The International Journal of Psychosocial Rehabilitation
 

Abstinence Predictors among Substance Dependents 

Treated in a Brazilian Psychosocial Care Center

 

Maiko Marini, RN, MSc
Graduate Program in Nursing
Federal University of Rio Grande do Sul (UFRGS)
Porto Alegre (RS). City Department of Health of Caxias do Sul (RS), Brazil.

 Giovana Bertassi Brandalise
Undergraduate Program in Psychology
University of Caxias do Sul (UCS)

Taciana Madruga Schnornberger
Undergraduate Scientific Research Program
 
CNPq-UFRGS, Porto Alegre (RS), Brazil

Elizeth Heldt, RN, PhD

Graduate Program in Nursing
Federal University of Rio Grande do Sul (UFRGS)
 Porto Alegre (RS), Brazil
Graduate Program in Medical Sciences: Psychiatry, UFRGS
 Porto Alegre, RS, Brazil
 
 


Citation:
Marini M, Brandalise GB, Schnornberger TM & Heldt E. (2012) Abstinence Predictors among Substance Dependents
Treated in a Brazilian Psychosocial Care Center.
 International Journal of Psychosocial Rehabilitation. Vol 16(1) 125-135

Correspondence:
 963 São Manoel St. Porto Alegre
 Rio Grande do Sul, Brazil. Zip Code: 90620-110
 
Email: maikomarini@gmail.com 


Abstract
PURPOSE: To identify predictors of abstinence in users of Psychosocial Care Center for Alcohol and Other Drugs (CAPSad, by its initials in Portuguese). METHOD: The sample consisted of individuals with diagnosis of substance dependence being treated at a CAPSad for more than 6 months. The outcome factors - abstinence and substance use - were obtained based on the Addiction Severity Index (ASI6). Abstinence was defined as no substance use within 30 days or 6 months preceding the interview. FINDINGS: Seventy-seven individuals participated in the study. Most of them were men (n = 65; 84%), with mean age of 43.84 (SD=11.25) years. The sample was grouped into substance use (n = 27; 35%) and abstinence (n= 50; 65%). We identified significant associations between the abstinence group and lower severe problems in the areas of drugs, alcohol and social-familial. Higher psychiatric comorbidity and individual treatment with a psychiatrist were associated with the group that remained abstinence. However, the independent predictive variables for abstinence were psychiatric comorbidity (p = 0.041) and severity of alcohol dependence (p = 0.024). CONCLUSIONS: Our data indicate that individuals with psychiatric comorbidities and lower severity in the alcohol area treated at CAPSad are more likely to achieve abstinence.

Keywords:
Mental Health Services; Substance Dependence; Abstinence; Alcohol and Drugs; Comorbidities.


Introduction
Substance dependence (SD) is a significant and growing public health problem worldwide. It is a chronic and recurrent disease (Kelly, Stout, Zywiak, & Schneider, 2006; National Institute on Drug Abuse [NIDA], 2009) that is associated with negative consequences in different life domains (Laudet, Becker, & White, 2009). Population-based studies estimate that 18 to 38 million people in the world abuse or have substance dependence (United Nations Office on Drugs and Crime [UNODC], 2009). In Brazil, a study conducted in the main cities found that 2.1% of individuals had substance dependence, except for alcohol and tobacco. In addition, this study demonstrated a growth of around 3% in the number of individuals who used substance in four years. In relation to alcohol and tobacco dependence, respectively, 12.3% and 10.1% of individuals were considered addicted (Carlini et al, 2007).

Despite the advances in pharmacology and current knowledge of the psychopathology of the disease, SD treatment remains a challenge. Studies have shown that there are high rates of noncompliance (Elbreder, Silva, Pillon, & Laranjeira, 2011) among alcohol-dependent individuals. A compliance rate (individual's bond with the program, regardless of abstinence) of 30% with a multidisciplinary outpatient program at a university hospital (Garcia & Macieira, 2003).

In this context, the current Brazilian public policy "Integral Attention to Users of Alcohol and Other Drugs" recommends that the SD treatment considers the individual as a whole, respects the individuals' specific characteristics and the need to make patients comply with the treatment (Brasil, 2004a). This policy states that the treatment should be based on harm reduction (HR) (Brasil, 2004a, 2004b, 2008), which consists of policies, programs, and practices primarily aimed at reducing adverse consequences in terms of health, social and economic aspects caused by the use of legal and illegal drugs (International Harm Reduction Association [IRHA], 2011), trying to alleviate suffering and promote individual or collective well-being (Marinho, 2005).

This policy is focused on psychosocial rehabilitation model whose axis is the Psychosocial Care Center for Alcohol and Other Drugs (CAPSad, by its initials in Portuguese) (Brasil, 2004a, 2004b). This type of health care facility is an open and community health center of the Brazilian Unified Health System (SUS, by its initials in Portuguese) to which patients are referred for the treatment of problems arising from improper substance use, whose severity and/or persistence indicates the need for continuing care (Brasil, 2004b).

The public policies are managed at the CAPSad through the Therapeutic Project (TP) (Mângia & Barros, 2009). This project is characterized by a set of articulated practices focused on individuals or groups of patients. Such practices are defined by an interdisciplinary team, which results is an integrated performance of the team, valuing the different dimensions of the user under treatment, in addition to psychiatric diagnosis and medication (Brasil, 2009). The activities that may be included in the TP are: individual care (e.g., medication, psychotherapy), group care, therapeutic workshops, home visits, and detoxification (Brasil, 2004b).

TP interventions should be specific for each patient, covering the social and familial context, promoting independence and social inclusion (Cunha, 2005). Thus, broadening the interventions focused strictly on the treatment of symptoms, and offering a treatment that encompasses the other dimensions of the individual's life in a way that there is interaction with his context. This practice would also involve the support network, the individual's participation in the treatment, continued care, and dialogical actions (Mângia & Muramoto, 2006).

There is an increasing number of CAPSad in Brazil (approximately 262 units) (Brasil, 2011). However, there is no consensus on the effectiveness of this model (Alves, 2009; Diehl A, Cordeiro, & Laranjeira, 2011). Indeed, there are few recent studies evaluating the impact of current health policies on the efficacy of these centers (Gastal et al, 2007). In addition, among those studies investigating the effectiveness of psychosocial interventions, abstinence has been used as an outcome (Dutra et al, 2008).

Considering that individuals respond differently to treatment for SD (NIDA, 2009), as a consequence not everyone benefits from the TP proposed at CAPSad. However, there is a lack of studies assessing the outcomes in this therapeutic model. Therefore, the objective of the present was to identify demographic, clinical and psychosocial predictors related to abstinence in individuals treated at CAPSad in order to contribute to create guidelines regarding actions and strategies of the treatment for SD.

 Methods
This is a retrospective study comparing data regarding the 30 days prior to an assessment interview with the last six months during which the user attended the CAPSad. The study was approved by the Research Ethics Committee at Universidade Federal do Rio Grande do Sul (no. 17886) and all participants signed an informed consent form.

Participants
Participants were being treated at the CAPSad Reviver, located in the south region of Brazil, from May 2010 to April 2011. Inclusion criteria were: being older than 18 years, both sexes, having a diagnosis of SD recorded on the medical record; attending the CAPSad for at least 6 months; having completed the initial group assessments with reference professionals to determine the need for treatment at the CAPSad. According to these initial visits, the interdisciplinary team discussed a proposal of TP for each user. The team working at this CAPSad includes the following reference professionals: social workers, nurses, and psychologists. General practitioners and psychiatrists, nursing technicians, as well as music therapist, visual artists, and art therapists - who offer therapeutic workshops and do not perform the role of reference professionals. Exclusion criteria were: having severe mental deficiency, presence of psychotic symptoms, or being intoxicated at the time of interview.

A total of 285 users of the CAPSad met the inclusion criteria, and 150 individuals were randomly invited to participate in the study based on the order of visits to the CAPSad.
 
Procedures
Participants were interviewed using the sixth version of the Addiction Severity Index (ASI6) at a private office located at the CAPSad by two researchers previously trained in the use of the instrument - administration manual (Kessler &Pechansky, 2006a) and DVD (Kessler &Pechansky, 2006b). Data collectors made two different interviews with the same user in order to ensure interrater reliability. After that, the data collected were qualitatively compared for a final agreement.

The ASI6 is a semi-structured interview that characterizes and quantifies the problems commonly associated with SD (Kessler et al 2007; McLellan, Cacciola, Alterman, Rikoon, & Carise, 2006). It is considered the current gold standard in evaluations of SD (Murphy, Hser, Huang, Brecht, & Herbeck, 2010). The ASI6 weighs the severity of the problems in seven areas: medical, employment, legal, social-family, psychiatric, alcohol use, and use of other drugs. Therefore, it is a multidimensional instrument that enables an overall assessment of the individual (Cacciola, Alterman, Habing, & McLellan, 2011; Kessler et al, 2010; McLellan et al, 2006). The ASI6 is the most widely used instrument in research and the outcome indicator most commonly used in SD treatments (Ahmadi, Kampman, & Dackis, 2006; Dutra et al, 2008). It is also used to evaluate the effectiveness of the SD treatment (McLellan et al, 2006), as well as to identify relapse and abstinence predictors (Haraguchi et al, 2009).
The ASI6 was culturally adapted and validated for the Brazilian context (Kessler et al 2007, 2010). This version includes objective questions: number, severity, and duration of symptoms throughout the individual's life, within 30 days and 6 months prior to the interview; as well as subjective data: the individual's perception of the severity of current problems and the need for treatment in each area (Cacciola et al, 2011; Kessler et al 2007).
The outcome factors -- abstinence and substance use -- were obtained based on the ASI6 questions. Abstinence was defined as no substance use within 30 days to 6 months. Individuals currently using substance were those who had used substance in the 30 days preceding the interview.
Data on activities attended during the 6 months preceding the interview, psychiatric diagnoses, and medications being used were collected from the individuals' medical records.
 
Statistical Analysis
The ASI6 composite scores were calculated based on combinations of the items in each area (Kessler & Pechansky, 2006a). We used the Student's t test for independent samples and the nonparametric Mann-Whitney test to compare the parametric quantitative variables between the groups. The chi-square test was used for the analysis of the categorical variables between the groups. Logistic regression analysis was used to identify the independent variables with p < 0.05.

The statistical analyses of the variables were performed using the statistical computer program Statistical Package for the Social Sciences (SPSS) version 18.0. The significance level was set at 0.05 with a confidence interval of 95%.
 
Results
Of the 150 selected CAPSad users, 77 (51.3%) participated in the study: 13 (8.6%) refused to participate, and 60 (40%) did not attend the scheduled interviews. The mean age (standard deviation) of the sample was 43.84 (SD = 11.25) years. There was a predominance of male participants (n = 65; 84%). They had less than 8 years of schooling (n = 55; 72%). Most of them did not have a partner (n = 45; 58%) and were unemployed (n = 49; 64%). Clinical data indicate that the most frequent SD diagnosis was alcohol dependence (n = 41; 53%); whereas among the comorbidities, mood disorders were the most common (n = 17; 22%). Most individuals (80%) used medications (n = 62) and 65% met the abstinence criterion (n = 50).

Regarding the degree of concern about alcohol-related problems, need for treatment, and importance to achieve or maintain abstinence, there was moderate to extreme intensity (mean = 3.03; SD = 1.44 to 3.45; SD = 1.44). The degree of concern about problems related to the use of other drugs, need for treatment, and importance to achieve or maintain abstinence ranged from moderate to extreme intensity (mean = 3.71; SD = 0.66 to 3.80; SD = 0.52).
Characteristics of users of CAPS and abstinence.

The association between sociodemographic and clinical characteristics with abstinence is shown in Table 1. We only found significant association between presence of psychiatric comorbidity and being abstinent (p = 0.002).
 

 

 

Table 1 Association between sociodemographic and clinical characteristics with abstinence in users of CAPSad.

Characteristics

Total

n = 77

Use

27 (35%)

Abstinence

50 (65%)

P

Sociodemographic

 

 

 

 

Age (years) *

43.84 ± 11.25

44.63 ± 12.95

43.42 ± 10.33

0.656

Sex**

 

 

 

 

Male

65 (84)

25 (39)

40 (80)

0.197

Race ***

 

 

 

 

White

42 (54)

12 (44)

30 (60)

0.461

Brown

18 (23)

8 (30)

10 (20)

Black

10(13)

5(19)

5(10)

Other

7(9)

2(7)

5(10)

Educational level**

 

 

 

 

≥ 8 years

21 (28)

8 (30)

13 (27)

0.772

<8 years

55 (72)

19 (70)

36 (73)

Marital Status **

 

 

 

 

Without a partner

45 (58)

12 (44)

33 (66)

0.067

With a partner

32 (41)

15 (56)

17 (34)

Employment **

 

 

 

 

Unemployed

49 (64)

16 (59)

33 (66)

0.557

Employed

28 (36)

11 (41)

17 (34)

Clinical

 

 

 

 

Substance Dependence**

 

 

 

 

    Alcohol

41 (53)

13 (48)

28 (56)

0.633

Multiple Substance

36 (47)

14 (52)

22 (44)

Psychiatric comorbidities

29 (38)

4(15)

25 (50)

0.002

Use of medication

62 (81)

20 (74)

42 (84)

0.294

*Continuous variable, expressed as mean and standard deviation, was analyzed using the Student's t test.

**Categorical variables are presented as absolute and relative frequency (%) and were analyzed using the chi-square test.

*** Categorical variable analyzed with the chi-square test and adjusted residuals.

p <0.05

 


Severity of dependence, participation in the activities of the CAPSad and abstinence
The analysis of the severity dependence and the outcome revealed a significant association between abstinent individuals and lower severity in the areas alcohol (p = 0.012), other drugs (p = 0.033), and social-family (p = 0.006). The other areas assessed by the ASI6 did not show significant associated with the outcome (Table 2).  

 
Table 2 - Association between substance use and severity of dependence in users of CAPSad
ASI6* Total
n= 77
Use
27(35%)
Abstinence
50 (65%)
p
Alcohol 49.84 ± 6.98 52.51 ± 8.40 48.40 ± 5.65 0.012
Other drugs 38.96 ± 8.24 41.66 ± 9.92 37.50 ± 6.84 0.033
Psychiatric disorders 44.62 ± 8.16 44.62 ± 7.91 44.96 ± 8.36 0.867
Clinical problems 46.53 ± 9.42 48.37 ± 9.71 45.54 ± 9.20 0.211
Legal problems 46.52 ± 2.23 46.74 ± 2.66 46.40 ± 1.97 0.527
Employment/income 35.86 ± 5.65 36.40 ± 4.72 35.56 ± 6.11 0.533
Family 52.45 ± 7.05 53.25 ± 7.82 52.02 ± 6.64 0.466
Social-Family Support 39.38 ± 7.94 39.22 ± 7.19 39.46 ± 8.38 0.901
Social-Family Problem 47.40 ± 7.37 50.51 ± 7.00 45.72 ± 7.07 0.006
Notes: ASI6 - 6th edition of the Addiction Severity Index
* The variables are expressed as mean and standard deviation and were analyzed with the Student's t test.
p <0.05

 

Regarding the TP, we compared the type of activities attended between the abstinent group and the group of individuals who continued to use substance (Table 3). We found associations of intensive treatment (p = 0.025) and individual treatment with a psychiatrist (p = 0.010) with the group that remained abstinent. The other activities and types of care were not significantly associated. However, when compared on an ongoing basis, the total number of participations in the activities showed significance between the groups (p = 0.024), i.e., abstinent users participated in a larger number of the activities defined in the TP.
 

 

 Table 3 - Association between abstinence and treatment project at CAPSad.  
  Total
n = 77
Use
27(35%)
Abstinence
50(65%)
p  
Variables of treatment  
Model*  
Intensive 20 (26) 3 (11) 17 (34) 0.025  
Semi-Intensive 56 (73) 24 (89) 32 (64)  
Reference professional*          
Social worker* 35 (45) 11 (41) 24 (48) 0.542  
Nurse 22 (29) 7 (26) 15 (30) 0.706  
Psychologist 20 (26) 9(33) 11 (22) 0.279  
Participation in activities  
Groups#          
User 45 (58) 18 (67) 27 (54) 0.282  
Family 12 (16) 3 (11) 9 (18) 0.524  
Workshops## 33 (43) 8(11) 25 (50) 0.085  
Individual care          
Reference Technician 67 (87) 25 (93) 42 (84) 0.479  
Psychiatrist 41 (53) 9(33) 32 (64) 0.010  
General Practitioner 58 (75) 22 (81) 36 (72) 0.357  
Psychotherapy 12 (16) 2(7) 10 (20) 0.197  
Number of participations**  
Groups 3(0-9) 5(0-9) 2(0-8,25) 0,513  
Workshops 0(0-19) 0(0-15) 0.5(0-31.7) 0,070  
Individual care 8(4-12) 7(4-10) 9(4-13) 0,231  
Reference Technician 3(1-5.5) 3(2-5) 3(1-6) 0,914  
Medical Care 3(2-6) 3(2-5) 4(2-6) 0,235  
General Practitioner 2(0.5-3) 2(1-3) 2(0-3) 0,948  
Psychiatrist 1(0-4) 0(0-3) 2(0-4.2) 0,071  
Total 22 (14-40.5) 16 (13-28) 24 (16-48.2) 0.024  
Notes
* Categorical variables are presented as absolute and relative frequency (%) and were analyzed using the chi-square test*
** Continuous variables, expressed as median and interquartile range, were analyzed using the Mann-Whitney test.
p <0.05
# Relapse Prevention, Motivational, Experiences, Feelings and Women;
# # Music therapy, Painting, Body expression, Recreation, Cooking, Nutritional education, Culture of Peace, Physical Activity, Integration, Self Care, Texts and Chatting, Jewelry, Income Generation, Carving, Wall Paintings, Posters and Cards, Reuse of Materials, Art Therapy, Biodance, Needlework, Mosaic, Drawing, Newspapers, Threads, Crafts and Gardening.

 


 
Abstinence predictors at the CAPSad
We used logistic regression analysis to identify independent predictors of abstinence. Because of the small size of the sample and to select the relevant variables (p < 0.05), regression was performed separately between clinical characteristics (comorbidity, severity of alcohol dependence, other drugs, and social-family problems) and the characteristics related to the TP of the CAPSad (treatment model, full participation in the activities, and individual care with a psychiatrist). The selected variables that maintained their significance and entered the final model were: presence of comorbidity (p = 0.009), severity of alcohol dependence (p = 0.033), and individual care with a psychiatrist (p = 0.021). Among these factors, being seen by a psychiatrist was no longer significant (OR = 1.47 [0.41-5.32], p = 0.549), whereas presence of psychiatric comorbidity (OR = 4.78 [1.06-21.14], p = 0.041) and severity of alcohol dependence remained significant (OR = 1.10 [1.01-1.20], p = 0.024).

Discussion
Results showed that the presence of comorbidity was an abstinence predictor. This finding may indicate that SD is secondary to psychiatric disorders and that the continued use of psychotropic medications - which was frequent in our sample (80%) - stabilizes the symptoms of underlying disease and thus contributes to achieving and maintaining abstinence. Previous studies have also found that when comorbidities are properly treated, alcohol or other drugs abuse tend to be controlled (Schuckit, 2006). In addition, the extent of abstinence often involves the remission of the psychiatric disorder (Lejoyeux & Lehert, 2011). Furthermore, another study has demonstrated that the presence of comorbidities is associated with worse prognosis (Drake, O'Neal, & Wallach, 2008). The findings of this study indicated that being treated at a CAPSad promotes the achievement of positive results in substance abusers with psychiatric comorbidity.

The significant association between maintenance of treatment and presence of comorbidity in substance addicted individuals has been identified in a previous study. The authors included alcoholics treated in a service for SD that had a multidisciplinary team treating SD and psychiatric comorbidity at the same time. They found that had evaluated the therapeutic setting had appropriate complexity to meet the needs of individuals with this clinical picture, and thus contributed to improve their prognosis (Ribeiro et al, 2008, 2009). Therefore, the results of the present study support this consideration, bearing in mind that the association was identified with abstinence and not only with higher frequency or maintenance of treatment.

Lower severity of alcohol dependence was identified as a predictor of abstinence. Thus, this finding is in agreement with a previous study that evaluated the efficacy of a psychosocial intervention using the EuropASI (Garcia-Fernandez et al, 2011).

The demographic characteristics of our sample were similar to those of previous studies. The prevalence of males is consistent with that expected in studies involving clinical samples, whose sex ratio is 4.5:1 male/female, as well as the percentage of men seeking treatment at CAPSad (Monteiro et al, 2011; Peixoto et al, 2010). We also found prevalence of low educational level, unemployment, and not having a partner. These characteristics were similar to the sample of the study mentioned above (Peixoto et al, 2010). However, these variables were not associated with abstinence. This result was also demonstrated in a European study that did not identify a significant association between sociodemographic variables and abstinence in individuals treated for SD (Garcia-Fernandez et al, 2011).

The high frequency of alcohol dependence identified in the present study was also observed in the sample of studies conducted in other CAPSad (Monteiro et al, 2011; Peixoto et al, 2010). However, the type of substance used did not show significance, which indicates that this characteristic -alcohol dependence - is one of characteristics of the individuals who attend the CAPSad and remain in treatment, and this characteristic is not related to better outcomes. It is possible that the prevalence of this disorder in individuals being treated in this model of service is a reflection of the data of population surveys, which suggest that alcohol is the most used substance and with the largest number of dependent individuals (Carlini et al, 2007).

Most individuals of our sample (65%) were included in the study group that remained abstinent, indicating that treatment at CAPSad achieved good results when compared with different psychosocial interventions, which showed abstinence rates in about a third of the individuals treated (Dutra et al, 2008). However, these data should be analyzes with caution because the inclusion criteria of our study, such as: being treated for at least 6 months, having completed the initial assessment and medical evaluation, in addition to agreeing to participate and attending the interview, we included individuals who had better health status. Therefore, randomized trials are needed to confirm this finding.

The current policies regarding the care of individuals with abuse of alcohol and other drugs do not consider the extent of abstinence as the primary goal of treatment. However, these policies emphasize the participation of individuals in the treatment (Brasil, 2004a, 2004b, 2008) and the present sample attributed high importance to the achievement and maintenance of abstinence. Thus offering this group of subjects a treatment focused on reducing consumption would be inconsistent, considering that these individuals really want to achieve abstinence. This goal is evident, because substance dependent individuals, who keep using the drug they are addicted to, will hardly be able to control their impulsiveness of use, given that this is an inherent characteristic of SD (NIDA, 2010) Therefore, it is necessary that public policies cover the severity of the disorders related to the substance use, focusing on the need and motivation of those seeking treatment.

The present study has some limitations such as small sample size, retrospective design, and the fact that it does not have an initial assessment using the ASI6 for comparisons. Another limitation is the lack of evaluation and control of the confounding variables (e.g., individual motivation, encouragement from family and care team). However, often attending the visits indicates the individual's motivation. Nevertheless, to the best of our knowledge, this is the first study conducted at CAPSad assessing results and, at the same time, using a multidimensional assessment instrument (ASI6) at CAPSad.

Based on the results, it is possible to conclude that further studies assessing abstinence predictors at CAPSad and the effectiveness of this health services in the care of SD prospectively are needed. However, the Brazilian version of the ASI is not available yet. In the present study, the severity scores on the ASI6 were associated with the outcome. This finding suggests that assessment tools should be continuously used in research and clinical practice to help treat addicted individuals.

Currently, the adoption of CAPSad as a strategic service has been promoted. However, the use of this device alone does not meet the complex demands involving the substance use. Thus, it is necessary to consider other treatment models, such as specialized outpatient clinics, Primary Care Units, Family Health Strategies, or non-governmental institutions (therapeutic communities, Alcoholics Anonymous, Narcotics Anonymous), for individuals with single diagnosis of SD (Diehl et al, 2011).
  


 

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