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

Abstract

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.

Keywords: Addiction; Behavioral Economics; Partial Hospitalization; Stepped Care; Substance Use.

Figure 1.

Mean Relative Drug-related Activity Frequency Split by Primary Substance in both the Full Sample (N=5,481) and among those who Returned to Use (N =1,369) Note. Differences in relative drug-related activity engagement across primary substances. Bars represent raw means with standard errors. Numbers above each bar are Cohen’s d effect sizes, representing the size of the effects as compared to alcohol with 95% confidence intervals. The y-axis represents percentages. The top panel displays means and effect sizes in the full sample (N=5,481); the bottom panel displays means and effects sizes among a subsample of those who returned to use (N =1,369).

Figure 2.

Access to and Enjoyment of Non-drug Reinforcement Split by Primary Substance in both the Full Sample (N=5,481) and among those who Returned to Use (N=1,369) Note. Differences in access to and enjoyment of non-drug activities across primary substances. Bars represent raw means with standard errors. Numbers above each bar are Cohen’s d effect sizes, representing the size of the effects as compared to alcohol with 95% confidence intervals. The top panels display access to non-drug activities split by drug for the full and return to use samples, from left to right. The bottom panels display enjoyment of non-drug activities split by drug for the full and return to use samples.

Figure 3

Rates of Return to Use by Non-drug Activity Availability and Enjoyability Note. The top panel displays rates of return to use as a function of ratings on the access to non-drug activities item. The bottom panel displays rates of return to use as a function of ratings on the enjoyment of non-drug activities item.

Figure 4

Life Satisfaction by Non-drug Activity Availability and Enjoyability Note. Bars represent raw means with standard errors. The top panel displays adjusted means for life satisfaction as a function of ratings on the access to non-drug activities item. The bottom panel displays adjusted means for life satisfaction as a function of ratings on the enjoyment of non-drug activities item.