well as those with no substance use.


Puleo, C. M., Conner, B. T., Benjamin, C. L., & Kendall, P. C. (2011).  CBT for childhood anxiety and substance use at 7.4-year follow-up: A reassessment controlling for known predictors. Journal of Anxiety Disorders, 25(5), 690-696.

Summary

Many children experience childhood anxiety and evidence suggests that these childhood anxiety disorders frequently precede substance use disorders (SUDs) in adulthood. According to a 7.4 year randomized control study assessing the enduring effects of cognitive behavioral therapy (CBT) for childhood anxiety disorders on future substance use, children who successfully responded to treatment had reduced substance use and fewer associated problems during follow up compared to children who did not successfully respond to treatment. The present study sought to examine whether other predictors of SUDs and CBT outcomes, not controlled for in the original 7.4 year study, would account for the differences in outcomes among responders and non-responders. The predictors were extracted from previously administered batteries during the initial study and included comorbid ADHD pathology, perceived negative life events, family history of substance abuse, older child age, additional treatment and severity of internalizing pathology. Despite the significant contributions of these predictors on later drug-use related problems, successful responders to treatment still drank fewer days per month and were less likely to experience aversive interpersonal consequences of their drug use 7.4 years after treatment than participants who retained their principal diagnosis. Of all previously reported associations, only the relationship between unsuccessful treatment and the physical/psychological consequences of drug use were no longer significant.

Practical Considerations

Reducing substance related problems in adolescence and young adulthood by successfully treating child anxiety is another benefit of appropriate care. Informing parents and other care deciders of the multiple potential benefits of care may increase engagement and retention in treatment for childhood anxiety problems. Successful CBT may preclude the use of unhealthy anxiety-management techniques, such as substance use, by providing anxious individuals with alternative adaptive coping skills. Prevention of later substance use problems can occur despite other potential risk factors and targeting non-responders to treatment may lead to the prevention of future, and possibly more detrimental, disorders.

Special thanks to Daniel Kivlahan, PhD, Director of The Center of Excellence in Substance Abuse Treatment and Education, who assisted on this article.