Opioid
How does it affect us?
Opioid Use, Addiction, and Overdoses:
Read pages177 – 189in your text.
Opioid use, addiction, and overdoses have increased to alarming rates in the United States in recent years. Millions of Americans are affected by the opioid epidemic every day. Read Volkow et al.s (2014) article and pages 1-4 in Browns (2018) article before discussing the following questions:
For this weeks main post, answer the following questions. Be sure to include factual, properly cited information in your post.
What are some ways that opioid addiction is affecting the United States?
What are some forms of treatment available to those suffering from opioid addiction?
If you had a friend or family member suffering from opioid addiction, what sort of help would you recommend they seek?
References:
Brown, A. R. (2018). A systematic review of psychosocial interventions in treatment of opioid addiction,Journal of Social Work Practice in the Addictions. Advance online publication. doi:10.1080/1533256X.2018.1485574
Coon, D.,Mitterer, J.O., & Martini, T. (2019).Introduction to psychology: Gateways to mind and behavior(15th ed.). Belmont, CA:CengageLearning.
Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies tackling the opioid-overdose epidemic.New England Journal of Medicine, 370(22), 2063-2066. doi:10.1056/NEJMp1402780
PSYCHOLOGY DISCUSSION RUBRIC
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P E R S P E C T I V E
2063
hensive approaches to chronic pain
into their scope of services.
Health care systems can in-
corporate nonjudgmental screen-
ing, brief intervention, and refer-
rals for further assessment and
treatment of addiction into all
clinical settings where opioids are
prescribed. Conversely, addiction-
treatment providers can screen
patients for pain, recognizing that
inadequately treated pain is a risk
factor for relapse.
Payers, including Medicare and
state Medicaid programs, can use
data-analysis tools to spot the red
flags of inappropriate prescribing
and refer prescribers to medical
boards or other state agencies for
further review, education, and
oversight. Prescription-drug mon-
itoring programs can also identi-
fy prescribers in need of assis-
tance. Coherent, evidence-based
review of clinical practice can be
conducted with the
aim of supporting
high-quality care
for both chronic pain and addic-
tion and avoiding the unin-
tended consequence of deterring
physicians from caring for pa-
tients with complex needs.
Public and private insurers can
provide as generous coverage for
treatment of opioid-use disorder
as they do for management of
chronic pain. This standard is
infrequently met for example,
it is long past time for Medicare
to begin covering the effective
care provided in opioid-treatment
programs.
It is also time for the FDA to
address the intertwining of chron-
ic pain and addiction farther up-
stream in the drug-development
cycle. The agency might consider
creating a pathway for develop-
ment and review of new products
and indications for simultaneous
treatment of chronic pain and
opioid-use disorder. Building on
its own work to advance the sci-
ence of abuse-deterrent formula-
tions, the FDA should also re-
quire that prescription opioids
meet basic deterrent standards
and should facilitate the gradual
reformulation of existing products
to meet such standards. In declin-
ing to apply such a standard to Zo-
hydro, the agency noted that ex-
isting deterrent mechanisms have
had minimal impact by them-
selves. However, even modest
safeguards have been shown to
reduce the potential for inappro-
priate use.5 As part of a compre-
hensive strategy, a set of reason-
able requirements for opioid
medications is well in line with
the FDAs public health mission.
Taking such action will deter
others with less expertise from
filling a perceived void.
In the end, pointing the finger
at Zohydro is not going to resolve
the tension that exists today be-
tween chronic pain and addiction.
All concerned about the treatment
of chronic pain and all responding
to the rise in overdose deaths need
to come together to promote high-
quality and effective prevention
and treatment for both conditions.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Institutes for Behavior Resources
(Y.O.) and the Maryland Department of
Health and Mental Hygiene ( J.M.S.) both
in Baltimore.
This article was published on April 23, 2014,
at NEJM.org.
1. Public health grand rounds prescrip-
tion drug overdoses: an American epidemic.
Atlanta: Centers for Disease Control and Pre-
vention, February 18, 2011 (http://www.cdc
.gov/about/grand-rounds/archives/2011/
01-February.htm).
2. Policy impact: prescription painkiller
overdoses. Atlanta: Centers for Disease Con-
trol and Prevention, July 2, 2013 (http://
www.cdc.gov/HomeandRecreationalSafety/
pdf/PolicyImpact-PrescriptionPainkillerOD
.pdf ).
3. FDA Commissioner Margaret A. Ham-
burg statement on prescription opioid
abuse. Silver Spring, MD: Food and Drug
Administration, April 3, 2014 (http://www
.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/ucm391590.htm).
4. Federation of State Medical Boards of the
United States. Pain management policies:
board by board overview. February 2014
(http://www.fsmb.org/pdf/GRPOL_Pain_
Management.pdf ).
5. Severtson SG, Bartelson BB, Davis JM, et
al. Reduced abuse, therapeutic errors, and
diversion following reformulation of extend-
ed-release oxycodone in 2010. J Pain 2013;
14:1122-30.
DOI: 10.1056/NEJMp1404181
Copyright 2014 Massachusetts Medical Society.
Chronic Pain, Addiction, and Zohydro
Medication-Assisted Therapies Tackling the Opioid-
Overdose Epidemic
Nora D. Volkow, M.D., Thomas R. Frieden, M.D., M.P.H., Pamela S. Hyde, J.D., and Stephen S. Cha, M.D.
The rate of death from over-doses of prescription opioids
in the United States more than
quadrupled between 1999 and
2010 (see graph), far exceeding
the combined death toll from co-
caine and heroin overdoses.1 In
2010 alone, prescription opioids
were involved in 16,651 overdose
deaths, whereas heroin was im-
plicated in 3036. Some 82% of
the deaths due to prescription
An audio interview
with Dr. Olsen
is available at NEJM.org
The New England Journal of Medicine
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P E R S P E C T I V E
n engl j med 370;22 nejm.org may 29, 20142064
opioids and 92% of those due to
heroin were classified as unin-
tentional, with the remainder be-
ing attributed predominantly to
suicide or undetermined intent.
Rates of emergency department
visits and substance-abuse treat-
ment admissions related to pre-
scription opioids have also in-
creased markedly. In 2007,
prescription-opioid abuse cost in-
surers an estimated $72.5 billion
a substantial increase over
previous years.2 These health and
economic costs are similar to
those associated with other chron-
ic diseases such as asthma and
HIV infection.
These alarming trends led the
Department of Health and Hu-
man Services (HHS) to deem pre-
scription-opioid overdose deaths
an epidemic and prompted multi-
ple federal, state, and local ac-
tions.2 The HHS efforts aim to si-
multaneously reduce opioid abuse
and safeguard legitimate and
appropriate access to these med-
ications. HHS agencies are im-
plementing a coordinated, com-
prehensive effort addressing the
key risks involved in prescription-
drug abuse, particularly opioid-
related overdoses and deaths.
These efforts focus on four main
objectives: providing prescribers
with the knowledge to improve
their prescribing decisions and the
ability to identify patients prob-
lems related to opioid abuse, re-
ducing inappropriate access to
opioids, increasing access to effec-
tive overdose treatment, and pro-
viding substance-abuse treatment
to persons addicted to opioids.
A key driver of the overdose
epidemic is underlying substance-
use disorder. Consequently, ex-
panding access to addiction-
treatment services is an essential
component of a comprehensive
response.2 Like other chronic dis-
eases such as diabetes and hyper-
tension, addiction is generally
refractory to cure, but effective
treatment and functional recov-
ery are possible. Fortunately, cli-
nicians have three types of medi-
cation-assisted therapies (MATs)
for treating patients with opioid
addiction: methadone, buprenor-
phine, and naltrexone (see table).
Yet these medications are mark-
edly underutilized. Of the 2.5 mil-
lion Americans 12 years of age or
older who abused or were depen-
dent on opioids in 2012 (according
to the National Survey on Drug
Use and Health conducted by the
Substance Abuse and Mental
Health Services Administration
[SAMHSA]), fewer than 1 million
received MAT.
When prescribed and moni-
tored properly, MATs have proved
effective in helping patients re-
cover. Moreover, they have been
shown to be safe and cost-effec-
tive and to reduce the risk of over-
dose. A study of heroin-overdose
deaths in Baltimore between 1995
and 2009 found an association
between the increasing availabil-
ity of methadone and buprenor-
phine and an approximately 50%
decrease in the number of fatal
overdoses.3 In addition, some
MATs increase patients retention
in treatment, and they all improve
social functioning as well as re-
duce the risks of infectious-disease
transmission and of engagement
in criminal activities. Nevertheless,
MATs have been adopted in less
than half of private-sector treat-
ment programs, and even in pro-
grams that do offer MATs, only
34.4% of patients receive them.4
A number of barriers contrib-
ute to low access to and utilization
of MATs, including a paucity of
trained prescribers and negative
attitudes and misunderstandings
Tackling the Opioid-Overdose Epidemic
N
o
. (
p
er
U
.S
. p
o
p
u
la
ti
o
n
)
8
3
4
1
2
0
5
6
7
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Kilograms of opioids
sold (per 10,000)
Deaths due to opioid
overdose (per 100,000)
Admissions for opioid-abuse
treatment (per 10,000)
AUTHOR:
FIGURE:
ARTIST:
OLF:Issue date:
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.
Please check carefully.
Volkow
1
mst
5-29-14 4-23-14
Opioid Sales, Admissions for Opioid-Abuse Treatment, and Deaths Due to Opioid
Overdose in the United States, 19992010.
Data are from the National Vital Statistics System of the Centers for Disease Control
and Prevention, the Treatment Episode Data Set of the Substance Abuse and Mental
Health Services Administration, and the Automation of Reports and Consolidated
Orders System of the Drug Enforcement Administration.
The New England Journal of Medicine
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n engl j med 370;22 nejm.org may 29, 2014
P E R S P E C T I V E
2065
Tackling the Opioid-Overdose Epidemic
about addiction medications held
by the public, providers, and pa-
tients. For decades, a common
concern has been that MATs
merely replace one addiction with
another. Many treatment-facility
managers and staff favor an ab-
stinence model, and provider
skepticism may contribute to low
adoption of MATs.4 Systematic
prescription of inadequate doses
further reinforces the lack of
faith in MATs, since the resulting
return to opioid use perpetuates
a belief in their ineffectiveness.
Policy and regulatory barriers
are another concern. A recent re-
port from the American Society
of Addiction Medicine describing
public and private insurance cov-
erage for MATs highlights several
policy-related obstacles that war-
rant closer scrutiny. These barri-
ers include utilization-manage-
ment techniques such as limits
on dosages prescribed, annual or
lifetime medication limits, initial
authorization and reauthorization
requirements, minimal counsel-
ing coverage, and fail first cri-
teria requiring that other thera-
pies be attempted first (www.asam
.org/docs/advocacy/Implications
-for-Opioid-Addiction-Treatment).
Although these policies may be
intended to ensure that MAT is
the best course of treatment, they
may hinder access and appropriate
care. For example, maintenance
MAT has been shown to prevent
relapse and death but is strongly
discouraged by lifetime limits.5
In addition, although Medicaid
covers buprenorphine and metha-
done in every state, some Medic-
aid programs or their managed-
care organizations apply the
utilization-management policies
described above. Most commer-
cial insurance plans also cover
some opioid-addiction medications
most commonly buprenorphine
but coverage is generally lim-
ited by similar policies, and ac-
cess to care may be limited to
in-network providers. Few private
insurance plans provide coverage
for the depot injection formula-
tion of naltrexone, and most do
not cover methadone provided
through opioid treatment pro-
grams.
Implementation of the Afford-
able Care Act (ACA) will increase
access to care for many Ameri-
cans, including persons with ad-
diction. This expansion builds on
the Mental Health Parity and Ad-
diction Equity Act, which re-
quires insurance plans that offer
coverage for mental health or
substance-use disorders to pro-
vide the same level of benefits
that they do for general medical
treatment. The ACA significantly
extends the reach of the parity
laws requirements, ensuring that
more Americans have coverage
for mental health and substance-
use disorders and that coverage
complies with the federal parity
requirements. These reforms pre-
sent new opportunities for reduc-
ing prescription-opioid abuse and
Characteristics of Medications for Opioid-Addiction Treatment.
Characteristic Methadone Buprenorphine Naltrexone
Brand names Dolophine, Methadose Subutex, Suboxone, Zubsolv Depade, ReVia, Vivitrol
Class Agonist (fully activates opioid re-
ceptors)
Partial agonist (activates opioid recep-
tors but produces a diminished re-
sponse even with full occupancy)
Antagonist (blocks the opioid receptors
and interferes with the rewarding
and analgesic effects of opioids)
Use and effects Taken once per day orally to reduce
opioid cravings and withdrawal
symptoms
Taken orally or sublingually (usually
once a day) to relieve opioid crav-
ings and withdrawal symptoms
Taken orally or by injection to diminish
the reinforcing effects of opioids
(potentially extinguishing the asso-
ciation between conditioned stimuli
and opioid use)
Advantages High strength and efficacy as long
as oral dosing (which slows brain
uptake and reduces euphoria) is
adhered to; excellent option for
patients who have no response
to other medications
Eligible to be prescribed by certified
physicians, which eliminates the
need to visit specialized treatment
clinics and thus widens availability
Not addictive or sedating and does not
result in physical dependence; a re-
cently approved depot injection for-
mulation, Vivitrol, eliminates need
for daily dosing
Disadvantages Mostly available through approved
outpatient treatment programs,
which patients must visit daily
Subutex has measurable abuse liability;
Suboxone diminishes this risk by in-
cluding naloxone, an antagonist
that induces withdrawal if the drug
is injected
Poor patient compliance (but Vivitrol
should improve compliance); initi-
ation requires attaining prolonged
(e.g., 7-day) abstinence, during
which withdrawal, relapse, and early
dropout may occur
The New England Journal of Medicine
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P E R S P E C T I V E
n engl j med 370;22 nejm.org may 29, 20142066
its consequences by expanding
the number of high-risk people
who receive MATs through either
public or private insurance. The
importance of access to MATs
and other treatment services for
substance-use disorder is under-
scored by the recent recognition
of increased heroin use; what
may be less widely recognized is
that the majority of these new
heroin users initially abused pre-
scription opioids before shifting
to heroin.
HHS agencies are actively col-
laborating with public and private
stakeholders in efforts to expand
access to and improve utilization
of MATs, in tandem with other
targeted approaches to reducing
opioid overdoses.2 For example,
the National Institute on Drug
Abuse (NIDA) is funding research
to improve delivery of MATs to
vulnerable populations, includ-
ing those in the criminal justice
system. NIDA is also working to
develop new pharmacologic treat-
ments for opioid addiction and
helping to fund user friendly
delivery systems for naloxone (i.e.,
intranasal rather than injection).
SAMHSA is encouraging MAT
use in its state funding of sub-
stance-abuse treatment programs
through the Substance Abuse
Prevention and Treatment Block
Grant and regulatory oversight of
methadone and buprenorphine for
opioid addiction. Furthermore,
SAMHSA supports production
and dissemination of educational
resources to MAT prescribers, as
well as an Opioid Overdose Tool-
kit to educate first responders,
treatment providers, and patients
about ways to prevent and inter-
vene in opioid-overdose cases.
The Centers for Disease Con-
trol and Prevention is working to
empower states to implement com-
prehensive strategies, including
MATs, for preventing prescrip-
tion-drug overdoses. These strat-
egies focus primarily on address-
ing the overdose epidemic through
enhanced surveillance, effective
policies, and clinical practices that
establish statewide prescribing
norms. Such efforts can be en-
hanced by using data sources to
identify and intervene in cases of
patients or providers who fall out-
side those norms. And the Centers
for Medicare and Medicaid Ser-
vices is working to enhance access
to MATs by Medicaid programs
through improved benefit design
and application of the Mental
Health Parity and Addiction Equi-
ty Act. But to be successful, all
these initiatives require the active
engagement and participation of
the medical community.
The epidemic of prescription-
opioid overdose is complex. Ex-
panding access to MATs is a
crucial component of the effort
to help patients recover. It is also
necessary, however, to implement
primary prevention policies that
curb the inappropriate prescrib-
ing of opioid analgesics the
key upstream driver of the epi-
demic while avoiding jeopar-
dizing critical or even lifesaving
opioid treatment when it is need-
ed. Essential steps for physicians
will be to reduce unnecessary
or excessive opioid prescribing,
routinely check data from pre-
scription-drugmonitoring pro-
grams to identify patients who
may be misusing opioids, and
take full advantage of effective
MATs for people with opioid ad-
diction.
Disclosure forms provided by the au-
thors are available with the full text of this
article at NEJM.org.
From the National Institute on Drug Abuse,
National Institutes of Health, Bethesda
(N.D.V.), the Substance Abuse and Mental
Health Services Administration, Rockville
(P.S.H.), and the Center for Medicaid and
CHIP Services, Centers for Medicare and
Medicaid Services, Baltimore (S.S.C.) all
in Maryland; and the Centers for Disease
Control and Prevention, Atlanta (T.R.F.).
This article was published on April 23, 2014,
and updated on May 1, 2014, at NEJM.org.
1. Jones CM, Mack KA, Paulozzi LJ. Pharma-
ceutical overdose deaths, United States,
2010. JAMA 2013;309:657-9.
2. Addressing prescription drug abuse in the
United States: current activities and future
opportunities. Atlanta: Centers for Disease
Control and Prevention, 2013 (http://www
.cdc.gov/homeandrecreationalsafety/
overdose/hhs_rx_abuse.html).
3. Schwartz RP, Gryczynski J, OGrady KE,
et al. Opioid agonist treatments and heroin
overdose deaths in Baltimore, Maryland,
1995-2009. Am J Public Health 2013;103:917-
22.
4. Knudsen HK, Abraham AJ, Roman PM.
Adoption and implementation of medica-
tions in addiction treatment programs. J Ad-
dict Med 2011;5:21-7.
5. Clark RE, Baxter JD. Responses of state
Medicaid programs to buprenorphine diver-
sion: doing more harm than good? JAMA In-
tern Med 2013;173:1571-2.
DOI: 10.1056/NEJMp1402780
Copyright 2014 Massachusetts Medical Society.
Tackling the Opioid-Overdose Epidemic
A key driver of the overdose epidemic is
underlying substance-use disorder.
Consequently, expanding access to
addiction-treatment services is an essential
component of a comprehensive response.
The New England Journal of Medicine
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Journal of Social Work Practice in the Addictions
ISSN: 1533-256X (Print) 1533-2578 (Online) Journal homepage: http://www.tandfonline.com/loi/wswp20
A Systematic Review of Psychosocial Interventions
in Treatment of Opioid Addiction
Aaron R. Brown
To cite this article: Aaron R. Brown (2018): A Systematic Review of Psychosocial Interventions
in Treatment of Opioid Addiction, Journal of Social Work Practice in the Addictions, DOI:
10.1080/1533256X.2018.1485574
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Published online: 06 Jul 2018.
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A Systematic Review of Psychosocial
Interventions in Treatment of Opioid Addiction
AARON R. BROWN, LCSW
College of Social Work, University of Tennessee, Knoxville, Tennessee, USA
Opioid addiction has become a U.S. epidemic. It is important to
determine whether psychosocial interventions help prevent relapse.
A total of 14 studies were included in this systematic review. Most
studies compared psychosocial interventions in conjunction with
pharmacological maintenance. Only 2 studies found that psycho-
social interventions led to statistically significant benefits for out-
comes related to opioid abuse when compared to maintenance and
less or no psychosocial intervention. Psychosocial interventions
were not found to be additive to pharmacological treatments dur-
ing induction or maintenance stages. Further research is needed to
determine effectiveness of psychosocial interventions during dose
reduction and long-term relapse prevention.
KEYWORDS addiction, intervention, maintenance, opioid,
prevention, psychosocial, relapse, substance
In the last 20 years, both therapeutic and illicit opioid use have escalated in
the United States (Manchikanti et al., 2012). The total number of opioid
prescriptions dispensed from U.S. outpatient retail pharmacies increased
from 174.1 million in 2000 to 256.9 million in 2009 (Governale, 2010). Hydro-
codone is not only the most commonly prescribed opioid, it is the most
prescribed medication in the United States (Manchikanti et al., 2012).
Manchikanti et al. (2012) stated, Drug dealers are no longer the primary
source of illicit drugs (p. ES31). As the number of opioids prescribed has
increased, so has their illicit use. According to the 2014 National Survey on
Received March 11, 2017;revised June 6, 2016;accepted May 30, 2017.
Address correspondence to Aaron R. Brown LCSW, College of Social Work, University of
Tennessee, Knoxville, 1618 Cumberland Ave., Knoxville, TN 37996. E-mail: [emailprotected]
Journal of Social Work Practice in the Addictions, 00:121, 2018
Copyright Taylor & Francis Group, LLC
ISSN: 1533-256X print/1533-2578 online
DOI: https://doi.org/10.1080/1533256X.2018.1485574
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Drug Use and Health (NSDUH), prescription opioids have been the most
frequently abused psychotherapeutic drug for more than a decade, and are
second only to marijuana for all illicit drugs (Hedden et al., 2014). An esti-
mated 4.3 million individuals 12 or older are current nonmedical users of
prescription opioids, which represents 1.6% of the population aged 12 or
older in the United States (Hedden et al.). The problem of opioid abuse is
most prevalent among young adults. The same 2014 survey estimated that
2.8% of young adults aged 18 to 25 in the United States were current non-
medical users of opioids (Hedden et al.). Looking at the problem in a more
local context, Wright et al. (2014) examined opioid abuse at the county level
in Indiana and found a significant association between the rate of opioid
dispensed and the rate of opioid abuse.
A serious risk associated with prescription opioid abuse is the develop-
ment of opioid addiction, which can be defined as a pattern of compulsive,
prolonged use of opioids for nonmedical reasons or in excess of the amount
necessary for legitimate medical use marked by psychological and physiolo-
gical dependence and leading to significant impairment (American Psychiatric
Association, 2013). An estimated 2.4 million Americans suffer from a substance
use disorder related to prescription opioids, more than for cocaine and heroin
combined and second only to marijuana for illicit drugs (Ali & Mutter, 2016;
Hedden et al., 2014).
Societal Cost
Prescription opioid abuse is taking an increasingly large toll on the United States
in terms of the costs related to its prevention and treatment as well as the losses it
inflicts on families and communities. Between 2005 and 2011, the number of
emergency room visits in the United States involving abuse of prescription
opioids more than doubled from 168,379 to 366,181 (Crane, 2015). There has
also been a substantial increase in those seeking treatment for opioid abuse. The
number of individuals in the United States reporting substance abuse treatment
related to prescription opioid abuse more than doubled between 2002 and 2014
(Substance Abuse and Mental Health Services Administration [SAMHSA], 2015b).
The mortality rate in the United States associated with opioid abuse drastically
increased during this same time period, from 4,400 to 18,893 (Centers for Disease
Control and Prevention, 2016).
There have been numerous indications that costs associated with the
growing prescription opioid abuse problem in the United States are substan-
tial. However, there are many aspects of the problem that incur costs, and
research on the overall economic burden has been limited. These aspects can
be grouped into categories of criminal justice, workplace, and health care
costs. Two systematic analyses of the total U.S. societal costs of prescription
opioid abuse estimated it at more than $50 billion as of 2007 (Birnbaum et al.,
2 A. R. Brown
2011; Hansen, Oster, Edelsberg, Woody, & Sullivan, 2011). Florence, Zhou,
Luo, and Xu (2016) estimated the economic burden of prescription opioid
overdose, abuse, and dependence to be $78.5 billion as of the end of 2013.
Relapse Prevention and Opioid Abuse
Prescription opioid use and abuse in the United States have significantly
increased over the last decade. Given the substantial number of individuals
with substance use disorders related to prescription opioid abuse and the
increasing utilization of treatment for these disorders, outpatient clinicians are
more and more likely to encounter individuals who abuse prescription opioids
in their practice (Hedden et al., 2014; SAMHSA, 2015b). Typically, these clients
seek assistance in preventing relapse to maintain abstinence from the abuse of
prescription opioids. A better understanding of whether psychosocial inter-
ventions are effective for relapse prevention is needed.
The first line of treatment for opioid use disorders is often medical
detoxification, a short-term inpatient process of providing medical supervision
to assist in the achievement of abstinence while treating the symptoms of
withdrawal (Veilleux, Colvin, Anderson, York, & Heinz, 2010). The adverse
symptoms associated with withdrawal are rarely medically serious, but fear of
withdrawal might discourage individuals from seeking treatment and the
discomfort experienced during withdrawal might lead clients to drop out of
treatment (Gossop, 2006). For these re
