Attrition prevention with individuals awaiting publicly funded drug treatment.

AIMS: To evaluate the effectiveness of a motivational intervention to reduce attrition from a waiting list for substance abusers seeking publicly funded treatment. DESIGN: Randomized clinical trial comparing an "attrition prevention" condition to standard care while awaiting treatment admission. SETTING: A centralized substance abuse assessment and referral center in Seattle, Washington. PARTICIPANTS: Substance abusers (n = 654) eligible for publicly funded drug abuse treatment. MEASUREMENTS: Alcohol and drug use, substance-related negative consequences, areas in need of help, perceived need for help, emotional status, readiness to change, reasons for seeking and perceived barriers to entering treatment. FINDINGS: Overall, approximately 70% of clients entered treatment, and of these approximately 70% completed their assigned treatment. Those who entered treatment showed significant reductions in substance use and improved psychosocial function at a short-term 3-month follow-up. However, the attrition prevention intervention had no differential effect on treatment entry, completion or outcome compared to the standard waiting list. Further, there were no differences across therapists on these outcome measures. CONCLUSIONS: A motivational attrition prevention intervention did not enhance treatment entry, completion or outcome among treatment-seeking substance abusers. It is suggested that alternative strategies, such as contingency management and case management, may help facilitate treatment entry for individuals seeking publicly funded treatment.

Sources of motivation for abstinence: a replication analysis of the reasons for quitting questionnaire.

The Reasons for Quitting Questionnaire (RFQ) as modified by McBride and colleagues (C. M. McBride et al., 1994) for use with substance users other than tobacco smokers, was administered to individuals approved for public-sector addiction treatment. Four motivation dimensions, similar to those found by McBride et al., were identified: self-concept issues, health concerns, legal issues, and social influence. A forced two-component solution yielded dimensions interpretable as intrinsic and extrinsic motivation. Self-concept issues provided the highest levels of motivation for abstinence in this sample, with moderate levels provided by health concerns, and the lowest levels provided by legal and social influence components. Intrinsic motivation was higher than extrinsic motivation. Logistic regression models, with adjustment for total motivation, tested the association of successful abstinence during a follow-up period with baseline extrinsic and intrinsic motivation, and with the difference between intrinsic and extrinsic levels. All three associations were significant: intrinsic motivation (positive association), extrinsic motivation (negative association), and the difference score (positive association). The results suggest the usefulness of the 20-item modified RFQ in evaluating motivation for abstinence among treatment seekers exhibiting severe negative consequences of addiction. Testing with samples varying in severity of addiction consequences is recommended.

Relationship between follow-up rates and treatment outcomes in substance abuse research: more is better but when is "enough" enough?

AIMS: To examine the effects of different follow-up rates on estimates of treatment outcome and predictive models thereof, and to specify participant characteristics associated with tracking difficulty. DESIGN: An observational study using data collected for a randomized, experimental design. SETTING: The King County Assessment Center in Seattle, Washington, an organization responsible for referral to publicly funded substance abuse treatment. PARTICIPANTS: Substance-addicted individuals referred to publicly funded inpatient or outpatient treatment. MEASUREMENTS: Standardized self-report instruments measuring substance use, substance use consequences and general functioning. Chart review was used to measure treatment entry and completion. FINDINGS: There was a significant association between follow-up difficulty and outcomes related to addiction treatment and later substance use. However, outcome estimates based on 60% of the sample who were easiest to locate were only minimally different from those based on the 90-100% ultimately captured, and predictive models of outcome based on the 60% group were reasonably similar to those based on the final sample. Of baseline characteristics examined, only age was associated with later tracking difficulty. CONCLUSIONS: Studies reporting follow-up rates below 70% may produce valid findings and study attrition may be largely unpredictable from participant characteristics at baseline. However, a number of factors such as type of population studied, geographical location of the sample, reasons for loss to follow-up and sample size must be considered when attempting to generalize the findings of this study.

To thine own self be true: self-concept and motivation for abstinence among substance abusers.

Individuals approved for public-sector addiction treatment were interviewed regarding their reasons for attempting abstinence. Follow-up interviews were completed 3 to 6 months after participants' removal from county-controlled treatment wait-lists. Rates of continuous self-reported abstinence for 90 days preceding follow-up were positively associated with motivation linked to discrepancies between substance use and self-standards. Characteristics associated with high identity-linked motivation were cocaine preference, a history of reducing self-dissatisfaction through substance use, low rewards and high costs associated with using. and low support for the user identity among significant others. The perception of discrepancies between substance use and self-standards was an effective motivator of abstinence even among those who reported previous use of substances to dampen self-dissatisfaction.

"I already stopped": abstinence prior to treatment.

AIMS: To determine pre-treatment abstinence rates among treatment seekers and identify factors associated with pre-treatment abstinence. To evaluate the association between pre-treatment abstinence and subsequent outcome. DESIGN: An observational study using data collected for a randomized, experimental design. SETTING: Conducted with participants immediately after assessment for publicly funded substance abuse treatment at the King County Assessment Center (KCAC) in Seattle. PARTICIPANTS: People referred for outpatient or inpatient treatment by KCAC who had illicit drug use in the previous 90 days (N = 565). Participants waited a median of 12 days (range = 0-108 days) until either treatment entry or waiting-list dropout. MEASUREMENTS: A modified Drug History Questionnaire quantified drug use at baseline, treatment entry or waiting-list dropout and 3 months later. Other measurement methods: Stages of Change Readiness and Treatment Eagerness Scale, participant confidence ratings and KCAC chart review. FINDINGS: Sample-wide, 45% of participants reported abstinence from initial assessment to when they entered or failed to enter treatment. Higher rates of abstinence were associated with shorter waiting periods, less substance use prior to initial assessment and higher scores on change readiness. Pre-treatment abstinence was not associated with either treatment entry or completion. There was a non-significant trend towards less improvement in substance use with pre-treatment abstinence, with the greatest effect observed for short waits. CONCLUSIONS: Participants can become abstinent prior to treatment, but this is not a good predictor of treatment entry, completion or outcome. A decisional balance strategy may be a more productive use of client and treatment program energy.