Attrition from treatment for substance abuse disorders (SUD) is a persistent challenge that severely limits the effectiveness of services. Though a large body of research has sought to identify predictors of retention, the perspective of clients of services is rarely examined. This exploratory qualitative study presents clients’ stated reasons for leaving outpatient treatment (N = 135, 54% of the sample of 250) and their views of what could have been done differently to keep them engaged in services. Obstacles to retention fell into program- and individual-level factors; the former includes dissatisfaction with the program, especially counselors, unmet social services needs, and lack of flexibility in scheduling; individual-level barriers to retention were low problem recognition and substance use. Study limitations are noted and the implications of findings for research and practice are discussed, emphasizing the need to understand and address clients’ needs and expectations starting at intake to maximize treatment retention and the likelihood of positive outcomes.

Commitment to abstinence, a motivational construct, is a strong predictor of reductions in drug and alcohol use. Level of commitment to abstinence at treatment end predicts sustained abstinence, a requirement for recovery. This study sought to identify predictors of commitment to abstinence at treatment end to guide clinical practice and to inform the conceptualization of motivational constructs. Polysubstance users (N = 250) recruited at the start of outpatient treatment were re-interviewed at the end of services. Based on the extant literature, potential predictors were during treatment measures of substance use and related cognitions, psychological functioning, recovery supports, stress, quality of life satisfaction, and treatment experiences. In multivariate analyses, perceived harm of future drug use, abstinence self-efficacy, quality of life satisfaction, and number of network members in 12-step recovery contributed 26.6% of the variance explained in the dependent variable, a total of 49.6% when combined with the control variables (demographics and baseline level of the outcome). Gender subgroup analyses yielded largely similar results. Clinical implications of findings for maximizing commitment to abstinence when clients leave treatment are discussed as are future research directions.

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Rates of return to active substance use after addiction treatment tend to be high; participation in 12-step fellowships (e.g., Alcoholics Anonymous) reduces relapse rates but many clients do not attend or attend for a short period only. This quasi-experimental study uses repeated measurement to explore the role of presence/absence of onsite 12-step meetings during treatment on post-treatment outcomes. Polysubstance-dependent clients (N = 219) recruited at a program with and one without 12-step onsite, were followed for one year post-treatment. Onsite 12-step enhanced 12-step attendance, especially during treatment, and predicted continuous abstinence for the post treatment year. Holding 12-step meetings onsite is a low-cost strategy that programs should consider to foster post-treatment remission maintenance. Keywords 12-step; treatment; recovery; self-helpSubstance use disorders (SUD) are conceptualized as chronic (e.g., McLellan, Lewis, O'Brien, C., and Kleber, 2000); the chronicity of SUD is empirically supported by findings on addiction and treatment 'career' indicating that most SUD-affected individuals, especially those with severe dependence, make multiple attempts at remission often involving several treatment episodes prior to resolving their alcohol or drug dependence (e.g., Dennis, Scott, Funk, and Foss, 2005;Hser, Anglin, Grella, Longshore and Prendergast, 1997; Laudet, Stanick, Carway, and Sands, 2004). Because of the multiple costs of long chronic addiction 'careers' that include the acquisition/transmission of infectious diseases (e.g., HIV, HepC), deterioration in mental and physical health and other functioning impairments (e.g., Smith and Larson, 2003), it is critical to identify strategies that contribute to sustaining remission, thus shortening addition careers and resulting nefarious effects to the individual and to society. A number of therapeutic modalities have proven effective at addressing drug and alcohol dependence and improving related functioning but treatment gains are often short lived (Hser, Grella, Hsieh and Anglin, 1999). Participation in post-treatment 'stepped down' continuing (or after) care is associated with sustained treatment gains (McKay, Alterman, Cacciola, Rutherford and O'Brien, 1997;Mckay 2001). In the currently austere fiscal context of health services provision, few drug and alcohol treatment programs offer continuing care, NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript especially following outpatient treatment, the most prevalent treatment modality in the US. Twelve-step fellowships such as Alcoholics and Narcotics Anonymous are the most frequently used form of aftercare in the United States (Tonigan, Toscova, and Miller, 1996). Twelve-step fellowships are particularly well-suited to provide ongoing recovery support from chronic substance abuse and dependence because, unlike formal services that are limited in time, these groups are widely and consistently available throughout the US and free of charge. As with treatment, 12-st...

Background and Objectives Moderators of treatment response to serotonin reuptake inhibitor sertraline (SRT) for cocaine dependence were assessed in two randomized, double blind, placebo-controlled clinical trials. Methods Generalized estimating equation modeling was performed on data from cocaine-dependent volunteers randomized to receive SRT or placebo (N=126) who completed ≥ 2-week drug-free residential portions of the 12-week trials, in which subsequent outpatient treatment (weeks 3–12) included weekly cognitive behavioral therapy and thrice-weekly supervised urine toxicology. Primary outcome measure: relapse (2 consecutive cocaine-positive or missing urines) following residential stay. Potential moderators included treatment, sex, age, race, depression measures, baseline cocaine urine result, and alcohol dependence diagnosis (ADDx). Results Odds ratios (OR) for relapse showed placebo-treated participants were significantly more likely to relapse than SRT participants. Regardless of treatment condition, participants more likely to relapse were male, and those with lower Hamilton depression ratings, or baseline cocaine-negative urines. Older subjects or those with current ADDx had higher relapse risk than those without ADDx; however, treating older or ADDx participants with SRT reduced cocaine relapse more than placebo. Discussion and Conclusions Women or those with more severe cocaine use or depressive symptoms may have fewer cocaine relapses regardless of medication treatment. SRT at 200 mg reduced cocaine relapse more than placebo, especially in older participants or in those with comorbid ADDx. Scientific Significance SRT may be efficacious to support relapse prevention among cocaine-dependent patients in the context of brief residential followed by outpatient treatment, especially in older participants or those with comorbid alcohol/cocaine dependence.