Delivery Outcomes Among Pregnant Women With Comorbid Psychiatric and Substance Use Disorders Receiving Comprehensive Treatment.

BACKGROUND: Pregnant women with substance use disorders (SUDs) are at risk for adverse delivery outcomes, and some of these women have psychiatric comorbidities that increase this risk. AIMS: Although comprehensive care models offering prenatal care services and substance abuse treatment have been found to positively affect delivery outcomes for pregnant women with SUDs, there is a dearth of research to support such models for women who have psychiatric comorbidities. METHODS: A secondary data analysis was conducted to understand the relationship between pretreatment psychiatric comorbidity and delivery outcomes for pregnant clients with SUDs receiving comprehensive treatment. We analyzed two groups of pregnant women with SUDs and hypothesized that women with psychiatric comorbidities would have worse neonatal and maternal outcomes compared with those who did not have any pretreatment psychiatric comorbidity. Regression models were used to examine changes in delivery outcome criteria (birthweight, neonatal abstinence syndrome, maternal urine toxicology screens at delivery, and hospital length of stay) in relation to psychiatric comorbidity among a sample of 74 mother-baby dyads receiving comprehensive care treatment. RESULTS: Results did not support our hypothesis as delivery outcomes were statistically similar for both groups. CONCLUSION: Findings suggest comprehensive care can reduce the risk of negative delivery outcomes among women with SUDs who have psychiatric comorbidities. Treatment and research implications are provided.

Maternal buprenorphine treatment and fetal neurobehavioral development.

BACKGROUND: Gestational opioid use/misuse is escalating in the United States; however, little is understood about the fetal effects of medications used to treat maternal opioid use disorders. OBJECTIVE: The purpose of this study was to determine the effect of maternal buprenorphine administration on longitudinal fetal neurobehavioral development. STUDY DESIGN: Forty-nine buprenorphine-maintained women who attended a substance use disorder treatment facility with generally uncomplicated pregnancies underwent fetal monitoring for 60 minutes at times of trough and peak maternal buprenorphine levels. Data were collected at 24, 28, 32, and 36 weeks gestation. Fetal neurobehavioral indicators (ie, heart rate, motor activity, and their integration [fetal movement-fetal heart rate coupling]) were collected via an actocardiograph, digitized and quantified. Longitudinal data analysis relied on hierarchic linear modeling. RESULTS: Fetal heart rate, heart rate variability, and heart rate accelerations were significantly reduced at peak vs trough maternal buprenorphine levels. Effects were significant either by or after 28 weeks gestation and tended to intensify with advancing gestation. Fetal motor activity and fetal movement-fetal heart rate coupling were depressed from peak to trough at 36 weeks gestation. Polysubstance exposure did not significantly affect fetal neurobehavioral parameters, with the exception that fetuses of heavier smokers moved significantly less than those of lighter smokers at 36 weeks gestation. By the end of gestation, higher maternal buprenorphine dose was related to depression of baseline fetal cardiac measures at trough. CONCLUSION: Maternal buprenorphine administration has acute suppressive effects on fetal heart rate and movement, and the magnitude of these effects increases as gestation progresses. Higher dose (≥13 mg) appears to exert greater depressive effects on measures of fetal heart rate and variability. These findings should be balanced against comparisons to gestational methadone effects, relatively good outcomes of buprenorphine-exposed infants, and recognition of the benefits of medication-assisted treatment for pregnant women with opioid use disorders in optimizing pregnancy outcomes.

A comparison of cigarette smoking profiles in opioid-dependent pregnant patients receiving methadone or buprenorphine.

INTRODUCTION: Little is known about the relationship between cigarette smoking and agonist treatment in opioid-dependent pregnant patients. The objective of this study is to examine the extent to which cigarette smoking profiles differentially changed during the course of pregnancy in opioid-dependent patients receiving either double-blind methadone or buprenorphine. Patients were participants in the international, randomized controlled Maternal Opioid Treatment: Human Experimental Research (MOTHER) study. METHODS: A sample of opioid-maintained pregnant patients (18-41 years old) with available smoking data who completed a multisite, double-blind, double-dummy, randomized controlled trial of methadone (n = 67) and buprenorphine (n = 57) between 2005 and 2008. Participants were compared on smoking variables based on opioid agonist treatment condition. RESULTS: Overall, 95% of the sample reported cigarette smoking at treatment entry. Participants in the two medication conditions were similar on pretreatment characteristics including smoking rates and daily cigarette amounts. Over the course of the pregnancy, no meaningful changes in cigarette smoking were observed for either medication condition. The fitted difference in change in adjusted cigarettes per day between the two conditions was small and nonsignificant (ß = -0.08, SE = 0.05, p = .132). CONCLUSIONS: Results support high rates of smoking with little change during pregnancy among opioid-dependent patients, regardless of the type of agonist medication received. These findings are consistent with evidence that suggests nicotine effects, and interactions may be similar for buprenorphine compared with methadone. The outcomes further highlight that aggressive efforts are needed to reduce/eliminate smoking in opioid-dependent pregnant women.

Lessons learned from a randomized trial of fixed and escalating contingency management schedules in opioid-dependent pregnant women.

BACKGROUND: Contingency management (CM) has shown promise for treating substance use disorders in pregnant women. METHODS: A randomized clinical trial compared the relative efficacy of three conditions on the measures of opioid and cocaine abstinence and days retained in treatment. A total of 133 pregnant patients attending treatment for substance use disorders were randomized either to an escalating reinforcement condition, a fixed reinforcement condition, or an attendance control condition. Conditions were compared on drug abstinence rates and days retained in treatment. RESULTS: As expected, the pooled escalating + fixed conditions received a greater total amount of voucher money than the control condition mean [M = 392.40 (SE = 40.47) vs. 219.74 (SE = 39.78)], respectively; p < .001. However, the escalating and fixed conditions did not differ on the outcome variables of drug abstinence and treatment retention. CONCLUSIONS: The CM conditions examined in the current study did not emerge as superior to the control condition. The lack of significant differences among study conditions may be attributed, in part, to study sample size. Additionally, methodological issues related to the CM intervention may also have compromised outcomes, including delay in reinforcement following the target behavior and limited contact with the reinforcer. SCIENTIFIC SIGNIFICANCE: This study highlights the importance of key CM implementation features, including immediate reinforcement, and adequate access to the reinforcer. It may also be that the reset feature for missing samples in CM interventions is an essential contingency for promoting behavior change.

The efficacy of escalating and fixed contingency management reinforcement on illicit drug use in opioid-dependent pregnant women.

OBJECTIVES: Contingency management (CM), long known to be efficacious in the treatment of substance-dependent men and women, has also been found to be efficacious for substance-dependent pregnant women. However, the specific CM reinforcement parameters in the special population of opioid-dependent pregnant women have been less fully and systematically studied. The Drug Abuse Incentive Systems (DAISY) study, a randomized controlled trial (RCT) of opioid-dependent pregnant patients, found that escalating reinforcement was not superior to a fixed reinforcement CM schedule after a 13-week intervention. To further examine CM's reinforcement parameters in this population, this study aims to test the hypothesis that there is an early treatment response showing an escalating reinforcement schedule to be significantly more efficacious than a fixed schedule after 5 weeks of intervention in opioid-dependent pregnant patients. METHODS: Nine measures of opioid and cocaine abstinence among fixed and escalating CM schedule participants in the DAISY RCT (N=90) were compared over the initial 5 weeks of the intervention. RESULTS: No statistically significant difference in the opioid and cocaine abstinence measures was found between escalating and fixed conditions after 5 weeks (14 opportunities for each participant to leave a urine sample). The mean (SD) number of drug negative urine samples was 8.1 (4.5) and 7.4 (4.3), for escalating and fixed groups, respectively (p=0.46). CONCLUSIONS: These results further the scientific knowledge regarding CM treatment in opioid-dependent pregnant women by supporting the finding that the escalating and fixed CM schedules produce similar amounts of drug negatives urine samples early in treatment.

Building Equitable Community-Academic Partnerships for Opioid Recovery Research: Lessons Learned from Stakeholder Engagement With Peer and Provider Organizations.

Forming equity-based community-academic partnerships focused on recovery research is a time- consuming and challenging endeavor, but one well worth the care and effort required. Through building trusting relationships, vital research collaborations emerge, which are driven by expressed community needs and supported with university resources. This article describes the stakeholder engagement process utilized by a university-based and opioid-focused initiative entitled Innovations in Recovery through Infrastructure Support (IRIS). IRIS developed a diverse and representative network of clinical providers, peer recovery workers, academics, and other behavioral health leaders. The process was informed by community-based participatory research (CBPR) practices and principles aimed at creating equitable partnerships. Lessons learned include the need to reshape the relationship between research and the community through an acknowledgment of harms committed by academia, as well as the importance of maintaining an approach of humility, accountability, and patience with the partnership process. Concrete benefits that go beyond the long-term promise of change, including compensating partners financially for their time, help ensure equity. A commitment to always asking "Who's missing?" and then filling those gaps builds a broad network inclusive of the various constituencies that make up the recovery support system. As IRIS builds on these lessons learned and plans next steps, we share our experience to support others engaged in forming community-academic partnerships through deep stakeholder engagement and use of participatory approaches within and outside of recovery research.

Reinforcement-based treatment improves the maternal treatment and neonatal outcomes of pregnant patients enrolled in comprehensive care treatment.

This randomized clinical trial examined the efficacy of comprehensive usual care (UC) alone (n = 42) or enhanced by reinforcement-based treatment (RBT) (n = 47) to produce improved treatment outcomes, maternal delivery, and neonatal outcomes in pregnant women with opioid and/or cocaine substance use disorders. RBT participants spent, on average, 32.6 days longer in treatment (p < .001) and almost six times longer in recovery housing than did UC participants (p = .01). There were no significant differences between the RBT and UC conditions in proportion of participants testing positive for any illegal substance. Neonates in the RBT condition spent 1.3 fewer days hospitalized after birth than UC condition neonates (p = .03), although the two conditions did not differ significantly in neonatal gestational age at delivery, birth weight, or number of days hospitalized. Integrating RBT into a rich array of comprehensive care treatment components may be a promising approach to increase maternal treatment retention and reduce neonatal length of hospital stay.

Treating the partners of opioid-dependent pregnant patients: feasibility and efficacy.

BACKGROUND: Drug-dependent pregnant women with intimate partners who are also drug-dependent have been found to have compromised treatment outcomes. Thus, developing a treatment to reduce a male partner's drug use is the first step in a line of research with a distal goal of improving pregnant patient's treatment outcomes. OBJECTIVE: This study examined a novel intervention for engaging the male partner in drug treatment. METHODS: Men targeted for intervention were non-treatment-seeking opioid users. Motivational enhancement therapy (MET), an effective non-confrontational intervention approach for evoking behavioral change, was employed to encourage treatment participation. This six-session intervention was followed by a drug-abstinent contingency-based voucher incentive program. Moreover, to help maintain drug abstinence, male partners had rapid facilitation into either opioid detoxification with aftercare or methadone maintenance. Interwoven into treatment were both couple's counseling and a men's group educational program designed to strengthen the support provided by the men to their partners during pregnancy and post-delivery. Men (n = 45) received either the novel intervention package called HOPE (Helping Other Partners Excel) or a control condition (n = 17) that received weekly support and referrals for treatment. RESULTS: Men in the HOPE condition, compared with the usual care condition, showed increased treatment retention, transient decreases in heroin use, increased involvement in recreational activities, less reliance on public assistance, and increased social support for their pregnant partners. CONCLUSION AND CLINICAL SIGNIFICANCE: Results suggest that treatment of male partners is feasible and efficacious in the short term but modifications to the intervention are needed to sustain results.

Cigarette Smoking and Neonatal Outcomes in Depressed and Non-Depressed Opioid-Dependent Agonist-Maintained Pregnant Patients.

AIMS: To investigate whether cigarette smoking and/or depression contribute to neonatal abstinence syndrome (NAS) severity. DESIGN: Cohort study analyzing data from a randomized, controlled trial of methadone versus buprenorphine. SETTING: Seven study sites that randomized patients to study conditions and provided comprehensive addiction treatment to pregnant patients. PARTICIPANTS: 119 of 131 opioid-dependent pregnant patients who completed the MOTHER study. MEASUREMENTS: Smoking data and depression status were obtained from the Addiction Severity Index and Mini International Neuropsychiatric Interview, respectively. Neonatal outcomes (birth weight, preterm delivery and NAS pharmacologic treatment) were collected from the medical charts. Study site was a fixed-effect factor in all analyses. FINDINGS: Cigarette smoking was reported by 94% of participants and depression identified in 35%. Smoking was associated with low birth weight, preterm delivery, and NAS pharmacologic treatment in both depressed and non-depressed participants. The association between smoking and NAS treatment differed significantly between depressed and non-depressed participants. Among non-depressed participants, adjusting for site and illicit drug use, each additional average cigarette per day (CPD) increased the odds of NAS treatment by 12% [95%CI: (1.02-1.23), p=0.02]. Among depressed participants, each additional average CPD did not statistically increase the odds of NAS treatment [OR: 0.94, 95% CI: (0.84-1.04), p=0.23]. CONCLUSIONS: These results are consistent with the hypothesis that NAS expression is influenced by many factors. The relationship between CPD and NAS pharmacologic treatment is attenuated among depressed women in this study for reasons currently unknown. Further investigations are needed to clarify the complex relationships among maternal smoking, depression, and NAS.

The relationship between antidepressant use and smoking cessation in pregnant women in treatment for substance abuse.

BACKGROUND: Bupropion's efficacy for smoking cessation in pregnant women is unknown. OBJECTIVES: To determine if substance-dependent women prescribed bupropion smoked fewer cigarettes/day than those prescribed citalopram/escitalopram or no antidepressant medication. METHODS: Comparison of smoking in bupropion (n = 11), citalopram/escitalopram (n = 17), and no antidepressant (n = 28) groups. RESULTS AND CONCLUSIONS: Trend for greater decrease in smoking for the bupropion vs. citalopram/escitalopram group [-6.4 vs. -.4 cigarettes/day (p = .276)], although the bupropion decrease was similar to that seen in the no antidepressant group [-5.3 cigarettes/day]. SCIENTIFIC SIGNIFICANCE: Data support continued study of bupropion in depressed pregnant substance-dependent smokers.

Suicidality, aggression, and other treatment considerations among pregnant, substance-dependent women with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) and other Axis I comorbidity among women with substance use disorders (SUDs) appear similarly prevalent and are associated with comparable negative clinical profiles and treatment outcomes. The relative contribution of comorbid PTSD vs other Axis I psychiatric disorders to clinical characteristics is largely unexamined, however, despite theory and empirical data indicating that PTSD and SUDs may have a unique relationship that confers specific risk for clinical severity and poor treatment outcome. In a sample of pregnant, opioid- and/or cocaine-dependent women entering substance abuse treatment, women with PTSD (SUD-PTSD; n = 23) were compared to those with other Axis I comorbidity (SUD-PSY; n = 45) and those without Axis I comorbidity (SUD-only; n = 37). Data were collected via face-to-face interviews and urinalysis drug assays. Although the study groups had similar substance use severity, the SUD-PTSD group was more likely to report suicidality, aggression, and psychosocial impairment than both the SUD-PSY and SUD-only groups. Findings indicate treatment considerations for substance-dependent women with PTSD are broader and more severe than those with other Axis I conditions or substance dependence alone.

Relationship between cigarette use and mood/anxiety disorders among pregnant methadone-maintained patients.

This study investigates the association between cigarette use and current mood/anxiety disorders among pregnant opioid-dependent patients. Pregnant methadone-maintained women (N = 122) completed the Addiction Severity Index and Structured Clinical Interview for DSM-IV. Participants were categorized based on past 30 days cigarette use: no (n = 15) and any smoking (n = 107); this latter group was then subdivided into light (one to ten cigarettes/day; n = 55), and heavy smokers (11+ cigarettes/day; n = 52). Any smoking was significantly associated with any current mood/anxiety disorder (p < 0.001), any current mood disorder (p = 0.007), and any current anxiety disorder (p < 0.001). No significant association was found between specific level of cigarette use and mood/anxiety disorders. This association between smoking and psychiatric disorders has implications for the mental and physical health of methadone-maintained women and their children, and may contribute to the understanding of the physiological mechanisms underlying smoking and nicotine dependence.

The impact of mood disorders on the delivery and neonatal outcomes of methadone-maintained pregnant patients.

Methadone-maintained pregnant patients with mood disorders have compromised treatment outcomes ( [1] ). This study examined the relationship between the presence of mood disorders and delivery and neonatal outcomes. Participants were categorized into two groups: no current mood disorder (n = 30) or primary mood disorder (n = 38). The mood disorder group reported more serious lifetime and current depression than did the no current mood disorder group. Neonates from mothers with mood disorders had a longer length of stay in the neonatal intensive care unit than the no current mood disorder group. Findings emphasize the need to treat mood disorders in methadone-maintained pregnant patients.

Screening for Mood Disorder in Pregnant Substance-dependent Patients.

The Addiction Severity Index (ASI) and Beck Depression Inventory (BDI) were compared as screening tests for current mood disorder in pregnant substance-dependent patients (N = 187). Mean ASI psychiatric Interviewer Severity Rating (ISR) and BDI scores for Diagnostic and Statistical Manual of Mental Disorder-IV diagnosed current mood disorder patients (n = 51) were 4.4 and 17.1, respectively, and for those without current mood disorder (n = 136) were 2.7 and 14.0, respectively. Areas under receiver operating characteristic curves were 0.73 (ASI) and 0.59 (BDI). The ASI psychiatric ISR predicted mood disorder with better sensitivity and specificity versus the BDI (0.82 and 0.49 for scores ≥4 vs. 0.49 and 0.62 for scores ≥17, respectively).

Insights Into the Experience of Liver Transplant Recipients With Alcoholic Liver Disease: A Descriptive Qualitative Study.

BACKGROUND: Alcoholic liver disease (ALD) due to alcohol use disorder (AUD) is the primary cause of liver transplantation (LT) in the United States. Studies have found that LT recipients experience a range of physical and emotional difficulties posttransplantation including return to alcohol use, depression, and anxiety. The aim of this study is to better understand the experiences of LT recipients with ALD because they recovered posttransplant to inform the development of a patient-centered intervention to assist patients during recovery. METHODS: Using qualitative methods, researchers conducted semi-structured interviews with 16 ALD LT recipients. The primary topics of the interview were physical recovery, mental health, substance use including alcohol and tobacco use, and financial experiences. Common patient themes were identified and coded. RESULTS: Within the domain of physical health, patients stressed that undergoing LT was a near-death experience, they were helpless, changes in weight influenced their perception of their illness, and they have ongoing medical problems. In the domain of mental health, patients described cognitive impairments during their initial recovery, difficulty in processing the emotions of having a terminal condition, ongoing depression, anxiety, and irritability. The patients also described their perception of having AUD, the last time they used alcohol and their attitude to AUD treatment posttransplant. Patients also described their reliance on one member of their social support network for practical assistance during their recovery and identified one member of their medical team as being of particular importance in providing emotional as well as medical support during recovery. CONCLUSIONS: The patient's description of their lived experience during the months following transplant informed the development of a patient-centered intervention that colocates behavioral health components with medical treatment that helps broaden their social network while addressing topics that emerged from this study.

Methadone maintenance vs. methadone taper during pregnancy: maternal and neonatal outcomes.

This study compared five groups of participants: those receiving either three-day methadone-assisted withdrawal (MAW) alone (n = 67), three-day MAW followed by methadone maintenance (MM) (n = 8), seven-day MAW alone (n = 28), seven-day MAW followed by MM (n = 20), or a continuous MM sample (n = 52) enrolled between 1995-2001 in an urban drug treatment center. On average, patients in the three MM groups remained in treatment longer, attended more obstetrical visits, and more often delivered at the program hospital than patients in the two MAW alone groups. Given the poor maternal MAW outcomes, methadone maintenance should be considered as the primary treatment approach for opioid-dependent pregnant women.

The Impact of Early Substance Use Disorder Treatment Response on Treatment Outcomes Among Pregnant Women With Primary Opioid Use.

OBJECTIVES: This study examined the impact of early patient response on treatment utilization and substance use among pregnant participants enrolled in substance use disorder (SUD) treatment. METHODS: Treatment responders (TRs) and treatment nonresponders (TNRs) were compared on pretreatment and treatment measures. Regression models predicted treatment utilization and substance use. RESULTS: TR participants attended more treatment and had lower rates of substance use relative to TNR participants. Regression models for treatment utilization and substance use were significant. Maternal estimated gestational age (EGA) and baseline cocaine use were negatively associated with treatment attendance. Medication-assisted treatment, early treatment response, and baseline SUD treatment were positively associated with treatment attendance. Maternal EGA was negatively associated with counseling attendance; early treatment response was positively associated with counseling attendance. Predictors of any substance use at 1 month were maternal education, EGA, early treatment nonresponse, and baseline cocaine use. The single predictor of any substance use at 2 months was early treatment nonresponse. Predictors of opioid use at 1 month were maternal education, EGA, early treatment nonresponse, and baseline SUD treatment. Predictors of opioid use at 2 months were early treatment nonresponse, and baseline cocaine and marijuana use. Predictors of cocaine use at 1 month were early treatment nonresponse, baseline cocaine use, and baseline SUD treatment. Predictors of cocaine use at 2 months were early treatment nonresponse and baseline cocaine use. CONCLUSIONS: Early treatment response predicts more favorable maternal treatment utilization and substance use outcomes. Treatment providers should implement interventions to maximize patient early response to treatment.

Prenatal buprenorphine exposure and neonatal neurobehavioral functioning.

AIMS: Assessments of effects of prenatal opioid exposure on the neonate have consisted principally of evaluations of neonatal abstinence syndrome (NAS) to determine the need for pharmacotherapy. The purpose of this study was to comprehensively evaluate the effects of gestational maternal buprenorphine maintenance on newborn neurobehavioral functioning. STUDY DESIGN: Maternal substance use history and psychosocial demographics that can contribute to the neurobehavioral functioning of the infant were explored. Infants were assessed using the NICU Network Neurobehavioral Scale (NNNS) to measure their neurologic and behavioral functioning and signs of stress/abstinence on days 3, 14 and 30 of life. SUBJECTS: Participants were 41 pregnant buprenorphine-maintained women and their infants. RESULTS: Maternal buprenorphine dose at delivery was negatively correlated with infant quality of movement and self-regulation, and positively correlated with the central nervous system parameters of stress/abstinence at day 3 of life. As maternal buprenorphine dose increased, the mean morphine dose that the infant required for NAS treatment significantly increased. No differences were found when comparing the NNNS domain scores between infants who required pharmacotherapy for NAS versus those who did not at day 3 of life. CONCLUSIONS: Buprenorphine exposure during pregnancy can alter neonatal neurobehavioral and physiological responses to stimuli. A systematic evaluation of the newborn's functional domains above NAS assessment alone is crucial to address the challenges created by neurobehavioral dysregulation associated with substance exposure, improve caregiver/infant interaction and developmental trajectory. Comprehensive pre/postnatal treatment of buprenorphine-maintained mothers can lead to healthier outcomes for the dyad.

Mood disorders affect drug treatment success of drug-dependent pregnant women.

This study examined the impact of co-occurring Axis I disorders on drug treatment outcomes of drug-dependent pregnant women. Participants (N = 106) were women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for opioid dependence and were receiving methadone. Based on DSM-IV Axis I criteria, participants were categorized into three groups: (1) absence of mood/anxiety disorder (ND, n = 29), (2) primary mood disorder (MD, n = 39), or (3) primary anxiety disorder (AD, n = 38). Demographically, the groups were similar. The MD group was significantly more likely to be positive for drugs while in treatment compared with both the ND and AD groups. The MD and AD groups had more psychosocial impairment and higher incidence of suicidal ideation compared with the ND group. Interestingly, the AD group spent more days in treatment compared with the ND or MD group. These findings highlight the need to treat co-occurring Axis I disorders, particularly given the higher relapse risk for those with mood disorders.

A Comparison of Reinforcement Based Treatment (RBT) versus RBT plus Recovery Housing (RBTRH).

OBJECTIVES: Reinforcement-based treatment (RBT) plus recovery housing (RBTRH) improves outcomes for individuals with opioid use disorders. No studies have examined the efficacy of RBT in the absence of abstinent-contingent housing. METHODS: We compared highly similar participants from a study of outpatient RBT (RBT, n=55) and the RBTRH (n=80) arm of a randomized trial wherein participants received abstinent-contingent payment for recovery housing sponsored by the research program. Abstinence and employment outcomes were assessed at one, three, and six months. Regression was used to identify predictors of abstinence. Sensitivity analyses explored the impact of housing on outcomes. RESULTS: RBT and RBTRH participants had similar abstinence and employment outcomes. Predictors of abstinence in the sample included recovery housing residence and employment. However, a distinct RBT sub-group emerged, as 33% of the sample accessed self-pay RH (RBTSPRH). Sensitivity analyses compared the two RH groups (self-pay and program-supported) to RBT outpatient treatment (RBT). The RBTSPRH and RBTRH groups had similar abstinence outcomes, and both groups had superior abstinence outcomes compared to RBT. The RBTSPRH group had the most sustained effects relative to RBT, including higher abstinence rates, and more favorable employment outcomes at six months (ps<.05). The RBTSPRH group reported more days of employment compared to both the RBT and RBTRH groups at three months (ps<.05). CONCLUSIONS: Findings highlight the importance of recovery housing for promoting improved outcomes among RBT participants. Research is needed to explore the aspects of recovery housing versus outpatient treatment that are associated with improved outcomes in the population.