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. Author manuscript; available in PMC: 2025 Aug 1.
Published in final edited form as: J Subst Use Addict Treat. 2024 Jun 8;164:209430. doi: 10.1016/j.josat.2024.209430

Observations of substance use treatment engagement during the period of community re-entry following residential treatment

Noam G Newberger a, Diana Ho a, Emmanuel D Thomas a, Silvi C Goldstein a,b, Stephen M Coutu a, Alyssa L Avila a, Lynda AR Stein a,b,c, Nicole H Weiss a,*
PMCID: PMC12314836  NIHMSID: NIHMS2093560  PMID: 38852820

Abstract

Background:

The period of community re-entry following residential substance use treatment is associated with elevated risk for return to substance use. Although continuity of care is best practice, many individuals do not engage in follow-up treatment, struggle to engage in follow-up treatment, or continue to use substances while participating in follow-up treatment. There is a need to both characterize treatment engagement during community re-entry following residential substance use treatment as well as understand how treatment impacts substance use during this high-risk period.

Method:

This observational study used retrospective self-report to examine treatment engagement and substance use among individuals who had exited residential substance use treatment. Participants completed a Timeline Follow-back interview reporting substance use and treatment engagement in the 30 days following residential treatment.

Results:

Most participants (83.1 %) reported engaging in substance use treatment following discharge. The most common treatments were Alcoholics Anonymous/Narcotics Anonymous (61.1 %), medication for addiction treatment (40 %), and outpatient therapy (29.2 %). Participants were less likely to use substances on a day in which they engaged in outpatient therapy (OR = 0.32, 95 % CI [0.12, 0.90], p = 0.030) and more likely on days they engaged in medication treatment (OR = 21.49, 95 % CI [1.46, 316.74], p = 0.025).

Conclusion:

Findings characterize engagement in substance use treatment in the month following residential treatment. Treatment engagement was common during community re-entry; however, only outpatient therapy was found to reduce substance use during this high-risk period. Findings may inform intervention efforts during the high-risk period of community re-entry.

Keywords: Substance use, Treatment, Community re-entry, Continuity of care

1. Introduction

Nearly four million people seek treatment for substance use each year, of whom approximately 1.3 million (32.5 %) receive inpatient treatment at a rehabilitation or residential facility (Substance Abuse and Mental Health Administration, 2022). Residential treatment for substance use is a 24-h, structured level of care that places an emphasis on providing safe and stable housing, medical care, and recovery skills for individuals (Morey, 1996). Residential treatments aim to help individuals achieve stability and build recovery skills that can be implemented once they are discharged. However, individuals often leave residential treatment feeling unprepared for success in their recovery goals during the transition back into the community (Johannessen et al., 2020). Indeed, the period of community re-entry following discharge from residential substance use treatment is characterized by high rates of return to substance use (Andersson et al., 2019). Individuals are at highest risk for returning to use during the first month after leaving residential treatment (Nordfjærn, 2011). Returning to use after prolonged abstinence, such as that associated with residential treatment, is associated with increased risk of overdose, hospitalization, and death (Bukten et al., 2017). Thus, the period of community re-entry is a time during which individuals are at increased risk for returning to substance use and experiencing consequences associated with return to use.

Continuity of care following residential treatment is essential to promoting recovery from substance use (Blodgett et al., 2014). Residential treatment programs, although intended to provide lasting recovery skills to individuals, are often focused on acute stabilization and achieving abstinence rather than prioritizing linkage to care following discharge (Dennis & Scott, 2007). Indeed, although linkage to care is best practice, and although individuals may receive brief aftercare services, individuals are often left to organize their own outpatient care when transitioning from treatment (Stanojlović & Davidson, 2021). Even if individuals receive discharge planning and referrals to outpatient care, factors such as patient eligibility, provider knowledge, and treatment capacity may serve as barriers to follow-up treatment (Blevins et al., 2018). In a review of the effectiveness of residential treatment, de Andrade et al. (2019) notes that best practice in the context of residential treatments includes continuity of care post-discharge, but that few studies have tested the effects of continuity of care. Furthermore, studies assessing the lasting effects of residential treatment and the effects of aftercare on outcomes often follow up with individuals three months post-discharge or later (de Andrade et al., 2019). Given this gap in research, and the risks associated with community re-entry, there is a need to examine continuity of care immediately following discharge from residential treatment.

One study, by Cole et al. (2022), found that 63 % and 47 % of all residential treatment patients did not receive any follow up treatment at 7- and 30-days following discharge, respectively. This finding is especially notable given the heightened risk of return to use, overdose, and death during the first month following discharge from residential treatment (Andersson et al., 2019; Bukten et al., 2017). Continuing care can be defined broadly and can include any individualized follow-up treatment after residential treatment (McKay, 2009). There are a number of treatment pathways available to individuals leaving residential treatment. Potential treatments include mutual-help groups (e.g., Alcoholics Anonymous [AA], Narcotics Anonymous [NA]), medication for addiction treatment (MAT; e.g., methadone, buprenorphine, naltrexone), and outpatient therapy, among many other options. Despite these options, treatment accessibility might be limited for many people due to barriers existing at the individual, social, and structural levels (Farhoudian et al., 2022). Barriers could include psychiatric comorbidities (Priester et al., 2016), stigma (Farhoudian et al., 2022), or geographic access (Cummings, Wen, Ko, & Druss, 2014). Systemic racism can also serve as a barrier to treatment that operates at multiple levels and drives inequitable distribution of other barriers (Jordan et al., 2020). Those seeking care may experience racism directly from providers, or via policy that criminalizes rather than medicalizes (Lindsay & Vuolo, 2021). Given the variability of treatment utilization following residential treatment, there is a need to better understand patterns of treatment engagement during community re-entry.

In addition to characterizing treatment engagement, there is also a need to better understand how treatment impacts substance use during community re-entry. Even if individuals are able to access treatment, they may struggle to attend to treatment or maintain recovery success. Many individuals engage in a chronic cycle of treatment, return to use, and recovery, and nearly 60 % of individuals seeking residential treatment have previously received residential treatment (Scott et al., 2005). Furthermore, research demonstrates that individuals may continue to use substances while undergoing outpatient treatment, across different treatment types (Mahu et al., 2021; Wemm et al., 2019). Thus, beyond characterizing treatment, there is also a need to understand how treatment engagement impacts return to use, especially in the first month of community re-entry when individuals are at increased risk of return to use and associated consequences. Understanding the impact of treatment engagement will help improve understanding of the community re-entry process and help identify when and where breakdowns in the treatment pipeline occur, and thus provide crucial data for preventative interventions.

The current study was a secondary investigation of a larger experience sampling study examining the association between posttraumatic stress disorder and return to substance use. The goal of this study was to identify the types of substance use treatment that individuals engage in, as well as the timing and duration of these treatments, during the first 30 days of community re-entry following residential substance use treatment. This study also explored the effectiveness of different substance use treatment types on preventing same-day substance use during this high-risk period. Specifically, the current study examined how engagement in different types of substance use treatment on a given day impacted the likelihood of engaging in substance use on that same day.

2. Material and methods

2.1. Participants

The study recruited participants from two residential substance use treatment facilities located in the State of Rhode Island in the United States. These facilities provide residential care for individuals with a variety of needs; some individuals enter residential treatment from medically managed detoxification programs, others may be court-mandated to treatment, while others may be there voluntarily. Length of stay in treatment varies based on these factors, as well as individual preference. Behavioral healthcare organization, including residential treatments settings, are legally obligated to establish an individualized discharge plan, which can focus on services to be accessed upon discharge, activities to sustain progress made during treatment, and crisis planning. Researchers approached individuals who were scheduled to discharge from treatment within one week. Interested participants were screened to determine eligibility for the parent study. Inclusion criteria for the parent study were: (1) aged 18 years or older, (2) fluent in English, (3) owning a smartphone (because experience sampling methods were used in the parent study aims), (4) history of trauma experiences (because the parent study aims focused on posttraumatic stress disorder), and (5) scheduled to discharge from residential substance use treatment within seven days. Exclusion criteria were (a) current mania or psychosis (assessed with the Structured Clinical Interview for DSM-V [SCID-5]; First & Williams, 2016) and (b) current impairment in cognitive functioning (assessed in the baseline session using the Mini-Mental Status Exam and requiring a score > 24; Folstein et al., 1975).

2.2. Procedures

The University of Rhode Island Institutional Review Board reviewed and approved all procedures. The study had approval of leadership at the residential treatment facilities, however clinical staff were not involved in the implementation of the study or interpretation of results. At the end of each baseline interview session, participants received a list of community resources. The study provided assistance with referrals upon participant request. The principal investigator (Dr. Weiss), a licensed clinical psychologist in the state of Rhode Island, was available on-call if participants required additional trauma- and/or substance-related support.

2.2.1. Baseline session

A bachelors- or masters-level clinical psychology doctoral student conducted baseline sessions in a private office to protect participants’ safety and confidentiality. The parent study screened participants for eligibility, including asking if they had a history of lifetime trauma exposure (taken from the Primary Care PTSD Screen for DSM-5; Prins et al., 2016) and owned a smartphone. Willing and eligible participants provided informed consent and were interviewed using a structured diagnostic assessment and then answered self-report measures on a computer. Participants received $25 for completing the baseline session.

2.2.2. Follow-up session

Follow-up sessions occurred approximately 30 days after discharge from residential substance use treatment. A research assistant completed interviews in a private office to protect participants’ safety and confidentiality. Participants were interviewed using a timeline follow-back technique and then answered self-report measures on a computer. Participants received $40 for completing the follow-up session.

2.3. Measures

2.3.1. Demographics

All participants completed a demographics form that included items assessing age, gender, race, ethnicity, employment, and housing security.

2.3.2. Substance use disorder

The SCID-5 (First & Williams, 2016) is a semi-structured interview for DSM-5 diagnoses (American Psychiatric Association, 2013). The study team administered the SCID-5 to establish current and lifetime alcohol and drug (i.e., sedative/hypnotic/anxiolytic, cannabis, stimulant, opioid, inhalant, PCP, hallucinogen, other/unknown) use disorders. The SCID-5 shows moderate to excellent inter-rater reliability, including sensitivity of 0.90, specificity of 0.99, and a κ of 0.92 for any SUD (Osório et al., 2019). Internal consistency in the current sample was good for the alcohol and drug use disorders (αs ranging from 0.77 to 0.78).

2.3.3. Substance use and treatment engagement

A Timeline Follow-back (TLFB) interview (Sobell & Sobell, 1992) assessed the presence of alcohol and drug use and substance use treatment for each of the 30 days after leaving residential substance use treatment. The day of discharge was assigned Day 1. A calendar provided temporal cues to assist in recall. Types of drug use assessed included (a) sedatives/hypnotics/anxiolytics, (b) cannabis, (c) stimulants/amphetamines, (d) cocaine, (e) opioids, (f) hallucinogens, (g) PCP, (h) MDMA, (i) inhalants, and (j) “other” (with a write-in option). Dichotomous scores indicated any alcohol or drug use (coded yes [1] or no [0]), for each of the 30 days. Types of substance use treatments assessed included emergency room, inpatient hospitalization, detoxification, individual or group outpatient therapy, long-term residential treatment, short-term residential treatment, AA/NA, MAT, and “other” (with a write-in option). Participants indicated whether they engaged in a specific treatment (coded yes [1] or no [0]), for each of the 30 days. The TLFB exhibits good reliability (Sobell et al., 1996) and concurrent validity with other substance use measures (DeMarce et al., 2008).

2.4. Data management and analytic strategy

Analyses used descriptive statistics to characterize participants’ substance use and substance use treatment engagement in the 30 days following discharge from residential substance use treatment. The study calculated descriptive statistics on substance use from a dichotomized variable reflecting any use of alcohol or drugs on a given day. For substance use treatment, the study calculated descriptive statistics across all treatments, and by treatment type. Chi-square tests and descriptive statistics examined treatment engagement by race and gender.

A Logistic multilevel model with a random intercept examined the within-day associations between different substance use treatments and substance use. The dependent variable was the dichotomized variable reflecting any use of alcohol or drugs on a given day. Variables included in the model were the number of days since discharge and engagement in treatment types during a given day during the 30 days of the community re-entry process. Treatment types with low engagement were excluded from the final model. Race and gender were initially included as covariates in the model, but this was found to not influence results and was subsequently removed to maintain model parsimony. The final model included participant as a random effect and were estimated using ML and the nlminbwrap optimizer. The analysis omitted missing data listwise. The study tested models in R using the lme4 package (Bates et al., 2014).

3. Results

3.1. Descriptive results

The total sample for the parent study included 141 people, of whom one participant was excluded after the baseline session due to current mania/psychosis, 13 participants were only enrolled for the baseline session (i.e., it was the end of the data collection period and the consent was amended to continue to collect baseline data alone), 44 participants did not meet with research staff at discharge to schedule the follow-up interview (e.g., research staff not alerted of discharge, participants terminated treatment early), and 18 individuals met with research staff at discharge to schedule the follow-up interview but did not attend this interview (and research staff were unable to get ahold of them). The sample for the current study included 65 people who participated in both the baseline and follow-up sessions; this represents 78 % of all people who met with research staff at discharge to schedule the follow-up interview and 51 % of all possible participants. The only difference between those who did not complete the follow-up and those who did complete the follow-up was by gender, with 66.2 % of the included sample being women, and 60.2 % of those who did not complete the follow-up being men. Among the 65 participants that completed the TLFB, there was no missing treatment engagement or substance use data. The average age of included participants was 42.41. Participants were predominantly women (66.2 %), white (72.3 %), non-Hispanic (92.3 %), and unemployed (78.5 %). Chi-square tests demonstrated that there were no statistically significant differences in treatment engagement by race or gender. Supplemental Table 1 contains the distribution of treatment engagement by race and gender. Over half of participants (52.3 %) reported feeling secure about their housing situations during community re-entry. See Table 1 for demographic information and current SUD diagnoses as determined by the SCID-5.

Table 1.

Sample demographic characteristics.

M (SD) Range n (%)
Age 42.41 (10.67) 19–63
Gender
 Women 43 (66.2 %)
 Men 21 (32.3 %)
 Prefer not to respond 1 (1.5 %)
Racial/ethnic background
 Black or African American 6 (9.2 %)
 Native Hawaiian/Pacific Islander 1 (1.5 %)
 Bi-/multi-racial 7 (10.8 %)
 White 47 (72.3 %)
 Not listeda 4 (6.2 %)
Ethnicity
 Hispanic or Latinx 4 (6.2 %)
 Non-Hispanic or Latinx 60 (92.3 %)
 Prefer not to respond 1 (1.5 %)
Highest education completed
 Grades 6–8 3 (4.6 %)
 Grades 9–11 18 (27.7 %)
 High school 17 (26.2 %)
 College/professional school (1–4 years) 23 (35.4 %)
 College/professional school (5+ years) 4 (6.2 %)
Employment
 Full time (35+ hours per week) 3 (4.6 %)
 Part time (<35 h per week) 6 (9.2 %)
 Unemployed 51 (78.5 %)
 Not in labor force 4 (6.2 %)
 Prefer not to respond 1 (1.5 %)
Monthly household income
 $0–$9999 22 (33.8 %)
 $10,000–$19,999 5 (7.7 %)
 $20,000–$29,999 12 (18.5 %)
 $30,000–$39,999 14 (21.5 %)
 $40,000+ 11 (16.9 %)
 Prefer not to respond 1 (1.5 %)
Relationship status
 Not dating 26 (40 %)
 Dating 23 (35.4 %)
 Married 3 (4.6 %)
 Separated or divorced 11 (16.9 %)
 Prefer not to respond 2 (3.1 %)
Current substance use disorder diagnosis
 Stimulant use disorder 39 (60 %)
 Alcohol use disorder 36 (55.4 %)
 Cannabis use disorder 17 (26.2 %)
 Opioid use disorder 16 (24.6 %)
 Sedative use disorder 13 (20 %)
 Hallucinogen use disorder 3 (4.6 %)
 Phencyclidine use disorder 1 (1.5 %)
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a

Note.

a

Of the participants who indicated that their racial background was not listed, two self-described as Cape Verdean, one as Middle Eastern, and one identified as Puerto Rican.

Most participants (N = 54; 83.1 %) reported engaging in at least one day of substance use treatment in the 30 days after discharge from residential substance use treatment. Participants reported engaging in a total of 1688 days of treatment across the 30 days after residential substance use treatment, averaging out to approximately 17.88 days of treatment per person (SD = 11.16, Median = 17, Range = 1–30). There were 31 individuals (47.7 %) that engaged in multiple types of treatment during this period. The most common treatment was AA/NA, with 33 individuals (50.8 %) reporting having engaged in AA/NA on at least one day in the 30 days following discharge from residential treatment. The next most common treatment was MAT (N = 26, 40 %), followed by outpatient therapy (N = 25, 38.5 %), inpatient hospitalization (N = 3, 4.6 %), emergency room (N = 2, 3.1 %), long-term residential treatment (N = 1, 1.5 %), short-term residential treatment (N = 1, 1.5 %), peer-support specialist (N = 1, 1.5 %), and recovery coach (N = 1, 1.5 %). The most common treatment by total days of engagement was MAT (N = 734, Mean = 28.23, SD = 6.29, Median = 30, Range = 1–30), followed by AA/NA (N = 579, Mean = 17.55, SD = 9.48, Median = 15, Range = 1–30) and outpatient therapy (N = 217, Mean = 11.42, SD = 10.05, Median = 8, Range = 1–30). Table 2 includes a full description of engagement for all treatment types.

Table 2.

Treatment and return to use in the 30 days following discharge from residential treatment (N = 65).

Participants in treatment (N, %) Days of treatment (M, SD) Day of first treatment (M, SD) Return to substance use (N, %) Day of first substance use (M, SD)
All participants 54, 83.1 17.88, 11.16 1.69, 2.7 23, 35.4 9.65, 8.45
AA/NA 33, 50.8 17.55, 9.48 2, 2.18 5, 7.7 15.4, 11.99
MAT 26, 40 28.23, 6.29 2.23, 4.36 13, 20 8.92, 6.9
Outpatient 25, 38.5 11.42, 10.05 5.64, 7.52 4, 6.2 6.75, 4.5
Inpatient 3, 4.6 15.33, 14.05 14.33, 13.5 1, 1.5 28, NA
Emergency room 2, 3.1 1, 0 23.5, 6.36 1, 1.5 28, NA
Residential (long) 1, 1.5 14, NA 1, NA 1, 1.5 14, NA
Residential (short) 1, 1.5 6, NA 1, NA 0, 0 NA
Peer-support 1, 1.5 4, NA 2, NA 0, 0 NA
Recovery coach 1, 1.5 3, NA 1, NA 0, 0 NA
No treatment 11, 16.9 0, 0 NA 7, 10.8 5.57, 5.74
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Note. AA/NA = Alcoholics Anonymous/Narcotics Anonymous. MAT = Medication for Addiction Treatment, NA = Not Applicable. Treatments were not mutually exclusive. Day of first treatment/substance use refers to the first day of treatment/substance use in the 30 days after discharging from residential treatment.

Of the 54 individuals that engaged in any treatment during the community re-entry period, 46 (70.8 %) reported engaging in treatment on the first day following discharge. Another six people reported starting treatment within the first week of discharge (9.2 %). One participant initiated treatment after 14 days and another initiated treatment after 16 days. Table 2 includes a complete description of treatment initiation and treatment duration by treatment type.

With regards to substance use, 23 individuals (35.4 %) reported any alcohol or drug use in the 30 days following residential substance use treatment. Participants reported 10.83 days of alcohol or drug use on average (SD = 10.06, Median = 6, range = 1–30), and returned to substance use after an average of 9.65 days (SD = 8.45, Median = 10, range = 1–30). Among those that returned to substance use, 11 participants (16.9 %) returned to alcohol use. These individuals reported an average of 7.55 days of alcohol use (SD = 6.12, Median = 4, range = 1–18) in the 30 days following residential substance use treatment and returned to alcohol use after an average of 10.82 days (SD = 9.02, Median = 12, range = 1–30). Among those that returned to substance use, 15 participants (23.1 %) returned to drug use. These individuals reported an average of 12.27 days of drug use (SD = 11.56, Median = 7, range = 1–30), and returned to drug use after an average of 8.2 days (SD = 7.46, Median = 5, range = 1–26). Supplemental Table 2 includes a full breakdown of substance use by treatment type during the 30 day period of re-entry.

3.2. Model results

Model results are reported in Table 3. Engaging in outpatient therapy on a given day was significantly negatively associated with substance use on that same day. For individuals that reported any outpatient therapy, the odds of reporting any substance use were 0.32 times the odds of any substance use among those that did not report any outpatient therapy (OR = 0.32, 95 % CI [0.12, 0.90], p = 0.030). For individuals that reported any MAT, the odds of reporting any substance use were 21.49 times the odds of any substance use among those that did not report any MAT (OR = 21.49, 95 % CI [1.46, 316.74], p = 0.025). No other treatment types were associated with a significant change in likelihood of substance use on the same day.

Table 3.

Odds of substance use during community re-entry by treatment.

Predictors Odds ratios Confidence interval p
(Intercept) 0.00 0.00–0.01 <0.001
Days after discharge 1.04 1.01–1.06 0.008
Inpatient hospitalization 0.22 0.02–2.40 0.216
Medication for addiction treatment 21.49 1.46–316.74 0.025
Outpatient therapy 0.32 0.12–0.90 0.030
Alcoholics anonymous/narcotics anonymous 1.29 0.42–3.49 0.656
Random effects
σ2 3.29
τ00 59.62
ICC 0.95
N 65
Observations 1950
Marginal R2/conditional R2 0.040/0.950
AIC 650.15
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Note. σ2 = Residual variance. τ00 = Between-group variance. ICC = Intraclass correlation coefficient. AIC = Akaike Information Coefficient. Bold p-values indicate p < 0.05.

4. Discussion

The present study sought to characterize substance use treatment engagement and examine the same-day associations between substance use and treatment engagement during the period of community re-entry following residential substance use treatment. Results demonstrated that 83.1 % of the sample engaged in at least one day of substance use treatment during the 30-day re-entry period. In the 30 days following residential treatment, participants reported engaging in, on average, 18 days of substance use treatment, with AA/NA, MAT, and outpatient therapy as the most common treatments. Most participants reported engaging in substance use treatment on the first day following discharge from residential treatment, and nearly half of the sample endorsed engagement in multiple types of substance use treatment during the 30-day re-entry period. Over one-third of the sample returned to substance use after leaving residential treatment. Return to use occurred on average 10 days after re-entering the community. Engagement in outpatient therapy was associated with significantly lower odds of using substances on a given day, and engagement in MAT was associated with increased odds of using substance on a given day. Engaging in AA/NA was not associated with the likelihood of same-day substance use.

These findings highlight the nuances of treatment engagement in the 30 days following residential substance use treatment. Although the experience of leaving residential substance use treatment and continuing care can be tumultuous and marked by difficulty for many (De Andrade et al., 2019; Johannessen et al., 2020), participants in this study were able to engage in substance use treatment post-discharge. Cole et al. (2022) and other research (e.g., Sannibale et al., 2003) has demonstrated that approximately 50 % of individuals leaving residential do not access follow-up care. However, the current study found that 83 % of individuals leaving residential treatment engaged in some follow-up in the first 30 days after leaving residential settings. This discrepancy may be due to Cole and authors not assessing outpatient therapy engagement, daily treatment engagement, and not examining engagement in the State of Rhode Island. Thus, differences reported here may be explained by the nature of treatments assessed, the timing of follow-up assessments, or local policy factors.

The most common treatment type was AA/NA, with half of participants (50.8 %) engaging in at least one day of treatment during the 30-days post-discharge. This finding aligns with previous research demonstrating the popularity of AA/NA groups (Morgenstern et al., 2003), as well as with evidence that treatment providers often recommend AA/NA groups to individuals leaving residential treatment (Kelly et al., 2008). Additionally, AA/NA groups are free and widely accessible, thus removing many financial, geographic, and policy barriers to entry. Results suggest that participants engaged with AA/NA on more than half of the days (M = 17.55). Consistent with previous research (Witbrodt et al., 2012), however, there was significant variability in AA/NA engagement (SD = 9.48), suggesting that individuals engage with AA/NA groups in different ways, with some participants engaging daily, intermittently, or less consistently over time. Research has shown that greater AA/NA engagement earlier during post-discharge is associated with better long-term outcomes (Kelly et al., 2008). However, within the 30 days following residential treatment, engaging in AA/NA on a given day was not associated with one’s (reduced) likelihood of substance use on that same day. Replicating with larger samples, examining other clinically significant substance use outcomes (e.g., substance-related harms), and considering motivation for treatment are important next steps in this research.

MAT was the second most-common substance use treatment type, with 40 % of the sample engaging in at least one day of MAT during the re-entry period. This reflects greater MAT engagement than national estimates, which suggest only 22 % of those who would benefit from MAT receive it (Jones et al., 2023). MAT is often considered the gold-standard of care, but access to MAT inside and outside of residential treatment is limited (Huhn et al., 2020). Of people in the current sample who reported any MAT use during the 30-day period of community re-entry following residential substance use treatment, MAT was reported on almost all days (M = 28.23). This suggests that participants of the current study were able to engage in daily MAT during the period of community re-entry. Despite this attendance, engaging in MAT on a given day was associated with increased likelihood of substance use on that same day. This finding may reflect patterns of non-prescribed substance use concurrent with MAT (Taylor, 2015). Alternatively, it may be a result of the current study collapsing across all MATs and across all substances. Specific medications are used to address use of specific substances (e.g., methadone for opioids); thus, engaging in MAT may be effective treatment for targeted substances but not others. Future research would benefit from identifying the specific medications being used to treat specific substances and examining the impact of those medications on their targeted substance during the period of community re-entry following discharge from residential treatment.

Participants also frequently engaged in outpatient therapy for substance use, with 38.5 % of participants reporting engaging in at least one day of individual and/or group outpatient therapy during the 30 days following residential treatment. In the current study, participants engaged in, on average, 11.42 days of outpatient therapy. Although participants reported relatively fewer number of days of outpatient therapy compared to MAT or AA/NA, two to three days of outpatient therapy per week reflects a sufficient level of care. Attending at least one outpatient appointment per week has been found to improve substance use outcomes among those seeking continuity of care (Schaefer et al., 2008). The current sample seemed to have no issues attending outpatient care; however, access to outpatient treatment and treatment retention may be a concern for several reasons. Client dissatisfaction, difficulty scheduling, insurance coverage (as determined by federal and state policy, and by what is accepted by treatment providers), and racial and ethnic identity have all been found to impact treatment access and attendance (Cummings, Wen, Ritvo, & Druss, 2014; Lappan et al., 2020, Laudet et al., 2009; Mennis et al., 2019). While treatment retention can hinder treatment effectiveness, research has demonstrated that outpatient treatment can be as effective as residential treatment programs at reducing substance use (McCarty et al., 2014). Findings from the current study support this, as those reporting outpatient therapy were significantly less likely to report substance use on that same day. Understanding the roles of individuals’ preferences and motivation for outpatient therapy, financial stability, racial and ethnic identity, and health insurance coverage, as well as provider insurance policy, as it relates to treatment attendance and outcomes will be an important next step for future research.

Given these findings, it is important to consider how treatments differ and how these differences may have influenced our findings. For example, AA/NA settings often require abstinence, and attending AA/NA groups and outpatient therapy while intoxicated is considered a violation of treatment rules (Kelly et al., 2020; Washton & Zweben, 2006). On the other hand, MAT may not require abstinence, and using certain substances (e.g., cannabis) while engaging in specific MATs (e.g., opioid agonist treatments) may not be contraindicated or impact negative outcomes (Arnold et al., 2021). Thus, greater consideration of treatment context and features will improve the specificity and interpretation of research findings.

Expanding the definition of what constitutes substance use treatment to include harm reduction and other community-based treatment approaches, such as recovery community centers, that aim to reduce structural barriers to treatment engagement is an important future direction for this research. Similarly, expanding the definition of treatment effectiveness will also be an important next step. We did not assess individuals’ motivation for treatment or their recovery goals. Future research should consider giving attention to non-abstinence recovery (see Witkiewitz et al., 2020), including improvements in health and functioning, in addition to substance use outcomes.

5. Limitations and future directions

Results should be interpreted in the context of the study environment. The two residential facilities examined in the current study are subject to federal and state policy regarding treatment length, availability, and provision, insurance, and access to medication. These same factors may not be applicable to other programs or other states, and thus may impact the generalizability of the current findings. Furthermore, the current sample was a part of a larger study that required a history of trauma exposure and smartphone ownership for inclusion. Over 85 % of adults in the United States, and over 95 % of those under the age of 50, own a smartphone (Ashford et al., 2020). Additionally, rates of lifetime trauma exposure among those in residential treatment are approximately 97.5 % (Gielen et al., 2012). This suggests that the current sample did not differ significantly from the average adult in residential treatment. Also, regarding generalizability, the sample was mostly representative of the surrounding community, with the exception that Hispanic or Latinx individuals were underrepresented in the sample. It will be important for future work to consider disparate outcomes across groups such as treatment admission and post-discharge access to treatment. Examination of potential disparities may illuminate larger structural symptoms of systemic racism.

The current study did not consider when participants began MAT. Thus, it is unclear whether participants initiated MAT before or after leaving residential treatment. It is unknown whether treatment preceded substance use or vice versa on any given day because of the nature of TLFB data. Similarly, all alcohol and drug use was aggregated into one variable, limiting the specificity of the current findings, and the final model only included three substance use treatment types due to small sample sizes.

6. Conclusions

The current study characterized, and examined the associations between, daily treatment engagement and substance use among a sample of individuals leaving residential substance use treatment. This study found that AA/NA, MAT, and outpatient therapy were the most popular treatment types, and that engaging in outpatient therapy was associated with decreased likelihood of same-day substance use. These findings update our understanding of treatment engagement during the high-risk period of community re-entry immediately following residential treatment. Findings also highlight opportunities for future research to further examine preferences for treatment, treatment goals, and treatment engagement patterns with improved specificity and precision. Understanding the unique factors that influence substance use treatment engagement during the high-risk period of community re-entry following residential treatment will inform best practices for continuity of care and development of evidence-based tools that may ultimately delay and/or prevent return to substance use.

Supplementary Material

Supplemental Table 1
Supplemental Table 2

Supplementary data to this article can be found online at https://doi.org/10.1016/j.josat.2024.209430.

Acknowledgments

This research was supported by a grant from the Rhode Island Foundation awarded to Nicole H. Weiss. Work on this paper by Nicole H. Weiss was also supported by a grant from the Center for Biomedical Research and Excellence (COBRE) on Opioids and Overdose funded by the National Institute of General Medical Sciences (P20GM125507). Work on this paper by Emmanuel D. Thomas was supported by National Institute on Alcohol Abuse and Alcoholism Grant F31AA030502 and by National Institute on Alcohol Abuse and Alcoholism Grant R25AA028464. Work on this paper by Silvi C. Goldstein was supported by National Institute on Alcohol Abuse and Alcoholism Grant F31AA029274. Work on this paper by Lynda Stein was supported by U01DA05044.

Declaration of competing interest

The authors have no conflicts of interest to report. This research was supported by a grant from the Rhode Island Foundation awarded to Nicole H. Weiss. Work on this paper by Nicole H. Weiss was also supported by a grant from the Center for Biomedical Research and Excellence (COBRE) on Opioids and Overdose funded by the National Institute on General Medical Sciences (P20GM125507). Work on this paper by Emmanuel D. Thomas was supported by National Institute on Alcohol Abuse and Alcoholism Grant F31AA030502 and by National Institute on Alcohol Abuse and Alcoholism Grant R25AA028464. Work on this paper by Silvi C. Goldstein was supported by National Institute on Alcohol Abuse and Alcoholism Grant F31AA029274. Work on this paper by Lyn Stein was supported by U01DA05044.

Footnotes

CRediT authorship contribution statement

Noam G. Newberger: Writing – review & editing, Writing – original draft, Formal analysis, Conceptualization. Diana Ho: Writing – review & editing, Writing – original draft. Emmanuel D. Thomas: Writing – review & editing, Writing – original draft, Project administration. Silvi C. Goldstein: Writing – review & editing, Project administration. Stephen M. Coutu: Writing – review & editing, Project administration. Alyssa L. Avila: Writing – review & editing, Project administration. Lynda A.R. Stein: Writing – review & editing. Nicole H. Weiss: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Conceptualization.

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Supplementary Materials

Supplemental Table 1
NIHMS2093560-supplement-Supplemental_Table_1.docx (17KB, docx)
Supplemental Table 2
NIHMS2093560-supplement-Supplemental_Table_2.docx (17.2KB, docx)

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