Reasons to cut down on drinking and drug use: The role of treatment

1. Reasons to cut down on drinking and drug use: The role of treatment Jessica Storbjörk Centre for Social Research on Alcohol and Drugs (SoRAD), Stockholm University jessica.storbjork@sorad.su.se Presented at the Nordic Alcohol and Drug Researchers’ Assembly, Reykjavik, Iceland, 23-25/8-10.

2. Background I Outcome (OC) studies generally study the effect of treatment (Tx) methods Tx can be beneficial (Moos & Moos 2005; Prendergast et al 2002; Weisner et al 2003b), but Tx is ONE ingredient of recovery Other important factors: social context, social environment, social situation (income, etc.), social networks (loneliness, quality and general support, abstinence oriented/supportive of soberness), severity, life-events and personal factors Treatment important for reduced drinking after 1 year (Weisner et al 2003b) but effect diminish (5 yrs, (Weisner et al 2003a). Informal network (non-misusers, AA) more strongly related to reduction in drinking (5 years) than treatment (Weisner et al 2003a) Correlations between variables…

3. Background II Clients’ perspective on/explanations for change: quantitative (cf. Matzger et al 2005) and qualitative research (cf. Orford et al 2006; McIntosh & McKeganey 2000). Matzger et al 2005: Reasons cut down endorsed among the treated (alc): 73% weighting pros/cons; 68% major change in life; 67% hit rock bottom; 58% drinking cause health problems; 45% traumatic experience; 43% religious/spiritual awakening; 38% spouse wanted cut down; 37% affected by seeing someone drunk/high; 32% doctor’s warning health problems/cut down; 31% someone know quit. Theory/model of change by Orford et al 2006 (the UKATT study): Pre-treatment catalysts (pressures seek tx, accelerating problems etc), treatment (incl. assessment), self-directed change, family and friend support, thinking differently, acting differently, seeing the benefits.

4.  Aim and questions The aim is to explore clients’ endorsed reasons for cuttingdown on alcohol and drug use (from a list of potential factors), among alcohol and drug users one (and 5) year(s) after initiating a treatment episode: Which reasons are endorsed and viewed as (most) important for cutting down? - Hypothesis: social, personal/self-evaluative and network-related reasons are more important than treatment. Are there patterns of reasons for cutting down? Do some reasons occur together? For whom is treatment the most influential reason for cutting down – when and for whom does treatment work? Are there differences by sex? 4

5. Data & Method Large, representative and naturalistic treatment system sample (Stockholm County, covering the range of treatment on offer in health and social welfare system) 1210 alcohol and drug misusers interviewed and re-interviewed (12 months): 65-80% response rate depending on calculation List of 10 reasons to cut down (adapted from Matzger, Kaskutas & Weisner 2005) asked of those who reported a reduction in drinking or use of main drug of choice in the last year. - n=613 alcohol users (52% had cut down) and 434 drug users reported a reduction (64%) and were asked for their reasons. Preliminary: Reasons to cut down after 5 years, random sample followed-up (items reformulated to better fit Matzger et al 2005) 5

6. Characteristics of followed-up clients At baseline (BL): 1/3 women, mean age 43 yrs 56% had own apartment/house 27% work as main occupation (30 days) 24% married/cohabiting, 33% had children <18 21% had NOT been in tx last year, 32% had 90+ days in tx Changed consumption between BL and follow-up (FU) Mean no. alc using days out of 30: 8  4,7 Mean no. 5+ drinks out of 30: 7,4 3,9 Main drug among those who had used drugs (12 months): 40% opiate, 22% cannabis, 18% amphetamines, 14% benz, 6% other Mean no. drug using days out of 30: 14,4  5,2 6

7. Reasons to cut (% yes)

8. Factor analyses (note: 0/1 endorsed)

9. Most important (%)

10. Correlates/log reg variables – when/for whom tx most influential Demographics/social situation: (sex), age, housing, living situation last 3 years, live with alc/drug misuser, hang out with misusers or not, have at least one close friend, education, main source of income, severity- no of dependence criteria (for alc, drugs) and simultaneous alc/drug dependence (3+ ICD-10), Tx need alc, drugs, physical health, judicial problems, family, mental health BL treatment: recruited from Health system (HS) detox, HS special programs, HS outpatient, Social services (SS) outpatient, SS housing, SS residential + No of months in tx last year (history) Treatment BL-FU: HS addiction inpatient, HS addiction outpatient, HS mental health, HS general health care, SS residential, SS housing, SS outpatient, criminal justice system, voluntary organization/self-help group, private sector + continuity/coordination scale 10

11. Sig. Odds ratios – Treatment most important cut down on.. ALCOHOL Higher no of alc dep criteria (0-6): OR 1,20 Drug dependence 2,71 Institution last 3 yrs (vs partner/children 3,89 Tx need judicial problems 0,71 Elementary school (vs university, ref) 0,32 Baseline tx – NS SS residential 2,48 Continuity of care 1,33 HS mental health 0,41 DRUGS Higher no of drug dep criteria: OR1,24 Main source of income illegal activity (vs work): 2,52 Tx need judicial problems 0,72 Live with misuser 0,47 Hang out misusers and non-misusers (vs mainly non): 0,43 Baseline tx – NS SS outpatient 0,60 Private sector 4,88 11

12. 5 years: Reasons to cut (% yes) Very preliminary! (n= c 350 alc, 140 drug)

13. To sum up Treatment IS important for cutting down on alc/drugs, according to clients – hypothesis falsified (Note: treated sample) Personal/self-evaluative reasons also important (tired of life, stopped/decreased by self) Treatment more important for more severe problems (no. of dep criteria). Tendency: inpatient treatment - more likely say tx most influential. Non-misusing social networks (and social situation – housing etc) – not as important for change/recovery as in international literature Treatment interact with other factors (jfr Orford et al 2006), but separated from self-directed change (cf “Assisted and comprehensive make-over”) Women more likely than men reduce drinking because of changes in circle of friends, overwhelming experience, becoming religious. Men stress self-directed change. Stereotypical images  more research is needed 5 year data validates findings from 1 year (preliminary) 13

14. Discussion Cultural differences in change/recovery? Religion/hit rock bottom much more important in US than in Sweden – influence of AA? Treatment more important when easily available (Sweden)?  Further international comparisons needed! Useful way study change? How measure? Who is to judged what works – client, researcher, practitioner, correlates... combination? Constructions/narratives of change? 14

15. Thank you for listening! REFERENCES Berglund, M., Thelander, S., Salaspuro, M., Franck, J., Andréasson, S., Öjehagen, A. 2003. Treatment of alcohol abuse: An evidence-based review. Alcoholism: Clinical and Experimental Research, 27(10), 1645-1656. Matzger, H., Kaskutas, L.A., Weisner, C. 2005. Reasons for drinking less and their relationship to sustained remission from problem drinking. Addiction, 100(x), 1637-1646. McIntosh, J. & McKeganey, N. 2000. Addicts’ narratives of recovery from drug use: constructing a non-addict identity. Social Science & Medicine, 50(10), 1501-1510. Moos, R., Moos, B. 2005. Sixteen-year changes and stable remission among treated and untreated individuals with alcohol use disorders. Drug and alcohol dependence, 80(3), 337-347. Orford, J. et al. on behalf of the UKATT Research Team. 2006. The clients’ perspective on change during treatment for alcohol problem: Qualitative analysis of follow-up interviews in the UK Alcohol Treatment Trial. Addiction, 101, 60-68. Prendergast, M., Podus, D., Chang, E. & Urada, D. 2002. The effectiveness of drug abuse treatment: a meta-analysis of comparison group studies. Drug and Alcohol Dependence, 67(1), 53-72. Weisner, C., Delucchi, K., Matzger, H., Schmidt, L. 2003a. The role of community services and informal support on five-year drinking trajectories on alcohol dependent and problem drinkers. Journal of Studies on Alcohol, 64, 862-873. Weisner, C., Matzger, H. & Kaskutas, L. 2003b. How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals. Addiction, 98, 901-911. 15