The association of pain impact and sleep disruption with opioid withdrawal during opioid-use disorder treatment.

AIMS: Persons with opioid-use disorder (OUD) often experience opioid withdrawal and opioid craving, which can drive continued opioid use and treatment discontinuation. In addition, hyperalgesia is common among persons with OUD, yet few studies have examined the role of pain impact during OUD treatment. The purpose of the present study was to test whether opioid withdrawal and craving were elevated in the context of greater pain impact (i.e. greater pain intensity and interference), and whether these associations changed throughout treatment. METHODS: Participants in residential OUD treatment (n = 24) wore wrist actigraphy to measure sleep and completed daily measures of pain impact, opioid withdrawal and opioid craving for up to 28 days. Mixed effects models were used to examine whether daily elevations in pain impact and sleep continuity were associated with withdrawal severity and opioid craving. RESULTS: Elevations in withdrawal, but not craving, occurred on days when individuals reported higher scores on the pain impact scale. Associations between pain impact and withdrawal were present throughout treatment, but stronger during early treatment. In contrast, both withdrawal and opioid craving were elevated following nights of greater wake after sleep onset and awakenings, but these findings were often more pronounced in early treatment. CONCLUSIONS: Pain impact and sleep disturbance are 2 factors associated with opioid withdrawal and opioid craving. Novel pharmacotherapies and scalable adjunctive interventions targeting sleep and pain impact should be tested in future work to improve OUD treatment outcomes.

COVID-19-Related Financial Hardship Is Associated With Depression and Anxiety in Substance Use Treatment Across Gender and Racial Groups.

ABSTRACT: Many individuals lost their employment during the COVID-19 pandemic and experienced financial hardship. These experiences may increase risk for co-occurring conditions, including substance use disorders (SUDs) and related symptoms of depression and anxiety. This study aimed to examine the associations between COVID-19-related financial hardship and/or job loss and co-occurring symptoms, across gender and racial groups. Respondents (N = 3493) included individuals entering SUD treatment in the United States in March-October of 2020. Results demonstrated that COVID-19-related financial hardship and unemployment in the household was associated with greater depression and anxiety severity among people in SUD treatment (p's < 0.05). Our findings highlight financial hardship and loss of employment as risk factors for co-occurring depression and anxiety. However, additive effects between marginalized identity status and COVID-19 economic hardship on co-occurring symptoms were not observed.

Naloxone Knowledge and Attitudes Towards Overdose Response Among Family Members of People who Misuse Opioids.

Providing family members of individuals with opioid use disorders (OUD) naloxone is a cost-effective way to prevent overdose deaths. However, misconceptions and negative attitudes towards naloxone hinder family engagement with naloxone programs. This study examines factors associated with knowledge and attitudes toward naloxone among adults with close family members who misused opioids. Adults with family members (parent, step-parent, child, spouse, sibling, or step-sibling) who misused opioids (N = 299) completed a web-based survey. Participants were recruited through treatment providers, community groups, and social media. Surveys assessed naloxone knowledge, attitudes toward overdose response, demographics, completion of naloxone training, attitude toward medications for OUD, and family members' overdose history. Multiple regression was used to identify factors associated with naloxone knowledge (Model 1) and attitudes toward overdose response (Model 2). A graduate degree (B = .35, p < .003) and a history of overdose (B = 0.21, p = .032) were associated with greater naloxone knowledge. Age (B = .11, p < .001), race/ethnicity (B = -1.39, p = .037), naloxone training (B = 2.70, p < .001), and more positive attitude toward medications for OUD (B = 1.50, p = .003) were associated with attitudes toward overdose response. Family members are potential allies in reducing drug overdose deaths, and families may need broader education about naloxone. Awareness of previous overdose was associated with greater naloxone knowledge. Findings related to race/ethnicity suggest the need to reach family members of minoritized racial groups to provide access to naloxone training. Findings point to where education and distribution efforts may focus on increasing knowledge and improving attitudes among those closest to people with OUD.

Childhood Adversity, Addiction Severity, and Comorbidity Among Patients Receiving Opioid Use Disorder Treatment: The Role of Emotion Regulation.

ABSTRACT: Patients in opioid use disorder (OUD) treatment report high rates of childhood adversity, and women experience greater exposure to certain types of childhood adversity ( e.g. , sexual abuse). Childhood adversity is associated with clinical severity, but the mechanisms explaining this association are not well understood. Participants ( N = 171) in opioid agonist treatment completed measures of childhood adversity, emotion regulation, and clinical severity ( i.e. , addictive behaviors, depression, and anxiety). Women endorsed greater childhood adversity and higher current psychopathology than men. The association between childhood adversity and clinical severity varied as a function of symptom type, although emotion regulation was a strong predictor in all models. Women reported higher levels of anxiety after controlling for covariates, childhood adversity, and emotion dysregulation. Future research should investigate treatment strategies to address emotion dysregulation among patients in OUD treatment, particularly women who may present with greater childhood adversity exposure and anxiety.

Binge Drinking and Cannabis Use among Transgender and Gender-Diverse Young Adults in Michigan.

Substance use rates are higher among transgender and gender-diverse people than cisgender people. Rates of substance use are also higher among young adults compared with other age groups. However, little research examines substance use among transgender and gender-diverse young adults. This study examines factors associated with binge drinking and cannabis use among transgender and gender-diverse young adults in Michigan. Participants (N = 78; ages 18-25) completed an online survey that included demographics and substance use and related characteristics. Race, stimulant misuse, and sedative misuse were associated with more frequent binge drinking. Older age and past-year pain reliever misuse were associated with less frequent cannabis use. Past-year stimulant use and using cannabis alone were associated with more frequent cannabis use. These findings suggest that additional marginalized identities may increase the risk for maladaptive substance use. Future research should examine substance use behaviors and correlates to inform interventions among this population.

Clinical correlates of drug-related dreams in opioid use disorder.

BACKGROUND AND OBJECTIVES: Drug-related dreams are commonly reported by individuals in treatment for substance use disorders, which may be distressing. Existing evidence suggests that dream recollection may be influenced by clinically relevant phenomena, such as opioid use and withdrawal, general sleep disturbance, affective symptoms, and chronic pain. However, very few studies have explored drug-related dreams among individuals who screened positive for opioid use disorder (OUD). METHODS: Adults recruited from Amazon Mechanical Turk (MTurk) who screened positive for OUD (N = 154) completed a questionnaire about drug-related dreams, as well as measures assessing sleep, opioid use history, stress, anxiety, and chronic pain. χ2 analyses, one-way analysis of variance, and bivariate correlations, correcting for the false discovery rate, were used as appropriate to explore correlates of (1) recollecting a drug-related dream, and (2) experiencing post-dream craving and distress. RESULTS: Individuals who recollected a past-week drug-related dream were more likely to report other recent sleep disturbances, including poorer sleep quality, greater insomnia symptoms, and a higher risk for sleep apnea. Post-dream craving and distress were both associated with greater insomnia symptoms, poor sleep hygiene behaviors, and greater anxiety symptoms. Individuals who had ever experienced a drug-related dream (recently, or in their lifetime) were more likely to report a history of severe withdrawal, overdose, and intravenous opioid use. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Drug-related dreams were common among individuals in the present sample and were related to other clinically relevant phenomena. Interventions that treat co-occurring OUD, pain, sleep symptoms, and affective symptoms may improve overall well-being in this population.

The Effects of Anger on Alcohol Demand and Subjective Alcohol Craving.

BACKGROUND: Anger and anger-related traits have been related to alcohol use in both cross-sectional and prospective studies. However, only a small number of studies have experimentally manipulated anger to examine whether the manipulation of anger influences alcohol craving or the relative reinforcing value of alcohol. METHODS: Participants (N = 231) recruited through Amazon's MTurk were randomly assigned to a provocation condition or a neutral condition prior to completing both the Alcohol Purchase Task and a self-report measure of alcohol craving. Linear regression analyses were conducted to examine the effects of the anger induction, trait hostility, frequency of alcohol use in the past month, and relevant demographic characteristics (gender, age, income) on alcohol craving and indices of alcohol demand. RESULTS: Participants assigned to the provocation condition had greater PMax (B = 0.17, p = 0.012) and breakpoint (B = 0.18, p = 0.006) values, less elastic demand (B = -0.15, p = 0.020), and lower drinking intensity (B = -0.14, p = 0.025) than participants assigned to the neutral condition. Trait hostility was positively related to OMax (B = 0.22, p = 0.001), intensity of demand (B = 0.27, p < 0.001), and subjective alcohol craving posttask (B = 0.32, p < 0.001), but did not moderate the relationship between condition and outcomes. CONCLUSIONS: Although most persistence indices of alcohol demand were sensitive to the anger induction, we did not observe higher scores on amplitude indices or subjective craving in the provocation condition relative to the neutral condition. Further investigation into the role which anger plays in alcohol use is warranted.

Substance Use, Gambling, Binge-Eating, and Hypersexuality Symptoms Among Patients Receiving Opioid Agonist Therapies.

BACKGROUND AND OBJECTIVES: Patients receiving opioid agonist therapies have high rates of psychiatric comorbidity. Some data suggest that comorbidity is associated with poorer treatment outcomes. The current study assessed predictors of multiple putative addictive behaviors among patients receiving opioid agonist therapies. METHODS: Adults (N = 176) recruited from an outpatient clinic providing opioid agonist therapy completed self-report measures of depression, anxiety, impulsivity, adverse childhood events, and the Recognizing Addictive Disorders (RAD) scale, which includes seven subscales assessing symptoms related to alcohol use, drug use, tobacco use, gambling, binge-eating, hypersexual behavior, and excessive video-gaming. Linear regression and hurdle models identified significant predictors of RAD subscales. Hurdle models included logistic regression estimation for the presence/absence of symptoms and negative binomial regression for estimation of the severity of symptoms. RESULTS: Most patients did not report significant symptoms beyond drug or tobacco use. However, 7% to 47% of participants reported some symptoms of other addictive behaviors (subscale score > 0). Higher impulsivity predicted the presence and/or increased severity of symptoms of drug use, gambling, binge-eating, and hypersexuality. Higher depression significantly predicted increased severity of drug use and binge-eating symptoms. Increased anxiety predicted lower severity of alcohol use and binge-eating and higher severity of smoking symptoms. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: A broader range of potentially addictive symptoms may be present among patients engaged in treatment for opioid use disorder. Few studies have assessed symptoms of binge-eating, hypersexuality, and excessive video-gaming among patients receiving opioid agonist therapy. This study contributes to preliminary findings and highlights important future directions. (Am J Addict 2021;00:00-00).

Predictors of Safe Prescription Opioid Storage and Participation in Drug Take-Back Events: Results from a Statewide Survey.

Improper storage and disposal of prescribed opioids can lead to diversion or accidental poisonings. Studies of emergency department and cancer patients suggest prescription opioids are rarely stored securely or disposed of when unneeded. Safe storage and disposal practices reduce risks for others living in or visiting a household. The purpose of this study is thus to examine prescription opioid storage and participation in drug take-back events among Michigan adults. Participants (N = 702) were recruited through social media advertisements to complete an online survey in July and August 2018. Logistic regression was used to examine correlates of safe storage and disposal. 8.4% (n = 59) of participants reported always keeping opioids locked; 29.8% (n = 209) reported attending a drug take-back event. Black participants and those who believed that illegal drug use was a serious problem had greater odds of locking opioids; participants with higher levels of education or who knew someone who used heroin or misused prescription opioids had lesser odds of locking opioids. Age and race were associated with take-back event participation. Findings identify factors associated with safe prescription opioid storage/disposal and indicate safe storage/disposal seldom occurs. Education and provision of safe storage equipment should be designed for diverse ages, races/ethnicities, and levels of education. Drug take-back events not hosted by law enforcement may have broader appeal, as may those led by Black or other people of color. Wider use of drug donation boxes may facilitate increased disposal among those who do not wish to or cannot attend take-back events.

Overestimation of Prescription Pain Reliever Misuse and Heroin Use among Adults.

BACKGROUND: Estimates from the National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019) suggest 3.6% of persons aged 12 and older misused prescription pain relievers in the past year and 0.3% used heroin. However, research suggests that most individuals drastically overestimate rates of substance use and misuse. Those who overestimate substance misuse are often more likely to misuse substances themselves (Kilmer et al., 2015; McCabe, 2008). Purpose: To compare perceived versus actual rates of prescription pain reliever misuse and heroin use among a statewide sample of adults and identify correlates of these differences. Methods: Participants (N = 689) recruited through social media estimated rates of prescription pain reliever misuse and heroin use. Participants also indicated whether they engaged in pain reliever misuse or heroin use, and whether they knew anyone who misused prescription pain medications or heroin. Results: Almost all participants (98.11%) overestimated the prevalence of prescription pain reliever misuse (mean estimate = 41.25%) and heroin use (99.71%, mean estimate =25.46%). Women and African Americans were more likely to overestimate prescription pain reliever misuse and heroin use. Knowing someone who misused prescription pain relievers was significantly associated with overestimating prescription pain reliever misuse. Personal use was not associated with overestimating prevalence of either substance. Conclusions: Adults consistently overestimate rates of prescription pain reliever misuse and heroin use. Overestimation may increase normative perceptions of substance use and ultimately lead to increased substance use. Social-norms based education and interventions may be particularly important among groups that are more likely to overestimate use.

Correlates of Expressed Emotion Among Family Members of Individuals Who Sought Treatment for Opioid Use.

Expressed emotion has been robustly associated with negative mental health outcomes. Understanding correlates of expressed emotion by family members of individuals with opioid use disorder is important, as this group faces high levels of stress and can play an important role in their loved ones' treatment. Thus, immediate family members of individuals who sought treatment for opioid problems (N = 195) completed a web-based survey that included measures of expressed emotion, self-stigma, social support, and demographic characteristics. Multiple linear regression analyses were conducted to examine correlates of two types of expressed emotion-criticism and emotional overinvolvement. Results indicated that higher self-stigma and lower social support were significantly associated with higher emotional overinvolvement. Higher self-stigma and having experienced debt related to a family member's opioid use were associated with higher criticism. Thus, self-stigma and financial burden may exacerbate likelihood of expressed emotion, whereas social support may buffer against expressed emotion.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States.

BACKGROUND: Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers. OBJECTIVES: We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications. METHODS: We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability. RESULTS: Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints. CONCLUSIONS: Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

Public Perceptions of Risks Associated with Mixing Opioid Pain-Relievers with Alcohol and Benzodiazepines.

Objectives: Use of alcohol or benzodiazepines with opioid pain-relievers increases risk of overdose and overdose death. A substantial proportion of adults receives an opioid prescription each year, and a number of these adults also use benzodiazepines or alcohol. As public opinion continues to shape public policy, it is imperative to understand correlates of recognizing risk of mixing substances in order to inform public outreach and prevention efforts. Methods: Characteristics associated with perceived risk were explored using an online survey of a community sample of adults (N = 639) in Michigan. Two logistic regression models examined potential correlates of perceived risk of 1) mixing opioid pain-relievers with alcohol and 2) mixing opioid pain-relievers with benzodiazepines. Results: In the multivariate results, participants reporting at least one heavy drinking episode in the past month (AOR = 0.46, p = .001) and individuals with advanced degrees (AOR = 0.49, p = .014) had lower odds of believing that mixing alcohol and opioid pain-relievers poses a great risk, while women (AOR = 1.66, p = .042) had higher odds. Participants reporting lifetime (AOR = 0.58, p = .046) or past-year (AOR = 0.28, p = .001) non-medical opioid use had lower odds of reporting that mixing benzodiazepines and opioid pain-relievers poses a great risk, whereas older participants (AOR = 1.02, p = .037) had higher odds. Conclusions: Certain groups were more likely to underestimate risks of mixing opioid pain-relievers with alcohol or benzodiazepines. Results underscore the importance of targeted public awareness campaigns, prevention programing, and communication between physicians and patients about the risks of mixing substances, particularly among high-risk groups.

Development and Validation of the Recognizing Addictive Disorders Scale: A Transdiagnostic Measure of Substance-Related and Other Addictive Disorders.

OBJECTIVE: Substance use disorders and behavioral addictions commonly co-occur. However, few available self-report measures reliably and validly assess the full range of addictive conditions. The development and initial validation of a new measure-Recognizing Addictive Disorders (RADs) scale addresses a significant gap in the literature. Method: After items were generated and evaluated in Study 1, Study 2 (N = 300), applied exploratory factor analysis to the item pool using an online-based community sample. In Study 3 (N = 427), the factor structure was validated using an independent online-based community sample and confirmatory factor analysis. Results: The scale demonstrated good internal consistency (a = .92) and construct validity, including replication of the factor structure (χ2 (553) = 760.83, p < .001, CFI = .997, TLI = .997, RMSEA = .030) and correlation with a related transdiagnostic measure of addiction (r = .72). Discussion: Overall, results support the preliminary validity of a brief transdiagnostic measure of addiction that considers a diverse range of behaviors. For patients presenting to substance abuse treatment, this tool may be useful in identifying symptoms of other types of non-substance problems, which could ultimately aid in treatment planning.

Demographic, Cannabis Use, and Depressive Correlates of Cannabis Use Consequences in Regular Cannabis Users.

BACKGROUND AND OBJECTIVES: Regular cannabis users experience cannabis-related consequences across many domains of functioning. The present study examined demographic, cannabis use, and depressive correlates of cannabis consequences. We hypothesized that (1) earlier onset of use would predict greater psychological and functional consequences; and (2) women would endorse more psychological and withdrawal consequences. METHODS: Data were collected from an urban sample of 184 adults who reported regular cannabis use. Seventeen items from a cannabis consequence checklist were grouped into three domains: Psychological Consequences, Cannabis Withdrawal, and Functional Consequences. Three multiple regressions were performed to explore demographic and cannabis use correlates of each domain. Correlations between domains and depressive symptoms were assessed using Pearson's r. RESULTS: Greater endorsement on the Psychological Consequence subgroup was predicted by female sex, lower educational attainment, and treatment-seeking history for cannabis abuse/dependence. Individuals with greater number of quit attempts or treatment-seeking history endorsed more items in the Cannabis Withdrawal domain. Although the model failed to reach significance for Functional Consequences, age at onset of regular and daily cannabis use were negatively associated with this domain. Correlational analyses demonstrated higher Beck Depression Inventory-Second Edition scores were related to greater endorsement of Psychological Consequence and Cannabis Withdrawal items. DISCUSSION AND CONCLUSIONS: Regular cannabis users report consequences of use, which can be grouped into content-specific subgroups. Individual characteristics are differentially associated with these subgroups. SCIENTIFIC SIGNIFICANCE: Understanding which individual characteristics are related to cannabis use sequelae could help identify those at risk for greater consequences, thus leading to improved assessment and treatment interventions. (Am J Addict 2019;28:295-302).

Clinical and Personality Characteristics of Problem and Pathological Gamblers With and Without Symptoms of Adult ADHD.

The study examined the differential clinical and personality characteristics of problem and pathological gamblers (PPGs) with and without clinically significant symptoms of adult attention deficit hyperactive disorder (ADHD). Adults (N = 150, n = 75 women) with PPG were assessed by the SCID-IV, Conners' Adult ADHD Rating Scales, Multidimensional Personality Questionnaire, Gambling Motivation Questionnaire, and the Barratt Impulsiveness Scale. PPGs who reported symptoms of ADHD were more likely to be male, endorse psychiatric comorbidities (i.e., alcohol dependence, anxiety disorders, and antisocial personality disorder), report maladaptive personality traits (i.e., higher negative emotionality and lower positive emotionality), as well as higher impulsivity (attention impulsiveness, motor impulsiveness, and nonplanning impulsiveness). PPGs with symptoms of ADHD reported gambling for social, coping, and enhancement reasons. A multivariate binary logistic regression revealed that sex, higher scores on social reasons for gambling, and lack of premeditation were associated with an increased likelihood of reporting ADHD symptoms. The findings demonstrate important differences of PPGs with symptoms of ADHD and provide information for treatment consideration.

Suicidality among gambling helpline callers: A consideration of the role of financial stress and conflict.

BACKGROUND AND OBJECTIVES: High rates of suicidal ideation and attempts secondary to gambling are well established among those with gambling disorders. The present study explores potential risk factors for suicidal ideation and/attempt among a sample of help-line callers. METHODS: Participants (N = 202) completed measures assessing demographics; gambling behavior; and financial, family/social, employment, substance use, and legal difficulties related to gambling. Bivariate analyses, logistic regression, and mediation analyses were used to explore relationship between predictors and risk of suicidal ideation and attempt. RESULTS: Female gender, gambling severity (including engagement in illegal behaviors), a history of mental health problems, financial problems, and conflict related to gambling were associated with current suicidality in this sample. Mediation analyses revealed that financial problems were associated with increased familial conflict, which was in turn associated with increased suicidality. CONCLUSIONS: Family and social conflict may be one important way in which financial problems confer risk for suicidality among problem gamblers. These results align with findings from the substance use disorder (SUD) literature and highlight one potential factor that may merit further assessment and/or intervention. SCIENTIFIC SIGNIFICANCE: Researchers and clinicians may want to consider the overall level of conflict a patient is experiencing when assessing suicide risk among individuals with gambling problems. Professionals may also want to consider the suitability of interventions to address conflict within the context of gambling treatment. (Am J Addict 2018;27:531-537).

Harm Reduction for Opioid Use Disorder: Strategies and Outcome Metrics.

Tweet: The authors discuss harm reduction strategies and associated outcome metrics in relation to the ongoing opioid crisis.

Sleep Disruption Moderates the Daily Dynamics of Affect and Pain in Sickle Cell Disease.

Persons with sickle cell disease (SCD) often experience pain that can interfere with quality of life and daily activities. Pain can modulated by affect and sleep continuity; however, few studies have explored how these factors complementarily influence pain in adults with SCD. The study aims were to investigate 1) whether pain levels were heightened on days characterized by low positive affect and high negative affect, and 2) whether the relationship between affect and pain was intensified following nights of disrupted sleep. Adults with SCD (N = 25) completed ecological momentary assessments and daily sleep diaries. Mixed models were used to analyze the main and interactive effects of daily affect (positive affect and negative affect) and sleep disruption (wake after sleep onset and frequency of awakenings) on both daily average pain and daily maximum pain. Results suggested that daily average pain and maximum pain tended to be higher on days of low positive affect and high negative affect. Furthermore, the frequency of nocturnal awakenings moderated the relationship between positive affect and pain. On days where there were higher frequencies of nocturnal awakenings, low positive affect was associated with both average and maximum pain; however, this association was not observed with lower frequencies of nocturnal awakenings. The association between negative affect and maximum pain was also stronger at higher levels of awakenings. Results highlight the relevance of adjunctive interventions that target affect among populations with SCD and further suggest that sleep continuity may further facilitate these interventions, highlighting the importance of multimodal treatments. PERSPECTIVE: This study examined the effects of affect and sleep on pain among adults with sickle cell disease (SCD). Higher pain occurred on days of low positive affect and high negative affect, particularly following nights of more frequent awakenings. These findings emphasize the importance of addressing affect and sleep in SCD treatment.

A brief measure of non-drug reinforcement: Association with treatment outcomes during initial substance use recovery.

BACKGROUND: Translational research demonstrates that drug use is inversely associated with availability and engagement with meaningful non-drug reinforcers. Evaluation of non-drug reinforcement in treatment-receiving clinical populations is limited, likely owing to the time intensive nature of existing measures. This study explores the association of non-drug reinforcers with treatment outcomes using a novel, brief measure of past month non-drug reinforcement quantifying three elements: relative frequency, access, and enjoyability. METHODS: Respondents enrolled in substance use treatment (residential, intensive outpatient, and medically managed withdrawal) in clinics across the United States (N = 5481) completed standardized assessments of non-drug reinforcement and treatment outcomes (i.e., return to use and life satisfaction) one-month after treatment discharge. Non-drug reinforcement measures (availability, engagement, enjoyability) were used as predictors of return to use and life satisfaction using generalized linear models. RESULTS: Non-drug reinforcement indices were associated with return to use and life satisfaction in unadjusted models (e.g., 12.4 % versus 58.3 % return to use for those with the highest and lowest availability, respectively). Consistent results were observed in models adjusted for sociodemographic variables and risk factors (i.e., sleep disturbance, anhedonia, stress). Comparisons by drug class generally showed lower non-drug reinforcement among patients reporting heroin or methamphetamine as their primary drug. CONCLUSIONS: Results highlight the importance of non-drug reinforcement during the first month following treatment. Rapid measurement of non-drug reinforcement in stepped care settings may illuminate critical deficits in early stages of behavior change, identify those at greatest risk for return to use, and provide targets for treatment to improve recovery trajectories.