Addiction (1998) 93(1), 73± 92

RE SE AR C H RE PO R T

A m eta-analysis of predictors of continued

drug use during and after treatm ent for opiate
addiction

1 1
DEVON D. BREW ER , RICH ARD F. CATALANO , KEVIN
1 2 1
HAG GERTY , RANDY R. G AINEY & CH ARLES B. FLEM ING
1
University of W ashington, Seatle, W ashington & 2 Old Dom inion University, N orfolk,
Virginia, USA

Abstract
Aim s. M any people treated for opiate addiction continu e to use drugs during and after treatm ent. It m ay
be possible to im prove outcom es by addressing patient characteristics that predict continu ed drug use. This
review uses m eta-analytic techniques to identif y risk factors for continu ed drug use in patients treated for
opiate abuse. Design and M easu rem ents. A thorough search of the published literature yielde d 69
studies that reported information on the bivariate association between one or m ore independen t variables and
continu ed use of illicit drugs during and after treatm ent for opiate addiction . F indings. M ost of the patient
variables sum m arized have weak longitud inal relationships with continue d drug use, although several
variables display m oderate longitudinal associations. Ten variables show statistically signi® cant and longitu -
dinally predictive relationships (average r . 0.1) with continue d use, includin g: high level of pretreatm ent
opiate/drug use, prior treatment for opiate addiction , no prior abstinenc e from opiates, abstinence from /light
use of alcohol, depression, high stress, unem ploym ent/em ploym ent problems, association with substance
abusing peers, short length of treatment, and leaving treatm ent prior to completion . Several other variables
m ay be potentially longitud inally predictive. C onclusions. To prevent relapse, treatm ent intervention s
should address m ultiple variables because no single variable strongly predicts continue d drug use.

Introduction ior processes. Reviews of this type are ex-

Clinicians and researchers who employ a risk-fo-
cused approach to preventing and treating health
and behavior problems rely on the empirical
literature for guidance in designing interventions
and building theories. Once literature reviews
identify predictors of health and behavior out-
comes, interventions can be developed that ad-
dress these variables to reduce the risk of
problems and test theories of health and behav-
ploratory surveys of the literature, since the
variables reviewed are selected on the basis of
whether em pirical research has been conducted
on them, and not with respect to speci® c hypoth-
eses or theoretical assum ptions. M ost literature
reviews for identifying risk factors have not used
systematic and quantitative methods for summ a-
rizing research. This is particularly true for re-
views of variables associated with continued use

Correspondence: Devon D. Brewer, Alcohol and Drug Abuse Institute, University of W ashington, Box 351415 ,
393 7 15th Avenue N.E., Seattle, W A 98195 , U SA. Tel: 1 1 206 616 9087; Fax: 1 1 206 543 5473.
Subm itted 30th August 1996; initial review completed 28th October 1996; ® nal version accepted 7th April 1997 .

0965± 2140/98/010073 ± 20 $9.50 Ó Society for the Study of Addiction to Alcohol and Other Drugs

Carfax Publishing Lim ited

74 Devon D . Brewer et al.
of drugs, or relapse, during and after drug abuse
treatment. As a result, the identi® cation of risk
factors and assessm ent of their m agnitudes has
typically not been grounded on formal, objective
criteria (although exceptions existÐ see, e.g.
Hartka et al. , 1991, and Temple et al. , 1991). In
this paper, we report a meta-analysis of predic-
tors of continued drug use during and after
treatment for opiate addiction and discuss the
effectiveness of various treatm ent interventions
in light of these results.
M ost patients treated for opiate addiction
relapse after treatment, typically within the
® rst 3 months (Hunt & Bespalec, 1974,
Hubbard & M arsden, 1986). Furthermore,
as evidenced by numerous studies summarized
in this meta-analysis, m any patients continue
to use drugs while in treatment for opiate
addiction. This pattern of continued drug use
during and after treatm ent for opiate addiction
presents a major challenge to clinicians. In order
to m eet this challenge most effectively, the vari-
ables that predict continued use must ® rst be
identi® ed and then addressed in treatment inter-
ventions.
There have been several narrative literature
reviews, varying in scope and comprehensive-
ness, of the patient variables related to outcomes
for substance abuse treatment (M cClellan, 1983;
Hawkins & Catalano, 1985; Platt, 1986, 1995;
Surgeon General, 1988; Westerm eyer, 1989;
Anglin & Hser, 1990; Catalano et al. , 1990± 91;
Alem i et al. , 1995). These reviews provide initial
indications about the variables related to contin-
ued drug use. However, these reviews summ arize
studies that typically differ in terms of the types
of substance abusers (i.e. drug abusers generally
or users of speci® c substances) examined. It is
important to distinguish between abusers of dif-
ferent substances because they may vary sub-
stantially in their individual characteristics and
because different substances have different
physiological and psychological effects, which
may in¯ uence addiction processes. Prior narra-
tive literature reviews in the area also include
studies that vary in the outcomes m easured (e.g.
continued drug use, retention in treatment,
crim inal behavior, employment or com posite
outcome measures), research design (cross-
sectional or longitudinal), and type of results
(bivariate and/or m ultivariate). Therefore, new
syntheses are required that focus on speci® c out-
comes for abusers of particular substances and
carefully consider the research designs and types
of results of the studies summarized.
M ethod
L iterature search
To locate the studies to consider for inclusion in
the m eta-analysis, we searched com puterized
databases that index published scienti® c reports,
including Expanded Academic Index (1989± ),
M edLine (1966± ), Nursing and Allied Health
(1982± ), PsycINFO (1967± ), Social Work Ab-
stracts (1977± ), Socio® le (1974± ) and the Uni-
versity of Washington libraries catalog. These
searches were current to July 1996. For search-
ing each data base, 15 pairs of keywords were
used. The 15 pairs were form ed by taking all
possible combinations between one keyword
from the set (abstinence, relapse, treatment out-
come) and one keyword from the set (buprenor-
phine, heroin, methadone, naltrexone, opiate).
W e located those reports in English identi® ed in
the database searches that were available in the
holdings of the University of W ashington li-
braries and from the University of W ashington’ s
inter-library loan service. We supplemented
these reports with other, not previously
identi® ed, published studies cited in these re-
ports and in the narrative literature reviews of
variables related to substance abuse treatment
outcom es. We also included other, not previ-
ously identi® ed reports located in our ® les.
C riteria for inclusio n
W e included a result from a study in the m eta-
analysis if the following six criteria were m et:
(1) All subjects in the study were opiate/narcotic
addicts who received either some kind of
treatm ent for their addiction or institutional-
ization during which detoxi® cation from il-
licit opiates could reasonably be assumed. If
the subjects were not speci® cally described
in terms of primary drug of abuse but all
subjects were involved in treatm ent for opi-
ate abuse (i.e. methadone or naltrexone
treatm ent), then the study was included. If
the subjects in a study were explicitly
identi® ed as primary abusers of another sub-
stance (e.g. cocaine) and were not all opiate-
dependent, the study was excluded even

though subjects received treatment tradi-
tionally designed for opiate addicts.
(2) The study included a m easure of continued
use of illicit opiates or, if this was not avail-
able, illicit drugs in general during and/or
after treatm ent. We required that the m ea-
sure index continued illicit opiate/drug use
speci® cally and not be based on inference
from other outcomes, such as employment,
criminal behavior, imprisonment or contin-
ued treatment. Outcome measures of use of
particular non-opiate drugs were not accept-
able because such m easures do not indicate
whether subjects used the speci® c non-opi-
ate drug prior to treatment. In studies of
opiate addicts, abstinence from a particular
non-opiate drug during or after treatment
does not distinguish between non-initiation
and cessation of use of that non-opiate drug
(see Hanbury et al. , 1986, for em pirical data
related to this issue). As a result, these m ea-
sures cannot be considered measures of con-
tinued use or relapse. The study was
included if the measure of continued use
was based on self-report, report from an-
other knowledgeable person (such as a par-
ent, friend, spouse, case worker, parole
of® cer, etc.), of® cial records from the treat-
m ent program or other agencies or urinalysis
results. As noted by Wells, Hawkins & Cata-
lano (1988), the types of drug use m easures
that are employed in treatm ent outcome
studies vary widely. We included studies if
the measure of continued opiate/drug use
(typically for som e speci® ed period)
re¯ ected use/non-use, level of use, amount
of time using, addiction status or time to
relapse. We did not include studies in which
continued use was measured solely by read-
m ission to treatment. In addition, we con-
sidered length of treatment, participation in
treatment, behavior in treatment, and com-
pliance with treatm ent plan to be variables
potentially related to continued opiate/drug
use and not appropriate m easures of contin-
ued use itself.
(3) The independent variable clearly speci® ed a
single patient-related construct, and not a
conglomeration of multiple constructs. An
example of a conglomeration is Suffet et al. ’ s
(1978) ª conventionalityº variable that is
based on four distinct constructs (level of
heroin use at intake to treatment, number of
Predictors of continu ed drug use 75
arrests, type of residence and employm ent).
We excluded from consideration indepen-
dent variables that referred to treatm ent pro-
gram types, policies, practices, personnel
and settings.
(4) The independent variable referre d to a tim e
period prior to or concurrent with the tim e
period to which the dependent variable re-
ferred.
(5) Individual subjects were the unit of analysis
for both the independent and dependent
variables.
(6) A bivariate effect size (Pearson’ s r , Spear-
man’ s rho, or phi) indicating the direction
and strength of association between the in-
dependent variable and continued opiate/
drug use was reported or calculable from
inform ation given in the report. The only
exception to this inclusion rule was that we
included the partial correlation results re-
ported by Kaplan & Meyerowitz (1969).
These partial correlations control only for
the length of the follow-up period, a
methodological variable, and the coef® cients
represent the essential substantive bivariate
relationship between an independent vari-
able and continued opiate use.
A num ber of studies that met these inclusion
criteria had methodological and design ¯ aws
(e.g. varying length follow-up periods, high attri-
tion). We included these studies nevertheless in
order to maximize the inform ation on which to
base the meta-analysis. W e did not include an
independent variable if only one located study
reported relevant information on the association
between that variable and continued drug use.
The m ost comm on reason for excluding a study
was that not enough information was provided in
the report with which to compute a bivariate
effect size. Unfortunately, during our literature
search we did not record precisely how many
studies were excluded for this or any other rea-
son. Due to limited resources and time, we were
not able to contact the original authors of ex-
cluded reports for their raw data that might
yield, upon re-analysis, results suitable for in-
clusion.
Study characteristics
W e located 69 studies (published in 78 reports)
which m et the inclusion criteria. These studies
76 Devon D . Brewer et al.

Table 1. Characteristics of studies included in the meta-analy sis

Characteristic N studies Mean M edian SD Range

Year of publication 69 1981 1981 10.08 1943± 96

a
Mean age of subjects 43 31.45 31.20 4.47 25± 41
Fem ale subjects (% ) 52 24 24 22 0± 100
Non-white subjects (% ) 47 60 60 24 0± 100

If a report covers multiple studies but includes a description of subject characteristics

for all studies together, then these characteristics were attributed to all of the studies
included in that report. If the report only describes the characteristics of the pool of patients
from which the sample w as drawn, then these ® gures were used. If the study included
overlapping sam ples, then mean values, com puted after weighting by the sample sizes,
were used.
a
Age at adm ission to treatm ent, during treatm ent, or after treatm ent; if m ean age was
reported for m ultiple points during a study, the value for the earliest time point was used.

consisted prim arily of evaluations of treatment
effectiveness (typically employing pre-exper-
imental or quasi-experimental designs) and ob-
servational studies to identify predictors of
treatment outcom e. Seventy reports were journal
articles, six were chapters in books or mono-
graphs, one was a paper in a conference proceed-
ings, and one was a manuscript (unpublished at
the time) in our ® les. Publication bias could
possibly distort the results of our meta-analysis,
although it is unclear why such a bias would
occur on this topic. As this paper shows, there
are no variables that strongly predict continued
drug use. G iven that situation, we feel it is
unlikely that some results for some variables
have not been published because the ® ndings
were of small magnitude or not statistically
signi® cant.
Table 1 summarizes the characteristics of the
studies included in the m eta-analysis. All studies
but one were published after 1960, and about
half (52%) were published in 1980 or later. The
typical study involved a sam ple com posed pri-
marily of male and non-white subjects who had
an average age of 31. (The coarse white/non-
white distinction was necessary because ª whiteº
is the only comm on racial/ethnic category re-
ported in studies with racially diverse subjects.)
Fifty-nine studies were conducted in the United
States, ® ve were conducted in the United King-
dom , two were conducted in Italy, and one study
each was conducted in Canada, India and Laos.
The m ost common types of treatm ent for the 69
studies were m ethadone maintenance (43%) and
hospitalization (17%). Other types of treatment
included methadone detoxi® cation (7%), nal-
trexone (9%), drug-free (6%), prison/intensive
parole supervision (3%), various treatment types
across subjects (9%) and unspeci® ed treatment
types (6%). The m ean number of independent
variables per study included in our meta-analysis
is 3.5 (range: 1± 13).
Procedures
The ® rst author extracted all inform ation from
the included research reports. We used Pearson’ s
r as the index of effect size. In computing effect
sizes from inform ation in a report, we used the
standard m eta-analytic procedures described by
Rosenthal (1991). For m ost studies, the effect
sizes were reported clearly or were easily calcu-
lated. For other studies, however, we faced sev-
eral options for determining which results to
report or how to compute them. We used the
following procedures to ensure that we made
such determinations consistently across studies.
Sam ple de® nition . When the results in an article
were reported separately for different samples or
studies, we treated these results as separate and
independent. If a result in an article was pre-
sented separately for those subjects in the com -
m unity (i.e. ª at-riskº for continued use) and for
all subjects in the study (including those who
were institutionalized), we used the result for
only those subjects in the community. Similarly,
subjects who died during the course of a study
(and for whom continued drug use data were
unavailable) or whose continued drug use status
was unknown were omitted when we computed
effect sizes. When it was clear to us that the
samples in two or more reports overlapped (or

were the same), then we considered the results
for the samples to be from a single overall study.
E ffect size com putation. When a study had mul-
tiple effect sizes for the relationship between an
independent variable and continued opiate/drug
use (e.g. from m ultiple follow-up time points,
multiple m easures of a variable or overlapping
sam ples from the same study), we computed the
weighted (by degrees of freedom ) mean r , using
Fisher’ s Z -transformed correlations (see Rosen-
thal, 1991, and Maguin & Loeber, 1996, for a
discussion of similar procedures). C oncurrent
and longitudinal associations, if both types were
available for a study, were always treated sepa-
rately in analysis and were never averaged to-
gether. The corresponding sam ple size for a
study’ s weighted mean r was the m ean sample
size for the correlations from that study that were
averaged. If a sample size was not reported for a
particular correlation, we used the m ean sample
size of the other correlations from that study
included in the meta-analysis for which the au-
thor(s) did report corresponding sample sizes. If
only a probability value was reported in an article
but the speci® c statistical test used was not men-
tioned, we assumed that the typical test for that
kind of problem was used (e.g. t -test, c 2 ). If a
variable included a category for missing data
and/or unknown status, that category was omit-
ted when we calculated effect sizes. In those
cases when neither probability values nor alpha
levels were reported, but the results were only
referre d to as ª signi® cantº , we assumed conser-
vatively that one-tailed tests and alpha levels of
0.05 were used. W hen a variable was measured
on an ordinal scale, we treated it in our effect
size computations as if it were measured on an
interval scale. If there were multiple m easures of
a variable and one m easure was on a higher level
of measurement than the others, then only the
effect size based on this measure was included.
In all cases, effect size com putations were based
on the coding rule that higher values on contin-
ued drug use indicate m ore (or any) continued
drug use and lower values indicate less (or no)
continued drug use.
Longitud inal vs. concurrent associations. W here
appropriate, we summ arized the results for a
given independent variable separately for longi-
tudinal and concurrent associations. Effect sizes
were considered longitudinal associations when
Predictors of continu ed drug use 77
the independent variable referre d to a period
preceding the period for the dependent variable;
if the periods for the two variables overlapped or
were the same, then the association was con-
sidered to be concurrent. Independent variables
could be m easured for tim e periods before, dur-
ing, or after treatment, while dependent variables
could be m easured for tim e periods during or
after treatment. Life-time measures of indepen-
dent variables (e.g. ever arrested before) were
excluded because associations between such
m easures and continued use in the studies we
reviewed could not be classi® ed clearly as longi-
tudinal or concurrent (there were no studies in
which a life-tim e measure of an independent
variable was collected at one point in time and a
m easure of continued use was collected at a later
point in time).
R esults
O verall sum m ary
W e identi® ed 28 independent variables for which
there were at least two studies with results on the
association between the independent variable
and continued drug use. Table 2 presents the
m ain meta-analytic results. The ® rst colum n lists
the independent variables, and the second and
third colum ns indicate the number of subjects
and studies, respectively, involved in the sum -
m ary for a particular independent variable. The
fourth, ® fth and sixth columns show the range,
m edian and unweighted mean (based on Fisher’ s
Z -transformations) r s, respectively, for each in-
dependent variable’ s association with continued
use. The seventh column indicates the weighted
m ean r , which was calculated by using Fisher’ s
Z -transformations and weighting the result from
each study by its degrees of freedom (n 3) before
the mean was computed (Rosenthal, 1991). The
next column shows the cum ulative Z -score that
indexes the statistical signi® cance of the combi-
nation of correlations, and the last two columns
show the standard deviation and heterogeneity c 2
value, which index the magnitude and statistical
signi® cance, respectively, of the variation among
the correlations (Rosenthal, 1991). The refer-
ences list the reports included in the meta-analy-
sis and specify which reports contributed effect
sizes for particular variables.
Since the magnitude of variation in effect sizes
is generally mild to m oderate for most variables
(as indicated by the standard deviations of the
 Table 2. M eta-analytic summary of variables related to continued drug use during and after treatment for opiate addiction
78

N of N of Range U nweighted W eighted

Variable Ss studies of rs Median r mean r Mean r Z SD c 2 (df)

Dem ographic variables

b b
(1) Age 5093 17 2 0.27/0.31 2 0.01 2 0.02 2 0.06 2 2.58 0.16 36.47 (16)
a
(2) G ender 5764 18 2 0.29/0.28 0.00 2 0.01 0.00 2 0.53 0.14 31.58 (17)
c c
(3) W hite/non-white 7431 20 2 0.25/0.55 2 0.09 2 0.03 2 0.06 2 4.05 0.19 79.66 (19)
(4) Education 1936 11 2 0.29/0.42 0.00 2 0.01 0.00 2 0.48 0.18 18.02 (10)
(5) Occupational status
Longitudinal 49 2 2 0.35/ 1 0.13 2 0.11 2 0.12 2 0.20 2 1.05 0.34 2.32 (1)
Devon D . Brewer et al.

(6) M arital status

Longitudinal 341 5 2 0.24/0.13 2 0.08 2 0.09 2 0.06 2 1.25 0.16 5.59 (4)
Drug history and degree of pre-treatm ent opiate abuse problem
(7) Level of opiate/
b
drug use 436 6 0.00/0.31 0.13 0.15 0.11 2.58 0.15 6.67 (5)
(8) Level of opiate
addiction/dependence 263 4 2 0.12/0.15 2 0.02 0.00 2 0.04 2 0.30 0.11 2.06 (3)
(9) Duration of opiate
c
addiction/use 3166 15 2 0.23/0.40 0.00 0.03 0.03 1.52 0.14 79.29 (14)
(10) Age of onset of
opiate use/addiction
or drug abuse 1762 10 2 0.25/0.03 0.00 2 0.08 2 0.07 2 2.62 b 0.11 10.75 (9)
(11) Prior treatm ent
b
for opiate addiction 1087 4 0.06/0.15 0.12 0.11 0.12 3.25 0.04 1.92 (3)
(12) Prior abstinence
c c
from opiates 227 3 2 0.63/0.00 2 0.10 2 0.28 2 0.19 2 3.40 0.34 16.37 (2)
Non-opiate drug use
(13) Overall non-opiate
drug and alcohol use
Longitudinal 861 6 2 0.10/0.24 0.07 0.07 2 0.03 0.37 0.16 10.38 (5)
c a
Concurrent 1615 5 0.11/0.35 0.22 0.22 0.27 9.43 0.09 10.64 (4)
(13a) Cocaine use
Longitudinal 443 3 2 0.09/0.24 0.21 0.12 2 0.03 0.74 0.18 6.97 (2) a
c
Concurrent 1494 4 0.14/0.35 0.24 0.24 0.28 9.91 0.09 7.47 (3)
(13b) Alcohol use
Longitudinal 607 2 2 0.11/ 2 0.10 2 0.11 2 0.11 2 0.11 2 2.68 b 0.01 0.15 (1)
a
Concurrent 737 3 0.06/0.11 0.09 0.09 0.07 2.00 0.03 0.28 (2)
13(c) Alcoholism /alcohol
dependence
a
Longitudinal 692 3 2 0.16/0.27 0.00 0.04 0.04 0.17 0.22 7.29 (2)
(13d) M arijuana use
Concurrent 610 2 2 0.06/0.27 0.11 0.11 0.22 4.00 c 0.23 9.01 (1) b
(13e) Tranquillizer use
c a
Concurrent 610 2 0.09/0.34 0.22 0.22 0.30 6.27 0.18 5.53 (1)
(13f) Amphetam ine use
Concurrent 612 2 0.17/0.41 0.29 0.29 0.21 5.76 c 0.17 5.63 (1) a

Physical and m ental health

(14) Physical health
problems
c a
Longitudinal 834 6 2 0.03/0.37 0.17 0.17 0.09 3.60 0.16 14.54 (5)
a
Concurrent 772 4 0.00/0.25 0.06 0.09 0.11 2.54 0.12 4.22 (3)
(15) Overall m ental health
problems
c
Longitudinal 1663 12 2 0.28/0.41 0.06 0.07 0.00 1.41 0.22 51.00 (11)
Concurrent 276 4 0.00/0.20 0.02 0.06 0.04 0.82 0.10 0.97 (3)
(15a) Depression
a
Longitudinal 436 4 2 0.18/0.33 0.12 0.10 0.10 1.99 0.21 5.26 (3)
Concurrent 97 2 0.00/0.29 0.15 0.15 0.10 1.18 0.21 1.82 (1)
(15b) Paranoia
Concurrent 97 2 0.00/0.29 0.15 0.15 0.10 1.18 0.21 1.82 (1)
(15c) Psycasthenia
Concurrent 97 2 0.00/0.29 0.15 0.15 0.10 1.18 0.21 1.82 (1)
(15d) Schizophrenia
Concurrent 97 2 0.00/0.29 0.15 0.15 0.10 1.18 0.21 1.82 (1)
(15e) Psychopathic deviate
Concurrent 97 2 0.00/0.00 0.00 0.00 0.00 0.00 0.00 0.00 (1)
(15f) Hypomania
Concurrent 97 2 0.00/0.00 0.00 0.00 0.00 0.00 0.00 0.00 (1)
(16) Stress/life events
a
Longitudinal 226 4 0.07/0.38 0.15 0.19 0.17 2.56 0.14 2.06 (3)

Criminal behavior and legal variables

(17) Criminal behavior/
history
Longitudinal 1305 5 2 0.16/0.25 0.04 0.04 0.06 1.30 0.15 6.85 (4)
Concurrent 1431 5 0.08/0.38 0.24 0.24 0.35 9.06 c 0.11 13.68 (4) b
(18) Legal status
b
Longitudinal 4830 7 2 0.22/0.25 2 0.02 0.00 2 0.04 2 1.64 0.18 18.47 (6)
Concurrent 1297 5 2 0.07/0.28 0.18 0.13 0.13 4.47 c 0.16 18.41 (4) b
(19) Legal problem s
Longitudinal 503 2 2 0.04/0.17 0.07 0.07 0.11 1.93 0.15 4.64 (1) a
Predictors of continu ed drug use
79
 Table 2. (continued)
80

N of N of Range U nweighted W eighted

Variable Ss studies of rs Median r mean r Mean r Z SD c 2 (df)

Employm ent-related variables

(20) Em ploym ent/
em ploym ent problems
c c
Longitudinal 2651 12 2 0.33/0.22 2 0.13 2 0.11 2 0.16 2 6.06 0.19 46.23 (11)
c c
Concurrent 1662 15 2 0.66/0.03 2 0.26 2 0.28 2 0.26 2 10.46 0.18 41.38 (14)
(21) Source of incom e/
support
c
Devon D . Brewer et al.

Concurrent 644 3 2 0.45/ 2 0.21 2 0.21 2 0.29 2 0.23 2 6.07 0.14 4.01 (2)

Psychosocial variables
(22) Self-ef® cacy
Longitudinal 73 2 2 0.32/0.08 2 0.12 2 0.13 2 0.25 2 1.52 0.28 1.78 (1)
(23) Association with
substance abusing peers
b
Longitudinal 171 2 0.08/0.36 0.22 0.22 0.20 2.74 0.20 3.50 (1)
c b
Concurrent 143 2 0.00/0.46 0.23 0.24 0.34 3.48 0.33 6.90 (1)
(24) Social support
b
Longitudinal 130 3 2 0.38/0.05 2 0.26 2 0.21 2 0.12 2 1.79 0.22 4.63 (2)
(25) Fam ily/social problems
a a
Longitudinal 563 3 2 0.03/0.34 0.11 0.14 0.05 1.99 0.19 8.04 (2)
Concurrent 273 2 0.03/0.13 0.08 0.08 0.08 1.27 0.07 0.67 (1)
(26) Residential relocation
Concurrent 155 2 2 0.41/0.00 2 0.21 2 0.21 2 0.21 2 2.63 b 0.29 7.07 (1) b

T reatm ent length and com pletion

(27) T reatment length
Longitudinal 10769 17 2 0.38/0.00 2 0.21 2 0.22 2 0.14 2 15.90 c 0.11 120.62 (16)c
c c
Concurrent 2333 6 2 0.47/ 2 0.12 2 0.29 2 0.29 2 0.23 2 11.30 0.15 25.51 (5)
(28) T reatment
Com pletion 1994 4 2 0.46/ 2 0.05 2 0.30 2 0.28 2 0.25 2 11.46 c 0.17 54.40 (3) c
a b c
p, 0.05; p , 0.01; p , 0.001.

correlations), our description of the results fo-
cuses on the average effect size estim ates (i.e.
median, unweighted m ean, and weighted m ean
r s). We also note in the text the weighted m ean
correlations computed after eliminating those
correlations coded as ª 0.00º for results reported
merely as ª non-signi® cantº (provided that two
or more studies rem ained to be combined) if
they differ from the overall results presented in
Table 2. Our primary concern is with the magni-
tude of associations. We do not consider very
weak associations to be of clinical or etiological
importance even if they are statistically
signi® cant (as indicated by the cum ulative Z -
scores).
The 28 variables can be grouped into eight
basic conceptual categories: dem ographics, drug
use history, non-opiate drug use, physical and
mental health, crim inal behavior and legal prob-
lem s, employment, psychosocial variables and
treatment length and completion.
Demographics. In comparison to the other cate-
gories of variables, dem ographic variables have
been relatively well studied with respect to their
relationships with continued drug use. All dem o-
graphic variables except occupational status
show weak or virtually non-existent (i.e. r , u 0.1u )
associations with continued use for every esti-
mate of the average correlation. Younger, non-
white and unmarried subjects are slightly more
likely to continue using than older, white and
married subjects, respectively, but gender and
education have no perceptible relationships with
continued use. Occupational status has a slight
positive relationship with continued use (with
higher status patients less likely to continue using
than lower status patients), but this ® nding is
based on only two very small studies with incon-
sistent results. After excluding the effect sizes
coded as 0.00 for results reported only as ª non-
signi® cantº , none of the weighted mean correla-
tions change for any of the demographic
variables, except age (which increases to 2 0.07
[ n 5 13]) and marital status (which increases to
2 0.08 [ n 5 4]).
Drug use history. Variables re¯ ecting subjects’
drug history and degree of opiate/drug abuse
problems before treatm ent tend to have slightly
stronger associations with continued use, al-
though these are also generally of small magni-
Predictors of continu ed drug use 81
tude. Subjects who have a long history of opiate
use/addiction and began using opiates/drugs at
an early age are slightly m ore likely to continue
using during and after treatm ent than subjects
with short histories of opiate use/addiction and
late onsets of opiate/drug use, respectively
(weighted m ean r s , u 0.08u ). Som ewhat paradox-
ically, subjects with low levels of opiate addic-
tion/dependence (as measured by self-report,
naloxone challenge and amount of methadone
required to prevent withdrawal symptoms) are
slightly more likely to continue using than those
with high levels of pretreatment addiction/depen-
dence (weighted mean r 5 2 0.04). Pretreatment
level of opiate/drug use, prior treatment for opi-
ate addiction and prior abstinence from opiates
show more substantial, although still modest,
associations with continued use. Level of opiate/
drug use refers to self-reported amount or fre-
quency of use, while self-reported level of
addiction/dependence includes other aspects of
drug problem s, such as the perceived need for
the drug. Subjects who have high levels of pre-
treatment opiate/drug use and have had prior
treatment for opiate addiction are more likely to
continue using than those with low levels of
pretreatment opiate/drug use and no prior treat-
m ent for opiate addiction (weighted mean
r 5 0.11 and 0.12, respectively). Subjects with no
prior periods of abstinence from opiates are
m ore likely to continue using than subjects with
prior periods of abstinence from opiates
(weighted mean r 5 2 0.19). After excluding the
correlations coded as 0.00 for results reported as
ª non-signi® cantº , the weighted mean correla-
tions for m ost of the drug history variables shift
slightly, as follows: level of use (r 5 0.16 [ n 5 4]),
level of addiction (r 5 2 0.05 [ n 5 3]), duration
of addiction (r 5 0.04 [ n 5 11]), age of onset
( r 5 2 0.10 [ n 5 6]) and prior abstinence from
opiates/drugs (r 5 2 0.29 [ n 5 2]).
Non-opiate drug use. Non-opiate drug use vari-
ables display interesting relationships with con-
tinued illicit opiate use during and after
treatment. For these summaries, only results
with opiate-speci® c continued use outcomes
were included. The only exception to this is that
we included results for alcohol use and depen-
dence that involved general illicit drug use out-
come m easures because alcohol use was not
included in such m easures. Overall non-opiate
drug use was indexed by general non-opiate drug
82 Devon D . Brewer et al.
use m easures (if available) or measures of
speci® c non-opiate drug use (including alcohol).
If only speci® c non-opiate drug use m easures
were used in a study, the mean r (based on
Fisher’ s Z -transformations) of the associations
between the speci® c non-opiate drug use m ea-
sures and continued opiate use was used when
more than one such measure was em ployed;
otherwise, the result for a single non-opiate drug
was used. Overall non-opiate drug use is m oder-
ately positively correlated with continued opiate
use when m easured concurrently (weighted
mean r 5 0.27). Individual non-opiate drugs
show similar concurrent relationships with con-
tinued opiate use: alcohol use shows a slight
positive concurrent association, marijuana use
shows a somewhat stronger concurrent associ-
ation, and cocaine, tranquillizer and am-
phetamine use display moderate concurrent
relationships. However, overall non-opiate drug
use and cocaine use have essentially no longi-
tudinal associations with continued opiate use
during and after treatment. Two studies show
that alcohol use has a small inverse longitudinal
association with continued opiate use, indicating
that heavy alcohol users at one point in time are
less likely to continue using opiates at a later
point during or after treatment than light alcohol
users or alcohol abstainers. Alcohol dependence
bears no consistent longitudinal relationship with
continued use.
Physical and m ental health. Physical and mental
health variables have generally weak relation-
ships with continued drug use. Physical health
problems were indexed by measures of overall
health/medical status and m easures of speci® c
diseases or health problems. If only measures of
speci® c diseases or health problem s were used in
a study, the m ean r (based on Fisher’ s Z -trans-
formations) of the associations between the
speci® c disease/health problem m easures and
continued use was used; otherwise, the result for
a single disease/health problem was used. Physi-
cal health problems show slightly positive con-
current and longitudinal associations with
continued use. Overall m ental health problems,
as indicated by psychological distress, psycho-
pathology and negative em otional states, have
very slight positive longitudinal and concurrent
relationships with continued drug use. After ex-
cluding the correlations coded as 0.00 for results
reported as ª non-signi® cantº , the weighted
m ean correlation for overall mental health prob-
lems (concurrent) increases to 0.07 [ n 5 2]. Two
small studies suggest slight positive concurrent
associations between several speci® c mental
health problems and continued use. Depression
also displays a mildly positive longitudinal corre-
lation with continued use during and after treat-
m ent. In addition, stress/life events are m odestly
positively associated with continued drug use.
Crim inal behavior and legal problem s. A reason-
able num ber of studies have examined the rela-
tionship between various criminal behavior and
legal variables and continued drug use. The
criminal behavior/history variable refers to ar-
rests, convictions, general crim inal behavior or
involvement in particular crim es. W e excluded
possession of illegal drugs as a measure of this
variable because it is likely to be confounded
with continued use. Legal status indicates
whether subjects are on probation, parole or
som e other legal pressure or supervision (typi-
cally involving penalties for substance use or
treatment dropout). Legal problems are mea-
sured by the Addiction Severity Index composite
score on this variable (McLellan et al. , 1980).
The m eta-analytic results for these variables
show a pattern similar to those for non-opiate
use. The criminal behavior/history and legal
status variables have m ild to m oderately positive
concurrent associations with continued drug use.
In contrast, each of the three criminal behavior/
legal variables have very small longitudinal asso-
ciations with continued use. Crim inal
behavior/history and legal problem s both show
slightly positive longitudinal relationships with
continued use, while legal status displays a
slightly negative longitudinal relationship with
continued use. After excluding those correlations
coded as 0.00 for results reported only as ª non-
signi® cantº , the weighted mean correlations
change to 2 0.05 for legal status (longitudinal)
( n 5 6) and 0.22 for legal status (concurrent)
( n 5 4).
Em ploym ent. The relationship between em -
ployment and continued drug use has also been
relatively well studied. The employment/employ-
m ent problems variable refers to the degree of
employment or level of employment problems
(high scores re¯ ect full employment and low
scores re¯ ect unemployment), and the source of
income/support variable indicates whether a job

is a source of income or support. Unemployed
subjects are m ore likely to continue using than
em ployed subjects, although the strength of this
relationship is mild when m easured longitudi-
nally but m oderate when m easured concurrently.
The longitudinal em ployment/em ployment
problems association increases marginally to
2 0.19 after excluding two correlations coded as
0.00 for results reported merely as ª non-
signi® cantº .
Psychosocial variables. Psychosocial variables as
a category have some of the strongest longitudi-
nal and concurrent associations with continued
drug use, although very few studies have been
done in this area. Self-ef® cacy refers to
con® dence in the ability to remain abstinent.
The association with substance abusing peers
variable refers to social interaction with sub-
stance abusers or the number of friends and
intimates who are substance abusers. The social
support variable includes measures of perceived
social support generally or from fam ily m embers
speci® cally. The fam ily/social problems variable
includes Addiction Severity Index (M cLellan et
al. , 1980) m easures of fam ily/social problems.
The residential relocation variable refers to mov-
ing after treatment from the pretreatment town/
city of residence (and presum ably som e of the
social and environmental in¯ uences on contin-
ued drug use). Self-ef® cacy and social support
have slight to modest negative longitudinal asso-
ciations with continued use. Association with
substance-abusing peers is modestly positively
related to continued drug use when the relation-
ship is m easured longitudinally, and the relation-
ship strengthens when m easured concurrently.
Family/social problems show negligible to small
positive concurrent and longitudinal associations
with continued use. Residential relocation is
negatively associated with continued use.
Treatment length and com pletion . The relation-
ships between treatm ent length and com pletion
and continued drug use have been fairly well
studied. For longitudinal associations, treatment
length refers to the length of tim e in treatment
from adm ission to discharge or during some
uniform (across subjects) time period from ad-
mission to the follow-up assessment. C oncurrent
associations for treatment length are drawn from
cross-sectional studies in which the continued
Predictors of continu ed drug use 83
use outcom e was measured during treatm ent for
subjects whose admission dates varied consider-
ably. Treatment com pletion refers to completing
treatment as opposed to discharge for other rea-
sons. Across studies, treatm ent length and com -
pletion are consistently negatively related to
continued use whether the associations are mea-
sured concurrently or longitudinally, indicating
that subjects who rem ain in treatment longer and
complete treatment are less likely to continue
using than those who leave treatment earlier and
do not complete treatment, respectively. The
average effect sizes for these variables are small
to m oderate. Several studies reporting longitudi-
nal associations between treatm ent length and
continued use measured follow-up periods be-
ginning at intake to treatment or admission to
the study. Subjects in these studies who re-
m ained in treatment for long periods may not
have experienced signi® cant time ª at-riskº , i.e.
out of treatm ent, by the follow-up assessment,
and as a result m easurement of continued use at
follow-up m ay be confounded with treatment
length. Therefore, we also sum marized
the results for just those studies in which the
follow-up period was measured beginning at
discharge from treatment. The average longi-
tudinal correlations between treatment length/
completion and continued drug use for
these studies are somewhat smaller than those
reported in Table 2, but are still modest
(treatment length [n 5 9 studies]: me-
dian 5 2 0.17, unweighted mean 5 2 0.17,
weighted mean 5 2 0.11; treatment comple-
tion [n 5 2 studies]: median/unweighted
m ean 5 2 0.16, weighted mean 5 2 0.09).
Focused contrasts
W e also conducted exploratory focused contrast
analyses (Rosenthal, 1991) to examine whether
the longitudinal association with continued use
for different variables varied signi® cantly with
respect to four dimensions determined a priori,
including treatm ent type, study era, outcom e
period and outcom e speci® city. W e included in-
dependent variables in these further analyses if
each subgroup in the analysis for an independent
variable (e.g. during-treatment or post-treatment
m easurement of the dependent variable) was
represented by at least two studies (which re-
quired a minimum of four studies altogether for
an independent variable). The treatment type
contrasts compare studies involving methadone
84 Devon D . Brewer et al.
maintenance treatm ent with those involving
other treatments (including treatm ents that were
not speci® ed). W e included this contrast dimen-
sion because it is possible that relapse processes
differ between patients m aintained on a legal
opiate and those not receiving long-term phar-
macological treatment. The study era contrasts
compare studies in which all subjects received
treatment before 1970 with those in which some
or all subjects received treatment in 1970 or
later. This contrast dimension was included be-
cause the characteristics of opiate addicts and
the social and environmental contexts of opiate
addiction may be different in the two periods,
thus possibly resulting in different antecedents to
relapse The outcom e period contrasts compare
results in which the dependent variable was m ea-
sured during treatment with those in which it
was measured post-treatment. Contrasts on this
dim ension test whether relapse processes (as in-
dicated by the strengths of longitudinal associa-
tions between particular variables and continued
use) differ for during-treatm ent and post-treat-
ment periods. The outcom e speci® city contrasts
compare results for which the dependent variable
indicated continued use of illicit opiates
speci® cally with those for which it indicated con-
tinued use of illicit drugs in general. We included
this contrast dimension because predictors of
relapse for opiate addicts m ay be different for
opiates than for illicit drugs in general.
The focused contrasts involved computing Z-
scores that indicate the signi® cance of the differ-
ences in the size of correlations between different
groups of studies. The Z -scores are not indepen-
dent because the sam e set of studies are usually
involved in each contrast for a particular inde-
pendent variable and because m any studies in-
clude results for m ultiple independent variables.
Given these dif® culties and the large number of
tests conducted, it is not clear what alpha level
should be set for interpreting the statistical
signi® cance of the results. We selected the 0.001
level as a reasonable threshold (since the exper-
iment-wise alpha would be 0.0011 [i.e. 0.05/47
tests] if each of the contrasts were considered
independent), although we also note the
signi® cance of the results for different alpha lev-
els as well.
Table 3 shows the weighted mean correlations
for the two subgroups of studies involved in each
contrast and superscripts indicate the
signi® cance of the contrasts for various alpha
levels. The focused contrast results demonstrate
that the summary ® ndings in Table 2 generally
hold no m atter whether methadone maintenance
or other treatments were involved, whether treat-
m ent was provided before or after 1970, whether
continued use was measured during or after
treatment, or whether continued use of opiates
speci® cally or illicit drugs generally was used as
the outcom e m easure. Because we did not have
any speci® c hypotheses, these results m ust be
considered as merely suggestive of possible rela-
tionships that should be investigated in future
m eta-analytic research. The single contrast that
attains statistical signi® cance at the 0.001 level
indicates that treatm ent length is more strongly
negatively related to continued drug use in stud-
ies since 1970 than in those prior to 1970.
D iscussion
No variable included in the m eta-analysis is
strongly longitudinally predictive of continued
drug use, and only a handful of variables appear
to be modestly longitudinally associated with
continued use. M ost of the six demographic
variables show no m ore than a very slight associ-
ation with continued drug use. Variables refer-
ring to drug history tend to have somewhat
stronger relationships with continued drug use,
but these associations are still of fairly small
m agnitude. Non-opiate substance use, employ-
m ent, criminal behavior and legal variables tend
to have moderate concurrent correlations with
continued use. The longitudinal associations be-
tween these variables and continued use, how-
ever, tend to be weak. Physical and mental
health variables generally have small concurrent
and longitudinal associations with continued
drug use, although depression and stress show
slightly larger positive longitudinal correlations.
Psychosocial variables and treatment length and
completion display small to moderate concurrent
and longitudinal relationships with continued
drug use. These meta-analytic results are
roughly consistent with earlier narrative reviews
(McLellan, 1983; Hawkins & Catalano, 1985;
Surgeon General, 1988; Anglin & Hser, 1990;
Alemi et al. , 1995), although our ® ndings indi-
cate that several variables (e.g. psychiatric im-
pairm ent, polydrug use and criminal behavior)
previously thought to be moderate predictors of
relapse actually show only negligible to small
longitudinal associations with continued use.
 Predictors of continu ed drug use 85

Table 3. Weighted mean correlations for subgroups in focused contrasts

Treatment Study Outcome Outcome

type era period speci® city
(M M /other (pre-1970/ (during /post (opiates/
Independent variable treatments) 1970 1 ) treatment) illicit drugs)

Age 2 0.06/ 2 0.07 2 0.08/ 2 0.05 2 0.11/ 2 0.05 2 0.06/ 2 0.09

(7/10) (3/14) (6/11) (14/3)
Gender 2 0.03/0.00 0.01/ 2 0.01 2 0.08/0.02 0.00/ 2 0.11
(5/13) (2/16) (6/12) (16/2)
W hite/non-white 2 0.08/ 2 0.03 2 0.04/ 2 0.06 2 0.10/ 2 0.04 2 0.05/ 2 0.08
(10/10) (4/16) (5/14) (18/2)
Education 0.03/ 2 0.09b 2 0.11/0.03b 0.04/ 2 0.02 0.00/0.00
(5/6) (5/6) (3/8) (7/4)
Marital status 2 0.05/ 2 0.07 Ð 2 0.05/ 2 0.07 2 0.07/ 2 0.05
(2/3) (2/3) (3/2)
b
Level of use 0.25/0.08 Ð 0.28/0.03 0.05/0.15
(2/4) (3/3) (3/3)
Level of addiction Ð Ð Ð 2 0.09/0.05
(2/2)
Duration of addiction 0.05/0.00 Ð 0.00/0.04 Ð
(6/9) (3/12)
Age of onset 2 0.07/ 2 0.08 2 0.19/ 2 0.05b Ð Ð
(3/7) (4/6)
Non-opiate use 2 0.04/0.02 Ð 0.00/ 2 0.06 Ð
(4/2) (3/3)
Mental health problems 0.00/0.09 Ð 2 0.05/0.07 0.01/0.07
(7/5) (6/5) (7/5)
Depressio n 0.20/0.06 a 0.06/0.20 0.06/0.12a 0.20/0.06 a
(2/2) (2/2) (2/2) (2/2)
Criminal behavior 0.07/ 2 0.05 Ð Ð 0.05/0.10
(3/2) (3/2)
Legal status 0.24/ 2 0.05b 2 0.05/0.24b Ð 2 0.05/0.24 b
(2/5) (5/2) (5/2)
Em ploym ent 2 0.19/ 2 0.04 Ð 2 0.18/ 2 0.16a 2 0.18/ 2 0.13
(7/5) (4/8) (6/6)
2 0.22/ 2 0.12 2 0.07/ 2 0.26 2 0.14/ 2 0.30
c
Treatment length Ð
(4/12) (4/13) (15/2)

The number of studies for the weighted mean correlations are in parentheses.
p , 0.05; b p , 0.01; c p , 0.001.
a

The m ain meta-analytic results generally are
not contingent on the type of treatm ent involved,
the era in which studies were conducted, the
speci® city of continued drug use outcome m ea-
sures, whether continued drug use was measured
during or after treatment, or whether effect sizes
coded as 0.00 for results reported m erely as
ª non-signi® cantº were excluded. The single
signi® cant focused contrast, however, suggests
that treatment length is more strongly negatively
related to continued use in studies since 1970
than prior to 1970, perhaps because more re-
cently developed treatments for opiate addiction
tend not to involve hospitalization and thus may
be easier for patients to leave (for whatever rea-
sons), making them more vulnerable to relapse
in the short- and long-term. Moreover, in more
recently developed treatm ents, treatment length
m ay sim ply re¯ ect patients’ levels of motivation
to becom e abstinent, which is a relationship that
m ay not have been as prominent with earlier
treatments.
For several variables, there are only a few
studies reporting associations with continued
drug use, which lim its the generalizability of the
results obtained. However, even though the evi-
dence may be relatively scant for som e variables,
it is better to sum marize the available studies
quantitatively than rely solely on narrative re-
views of these reports.
Our meta-analytic results can inform the de-
velopment of clinical interventions to treat opiate
86 Devon D . Brewer et al.
addiction by identifying those variables meaning-
fully related to continued drug use. Variables
that display longitudinally predictive relation-
ships with continued use should be addressed
during and/or after treatm ent in order to reduce
patients’ risk for continued drug use. These lon-
gitudinally predictive variables m ay not actually
be causally related to continued use. However,
until research indicates otherwise, it seems pru-
dent to argue that addressing these variables may
reduce continued drug use.
We used the following two criteria in de® ning
longitudinally predictive variables: (1) all esti-
mates of the average correlation between the
variable and continued use must be greater than
u 0.1u , and (2) the associated cumulative Z -score
must be signi® cant at the 0.05 level for a two-
tailed test. Although very small effect sizes can
be practically m eaningful in some situations, it is
dif® cult to imagine how correlations less than
u 0.1u could be clinically signi® cant in this con-
text, especially given the challenges in changing
most m odi® able variables by appreciable
amounts. By our de® nition, the following 10
variables longitudinally predict continued drug
use: high level of pretreatment opiate/drug use,
prior treatment for opiate addiction, no prior
abstinence from opiates, abstinence from/light
use of alcohol, depression, high stress, unem-
ployment/employment problem s, association
with substance abusing peers, short length of
treatment and leaving treatment prior to com-
pletion.
Several other variables may be potentially lon-
gitudinally predictive. To be de® ned as such, at
least one estimate of the average correlation be-
tween the variable and continued use must be
greater than u 0.1u and the cumulative Z -score
must be signi® cant, or all estimates of the aver-
age correlation are greater than u 0.1u but the
cumulative Z -score is not signi® cant. By this
de® nition, the following ® ve variables are poten-
tially longitudinally predictive of continued drug
use: occupational status, physical health prob-
lem s, self-ef® cacy, social support and family/so-
cial problems. It should be noted that the
evidence for some of these variables is based on
a very few studies.
In some treatment programs, interventions
that clearly address these variables are offered as
adjuncts to treatment, including incentives to
rem ain in treatment, psychotherapy/counseling
(for depression), stress managem ent workshops,
attempts to establish sober personal networks,
m edical services, employment assistance and
m otivation enhancement strategies (to promote
treatment retention and compliance). Som e of
the longitudinally predictive variables, such as
prior treatment for opiate addiction, are not able
to be m anipulated by treatm ent interventions
but do indicate subgroups of opiate addicts that
m ay require especially intensive treatm ent efforts
to produce positive outcomes.
Randomized trials of interventions which
speci® cally address these variables can help
ascertain the causal status of such predictors. For
exam ple, at least three experimental evaluations
of psychotherapy with opiate addicts have been
conducted (Rounsaville et al., 1983, 1986;
W oody et al. , 1987, 1989, 1995). Following the
same procedures we used earlier for coding effect
sizes, we com puted Glass’ s delta values ((M of
experimental group 2 M of control group)/SD
of control group) (Glass, M cGaw & Sm ith,
1981) for the impact of the interventions on
self-reported opiate use at post-intervention fol-
low-up interviews. In these studies, psychother-
apy actually slightly increa sed opiate use
(weighted [by degrees of freedom ] mean
delta 5 0.06, range 5 0.00± 0.11). However, in
the two evaluations in which depression out-
comes were measured speci® cally (Woody et al.,
1987, 1989, 1995), psychotherapy did reduce
depression (weighted mean delta 5 2 0.14,
range 5 2 0.22± 2 0.06). These results suggest
that depression m ight not be a causal variable in
continued opiate use, although more observa-
tional and experim ental research on this associ-
ation is needed. In addition, Platt (1995)
reviewed several random ized controlled evalua-
tions of vocational rehabilitation/employment
programs that involved substance abusers. He
did not ® nd a consistent link between changes in
employment and changes in drug use in these
studies, which suggests that the small longitudi-
nal em ploymentÐ continued use association may
not re¯ ect a causal relationship. Evaluations of
other non-pharmacological treatment interven-
tions focused on single relapse variables have not
been replicated, and as a result do not yet pro-
vide good evidence on the causal status of the
variables addressed by the interventions.
In order to reduce continued substance use
m ost effectively, treatm ent interventions should
focus on m ultiple variables because no single

variable strongly predicts continued use and thus
changes on several variables may be required
before noteworthy reductions appear. Indeed,
most randomized trials of such multi-faceted
treatment interventions have dem onstrated de-
creases in opiate and other drug use (Stanton,
Todd & Associates, 1982; McAuliffe et al. , 1985;
McLellan et al. , 1993; C alsyn et al., 1994).
The results from the meta-analysis also shed
light on other issues related to relapse. That
some variables, such as criminal behavior and
non-opiate substance use, display moderate con-
current associations but essentially no longitudi-
nal associations with continued drug/opiate use,
suggests that these variables m ay be concomi-
tants or even consequences, and not causes, of
continued drug/opiate use. These results may
indicate that hard drug use and criminal behav-
ior represent a syndrom e of problem behaviors
for m any opiate addicts. Alternatively, it could
be that non-opiate drug use and criminal behav-
ior are immediate antecedents to continued opi-
ate use, but on a much shorter time scale than is
captured in the typical follow-up study. In ad-
dition, the concurrent correlations between use
of speci® c types of non-opiate substances and
continued opiate use increase with the severity of
the drug (as popularly perceived): the correla-
tions are lowest for alcohol, largest for am-
phetamines, cocaine and tranquillizers, and in
between for m arijuana. These results suggest
that the continued use of illicit opiates might
merely re¯ ect a propensity to use hard drugs
generally.
It is perhaps not surprising that few variables
are even modestly related to continued use.
Meta-analyses of variables associated with re-
lapse to som e m edical disorders after treatment
have shown that most variables show generally
small relationships with relapse. For instance,
Berg & Shinnar (1994) found average relative
risk ratios for various predictors of seizure re-
lapse after discontinuation of antiepileptic drugs
to be less than 1.8 in every case (the overall rate
of relapse in the studies they synthesized was
approximately 25%). In addition, some vari-
ables, such as demographic characteristics, might
not be expected to relate to continued use on
theoretical grounds. M oreover, other variables,
such as those referring to pretreatment drug
history, are unlikely to be strong predictors of
continued drug use given that all of the subjects
in the studies summarized were addicts in treat-
Predictors of continu ed drug use 87
m ent and would typically not exhibit much
m eaningful variation on such variables.
In com parison to other literatures that have
been synthesized with meta-analytic techniques,
relatively little research has been done on vari-
ables associated with continued drug use during
and after treatment for opiate addiction. As a
result, our ® ndings should be viewed as pro-
visional until a signi® cant amount of new re-
search can be done in the area and further
summarized quantitatively. Several other limita-
tions to our meta-analysis should also be noted.
Results were not differentially weighted on the
basis of study quality, and incomplete reporting
of results in the original papers reduced the
precision of effect size computations. The
signi® cant heterogeneity for many independent
variables is probably due to the crudeness of and
variation in the measurement of variables and
the conservative coding of effect sizes when only
signi® cance levels were available for determining
effect sizes of associations. Furthermore, a num-
ber of results and whole studies were not in-
cluded in the meta-analysis because estimated
bivariate effect sizes could not be calculated with
the information given in the original reports. W e
urge investigators in this area to report bivariate
associations, or suf® cient information with which
to com pute them, in future research.
Certainly other variables may exist which are
m eaningfully associated with continued drug
use. Indeed, a number of single studies have
investigated other variables, but because these
relationships have not been examined in m ultiple
studies they were not included in our m eta-
analytical summary. We suggest that among the
m any other variables that could be studied, fu-
ture research should at least examine the predic-
tive strength of such variables as skill de® cits,
m otivation and lack of active leisure (see, e.g.
Stephens & Cottrell, 1972; O’ Leary, O’ Leary &
Donovan, 1976; Greenstein et al. , 1983; Wells et
al., 1989; Sim pson & Joe, 1993; Simpson et al.,
1981). M eta-analytic research should also be
conducted to determine whether the longitudi-
nally predictive variables identi® ed in this m eta-
analysis are also predictors of continued use
during and after treatm ent for other chem ical
dependencies.
A cknow ledgem ents
This research was supported by a grant from the
National Institute on Drug Abuse (5 R01
88 Devon D . Brewer et al.
DA05824-02). We thank Richard Kosterman,
Eugene M aguin and John M . Roberts Jr
for advice on methodological issues, and
Sarah Roberts for her excellent library assistance.
Eugene Maguin and John Pollard provided
helpful comm ents on an earlier draft of this
paper.
R eferences
The num bers in parentheses following a particular
reference indicate the variables (according to their
num bers in Table 2) for which that report con-
tributed an effect size in the m eta-analysis. W here
necessary, an ª Iº or ª cº in brackets after a variable
num ber further indicates whether the effect size is
for a longitudinal or concurrent association.
A LEM I , F., S TEPH ENS , R. C., L LORENS , S. & O RRIS , B.
(1995 ) A review of factors affecting treatm ent out-
comes: Expected T reatment Outcome Scale, Am eric-
an Journal of Drug and Alcohol Abuse, 21, 483± 509 .
A NGLIN , M. D., A LM OG , I. J., F ISH ER , D. G . & P ETERS ,
K. R. (1989 ) Alcohol use by heroin addicts: evidence
for an inverse relationship. A study of m ethadone
m aintenance and drug-free treatm ent sam ples, Am e-
rican Journal of Drug and A lcohol Abuse, 15, 191± 207.
(2, 3)
A NGLIN , M . D. & H SER , Y. - I. (1990 ) Treatm ent of drug
abuse, Crime and Justice, 13, 393 ± 460.
A NGLIN , M. D., H SER , Y. & B OOTH , M. W . (1987 ) Sex
differences in addict careers. 4. Treatm ent, Am erican
Journal of Drug and Alcohol A buse, 13, 253± 280. (2,
3)
A NGLIN , M. D., R YAN , T. M ., B OO TH , M. W . & H SER ,
Y. (1988 ) Ethnic differences in narcotics addiction.
I. Characteristics of Chicano and Anglo m ethadone
m aintenance clients, International Journal of the Ad-
dictions, 23, 125 ± 149. (2, 3)
A NGLIN , M. D., B OOTH , M. W ., R YAN , T. M . & H SER ,
Y. (1988 ) Ethnic differences in narcotics addiction.
II. Chicano and Anglo addiction career patterns,
International Journal of the Addictions, 23, 1011±
1027. (2, 3)
B ALL , J., C ORTY , E., B OND , H., M YERS , C. & T OM -
M ASELLO , A. (1988 ) T he reduction of intravenous
heroin use, non-opiate use and crim e during metha-
done maintenance treatm ent: further ® ndings, in:
National Institute on Drug Abuse Research Monograph,
no. 81, pp. 224± 230 (Rockville, M D, National Insti-
tute on Drug Abuse). (27[c])
B ALE , R. N., V AN S TONE , W . W ., K ULDAU , J. M ., E N-
G ELSING , T. M. J., E LASH OFF , R. M . & Z ARC ONE , V.
P. (1980 ) Therapeutic comm unities vs. m ethadone
m aintenance. A prospective controlled study of nar-
cotic addiction treatm ent: design and one-year fol-
low-up, Archives of Genera l Psychiatry, 37, 179± 193.
(27[I])
B ATKI , S. L., S ORENSE N , J. L., G IBSON , D. R. & M AU DE-
G RIFFIN , P. (1989 ) HIV-infected IV drug users in
m ethadone treatm ent: Outcom e and psychological
correlatesÐ a prelim inary report, in: H ARRIS , L. S.
(Ed.) Problems of Drug Dependenc e 1989, National
Institute on Drug Abuse Research Monograph 95,
pp. 405 ± 406 (Rockville, M D, National Institute on
Drug Abuse). (13[I], 13a[I], 15[I], 15a[I])
B ERG , A. T. & S HINNAR , S. (1994 ) Relapse follow ing
discontinuation of antiepileptic drugs: a m eta-analy-
sis, Neurology, 44, 601± 608.
B ESS , B., J ANUS , S. & R IF KIN , A. (1972 ) Factors in
successful narcotics renunciation, American Journal
of Psychiatry, 128, 95± 99. (15[c], 15a[c], 15b ± 15f)
B OW DEN , C. L. & L ANG ENAU ER , B. J. (1972 ) Success
and failure in the NARA addiction program , A meric-
an Journal of Psychiatry, 128 , 853± 856. (1, 3, 4, 9,
10, 13[I], 15[c], 15a[c], 15b ± 15f, 17[c], 18[I],
20[c], 21, 27[I])
B RECH T , M. L. & A NGLIN , M. D. (1990 ) Conditional
factors of maturing out: legal supervision and treat-
ment, International Journal of Addictions, 25, 393±
407 . (1, 3, 9, 18[c])
B RECH T , M . L., A NG LIN , M. D., W OO DWARD , J. A. &
B O NETT , D. G . (1987 ) Conditional factors of m atur-
ing out: personal resources and preaddiction socio-
pathy, International Journal of A ddictions, 22, 55± 69.
(1, 3, 9, 18[c])
C AC CIO LA , J. S., R UTHERF ORD , M. J., A LTERM AN , A. I.,
M C K AY , J. R. & S NIDER , E. C. (1996 ) Personality
disorders and treatm ent outcome in methadone
maintenance patients, Journal of Nervous and M ental
Disease, 184, 234 ± 239. (15[I])
C ALSYN , D. A., W ELLS , E. A., S AXO N , A. J. et al. (1994)
Contingency managem ent of urinalysis results and
intensity of counseling services have an interactive
impact on m ethadone maintenance treatm ent out-
come, Journal of the Addictive Diseases, 13, 47± 63.
C ATALAN O , R. F., W ELLS , E. A., H AW KINS , J. D.,
M ILLER , J. L. & B REW ER , D. D. (1990 ± 91) Evalu-
ation of the effectiveness of drug abuse treatm ent,
assessment of risks for relapse, and prom ising ap-
proaches for relapse prevention, International Journal
of the Addictions, 25, 1085± 1140.
C H ATH AM , L. R., R OW AN- S ZAL , G . A., JO E , G . W .,
B RO WN , B. S. & S IM PSON , D. D. (1995 ) H eavy drink-
ing in a population of m ethadone-m aintained
clients, Journal of Studies on Alcohol, 56, 417± 422 .
(13c)
C U SHM AN J R , P. (1977 ) Ten years of methadone
maintenance treatment: som e clinical observations,
American Journal of Drug and A lcohol Abuse, 4, 543±
553. (28)
D ALE , R. T . & D ALE , F. R. (1973 ) The use of m etha-
done in a representative group of heroin addicts,
International Journal of the Addictions, 8, 293± 308 . (3)
D E F LEUR , L. B., B ALL , J. C. & S NARR , R. W . (1969 )
The long-term social correlates of opiate addiction,
Social Problems, 17, 225± 234 . (20[c], 27[I], 28)
D ES J ARLAIS , D. C., JO SEPH , H., D O LE , V. P. & S CH M EI-
DLER , J. (1983 ) Predicting post-treatm ent narcotic
use among patients terminating from methadone
maintenance, Advances in A lcohol and Substance
Abuse, 2, 57± 68. (9)
D ES J ARLAIS , D. C., W ENSTON , J., F RIEDM AN , S. R.,
S O TH ERAN , J. L., M ASLANS KY , R. & M ARM OR , M.
(1992 ) Crack cocaine use in a cohort of methadone
maintenance patients, Journal of Substance Abuse
Treatm ent, 9, 319± 325. (13[c], 13a[c])

D ISKIND , M. H. & K LONSKY , G . (1964 ) A second look
at the New York State Parole Drug Experiment,
Federal Probation, 28, 3441. (20[c])
D OLE , V. P. & J OSEPH , H. (1978 ) Long-term outcom e
of patients treated with methadone m aintenance, in:
K ISSIN , B., L OWINSON , J. & M ILLM AN , R. (Eds) Recent
Developments in Chemotherapy of Narcotic Addiction,
Annals of the New York Academ y of Sciences, 311,
pp. 181± 189 (N ew York, New York Academy of
Sciences). (1± 4, 9, 10, 17[I], 20[I], 27[I], 28)
F AIRBANK , J. A., D U NTEM AN , G. H. & C ONDELLI , W . S.
(1993 ) Do methadone patients substitute other drugs
for heroin? Predicting substance use at 1-year follow-
up, American Journal of Drug and Alcohol Abuse, 19,
465± 474. (13[c], 13a[c], 13b[c], 13d± 13f)
F ARLEY , T . A., C ARTER , M . L., W ASSELL , J. T. &
H ADLER , J. L. (1991 ) Predictors of outcom e in
m ethadone program s: effect of HIV counseling and
testing, AIDS, 6, 115± 121. (1± 3, 20[I], 27[c])
G LASS , G. V., M C G AW , B. & S M ITH , M. L. (1981 )
M eta-analysis in Social Research (Beverly H ills, CA,
Sage).
G O EH L , L., N U NES , E., Q U ITKIN , F. & H ILTON , I.
(1993 ) Social networks and m ethadone treatm ent
outcome: the costs and bene® ts of social ties, Am eric-
an Journal of Drug and Alcohol A buse, 19, 251± 262.
(1± 4, 6, 15[I], 16, 20[I], 23[I], 24, 27[c])
G O SSOP , M ., G REEN , L., P HILLIPS , G . & B RADLEY , B.
(1987 ) W hat happens to opiate addicts imm ediately
after treatment: a prospective follow up study, British
M edical Journal, 294, 1377± 1380. (2)
G REENST EIN , R. A., A RNDT , I. C., M C L ELLAN , A. T.,
O’ B RIEN , C. P. & E VANS , B. (1984 ) Naltrexone: A
clinical perspective, Journal of Clinical Psychiatry, 45
(no. 9, section 2), 25± 28. (27[I])
G REENST EIN , R. A., E VANS , B. D., M C L ELLAN , A. T.,
O’ B RIEN , C. P. (1983 ) Predictors of favorable out-
come following naltrexone treatment, Drug and A l-
cohol Dependenc e, 12, 173 ± 180. (27[I])
G REENST EIN , R. A., O’ B RIEN , C. P., M C L ELLAN , A. T.
et al. (1981 ) Naltrexone: a short-term treatm ent for
opiate dependence, A merican Journal of Drug and
Alcohol Abuse, 8, 291 ± 300. (27[I])
G REY , C., O SBO RN , E. & R EZNIKO FF , M. (1986 ) Psy-
chosocial factors in outcom e in two opiate addiction
treatm ents, Journal of Clinical Psychology, 42, 185±
189. (15[I], 16, 24)
H ANBU RY , R., S TU RIANO , V., C OHEN , M., S TIM M EL , B.
& A G UILLAU M E , C. (1986 ) Cocaine use in persons
on methadone maintenance, Advances in Alcohol and
Substance A buse, 6, 97± 106.
H ARTEL , D. M ., S C HOENBA U M , E. E., S ELWYN , P. A. et
al. (1995 ) H eroin use during m ethadone m ainte-
nance treatment: the importance of methadone dose
and cocaine use, Am erican Journal of Public Health,
85, 83± 88. (11, 13[c], 13a[c], 27[c])
H ARTKA , E., JOH NSTO NE , B., L EINO , E. V., M O-
TOYOSH I , M., T EM PLE , M. T . & F ILLM ORE , K. M .
(1991 ) A meta-analysis of depressive sym ptom atol-
ogy and alcohol consum ption over tim e, British Jour-
nal of Addiction, 86, 1283 ± 1298 .
H AW KINS , J. D. & C ATALAN O , R. F. (1985 ) Aftercare in
drug abuse treatm ent, International Journal of the
Addictions, 20, 917± 945.
Predictors of continu ed drug use 89
H SER , Y., A NG LIN , M. D. & L IU , Y. (1990 ± 91) A sur-
vival analysis of gender and ethnic differences in
responsiveness to methadone m aintenance treat-
ment, International Journal of the A ddictions, 25,
1295± 1315 . (2, 3)
H UB BARD , R. L. & M ARSDEN , M. E. (1986 ) Relapse to
use of heroin, cocaine, and other drugs in the ® rst
year after treatm ent, in: T IM S , F. & L EU KEFELD , C.
(E ds) Relapse and Recovery in Drug Abuse, National
Institute on Drug Abuse Research Monograph 72,
pp. 157 ± 166 (Rockville, M D, National Institute on
Drug Abuse).
H UNT , G. H. & O DO ROFF , M. E. (1962 ) Follow-
up study of narcotic drug addicts after hospitaliza-
tion, Public H ealth Reports, 77, 41± 54. (1± 3, 18[I],
27[I])
H UNT , W . A. & B ESPALE C , D. A. (1974 ) Relapse rates
after treatm ent for heroin addiction, Journal of Com-
munity Psychology, 2, 85± 87.
I G UC HI , M. Y. & S TITZER , M . L. (1991 ) Predictors of
opiate drug abuse during a 90-day methadone
detoxi® cation, Am erican Journal of Drug and Alcohol
Abuse, 17, 279 ± 294. (2, 3)
J AC OBSEN , L. K. & K O STEN , T. R. (1989 ) Naloxone
challenge as a biological predictor of treatment out-
com e in opiate addicts, Am erican Journal of Drug and
Alcohol Abuse, 15, 355 ± 366. (7, 8, 15[I], 15a[I])
J OE , G . W ., B ROW N , B. S. & S IM PSO N , D. D. (1995 )
Psychological problem s and client engagem ent in
methadone treatment, Journal of Nervous and M ental
Disease, 183, 704 ± 710. (15[I])
J OE , G. W ., L LOYD , M . R. & S INGH , B. K. (1982 ± 83)
Recidivism among opioid addicts after drug treat-
ment: an analysis by race and tenure in treatm ent,
American Journal of Drug and A lcohol Abuse, 9, 371±
382 . (3, 27[I])
J U DSON , B. A. & G OLDSTEIN , A. (1984 ) Naltrexone
treatment of heroin addiction: one year follow-up,
Drug and Alcohol Dependenc e, 13, 357 ± 365. (27[I])
K APLAN , H . B. & M EYEROW ITZ , J. H. (1969 ) Psychoso-
cial predictors of postinstitutional adjustm ent among
male drug addicts, Archives of General Psychiatry, 20,
278 ± 284. (10, 14[I], 15[I])
K OSTEN , T. A., B IANCHI , M . S. & K O STEN , T. R. (1992 )
The predictive validity of the dependence syndrom e
in opiate abusers, Am erican Journal of Drug and
Alcohol Abuse, 18, 145± 156. (1± 3, 7± 9, 11, 13[I],
13a[I], 27[c])
K OSTEN , T. R., R OU NSAVILL E , B. J. & K LEBER , H . D.
(1986 ) A 2.5-year follow -up of depression, life
crises, and treatm ent effects on abstinence among
opioid addicts, A rchives of G enera l Psychiatry, 43,
733 ± 738. (15[I], 15a[I], 27[I])
K OSTEN , T. R., R OU NSAVILL E , B. J. & K LEBER , H . D.
(1987 ) M ultidim ensionality and prediction of treat-
ment outcom e in opioid addicts: 2.5-year follow-up,
Comprehensive Psychiatry, 28, 3± 13. (7, 14[I & c],
15[I], 19, 20[I & c], 25[I & c])
K RU EG ER , D. W . (1981 ) Stressful life events and the
return to heroin use, Journal of H uman Stress, 7, 3± 8.
(15[I], 15a[I], 16)
M ADDU X , J. F. & D ESM OND , D. P. (1982 ) Residence
relocation inhibits opioid dependence, A rchives of
General Psychiatry, 39, 1313 ± 1317 . (26 )
90 Devon D . Brewer et al.
M AG U IN , E. & L OEBER , R. (1996 ) Academ ic perform-
ance and delinquency, Crime and Justice, 20, 145±
264.
M ANN , N. R., C HARU VASTRA , V. C. & M U RTHY , V. K.
(1984 ) A diagnostic tool with important implications
for treatm ent of addiction: identi® cation of factors
underlying relapse and remission tim e distributions,
International Journal of Addictions, 19, 25± 44. (18[I])
M C A ULIF FE , W . E., C H ’ IEN , J. M. N., L AUNER , E.,
F RIEDM AN , R. & F ELDM AN , B. (1985 ) The Harvard
G roup Aftercare Program : preliminary evaluation
results and implem entation issues, in: A SHERY , R. S.
(Ed.) Progress in the Development of Cost-effective
Treatment for Drug A busers, NIDA Research Mono-
graph 58, pp. 147± 155 (Rockville, M D, National
Institute on Drug Abuse).
M C C ABE , O. L., K U RLAND , A. A. & S ULLIVA N , D.
(1974 ) A study of m ethadone failures in an absti-
nence program, International Journal of the A ddictions,
9, 731± 740 . (11 )
M C G LOTH LIN , W . H. & A NG LIN , M . D. (1981 ) Long-
term follow-up of clients of high- and low-dose
m ethadone program s, Archives of General Psychiatry,
38, 1055± 1063. (1, 3, 9, 10, 13[I], 13b[I], 17[I],
20[I], 27[I])
M C L ELLAN , A. T. (1983 ) Patient characteristics associ-
ated w ith outcome, in: C OO PER , J. R., A LTM AN , F.,
B ROW N , B. S. & C ZECHO WICZ , D. (E ds) Research on
the Treatment of Narcotic Addiction: state of the art,
NIDA Research M onograph No. AD M 83± 1281,
pp. 500± 529 (Rockville, M D, National Institute on
Drug Abuse).
M C L ELLAN , A. T., A RNDT , I. O., M ETZG ER , D. S.,
W OO DY , G . E. & O’ B RIEN , C. P. (1993 ) T he effects
of psychosocial services in substance abuse treat-
m ent, Journal of the A merican Medical A ssociation,
269, 1953± 1959.
M C L ELLAN , A. T., L U BORSKY , L., O’ B RIEN , C. P. &
W OO DY , G . E. (1980 ) An improved diagnostic evalu-
ation for substance abuse patients: the Addiction
Severity Index, Journal of Nervous and Mental Dis-
ease, 168 , 26± 33.
O’ D O NNELL , J. A. (1964 ) A follow-up of narcotic ad-
dicts: m ortality, relapse and abstinence, Am erican
Journal of Orthopsychiatry, 34, 948± 954 . (2)
O’ L EARY , D. E., O’ L EARY , M. R. & D ONOVAN , D. M .
(1976 ) Social skill acquisition and psychosocial de-
velopm ent of alcoholics: a review, A ddictive Behav-
iors, 1, 111± 120 .
O PPENHE IM ER , E., S TIM SO N , G. V. & T HO RLEY , A.
(1979 ) Seven-year follow -up of heroin addicts: absti-
nence and continued use com pared, British Medica l
Journal, 2, 627 ± 630. (1, 2, 6, 9, 10, 12, 13[I & c],
13a[c], 13b[c], 13d-13f, 14[I & c], 17[I & c], 18[c],
20[I & c], 21, 23[I & c])
O SBORN , E., G REY , C. & R EZNIKO FF , M. (1986 ) Psy-
chosocial adjustm ent, m odality choice, and outcom e
in naltrexone versus methadone treatm ent, Am erican
Journal of Drug and Alcohol A buse, 12, 383± 388. (7,
25[I])
P ARW ATIKAR , S., C RAWF ORD , J., N ELKU PA , J. V. & D E-
G RAC IA , C. (1976 ) Factors in¯ uencing success in an
antagonistic treatment program , in: D EM ETRIOU S , J.
& R ENAU LT , P. (E ds) Narcotic A ntagonists: naltrexone,
National Institute on Drug Abuse M onograph 9, pp.
77± 81 (Rockville, MD, National Institute on Drug
Abuse). (4, 5, 17[I], 20[I])
P ERKINS , M . E. & B LO CK , H. I. (1970 ) Survey of a
methadone m aintenance treatm ent program, A meric-
an Journal of Psychiatry, 126, 1389± 1396. (14[c],
18[c], 20[c], 21, 27[c])
P ERSIC O , A. M., G IANNAN TONIO , M . D. & T EM PESTA ,
E. (1991 ) A prospective assessm ent of opiate addic-
tion treatm ent protocols for inpatients with HIV-re-
lated syndrom es, Drug and Alcohol Dependenc e, 27,
79± 88. (1, 2, 8± 10, 12, 14[I])
P ESCO R , M . J. (1943 ) Follow-up study of treated nar-
cotic drug addicts, Public Health R eports, suppl. 170 ,
1± 18. (18[I], 27[I], 28)
P LATT , J. J. (1986 ) Heroin A ddiction: theory, research,
and treatment, second edition (M alabar, FL , Krieger
Publishing Company).
P LATT , J. J. (1995 ) Vocational rehabilitation of drug
abusers, Psychological Bulletin, 117 , 416± 433.
P LATT , J. J. & L AB ATE , C. (1976 ) Recidivism in youth-
ful heroin offenders and characteristics of parole
behavior and environment, International Journal of
the A ddictions, 11, 651 ± 657. (20[c], 26)
P O W ELL , J., D AW E , S., R IC HARDS , D. et al. (1993) Can
opiate addicts tell us about their relapse risk? Subjec-
tive predictors of clinical prognosis, Addictive Behav -
iors, 18, 473± 490. (22 )
P RICE , S. & J AM ISO N , K. (1974 ) Correlates and extent
of drug abuse on a m ethadone maintenance pro-
gram, British Journal of Addiction, 69, 173± 179. (1, 4,
6, 8± 10, 17[I], 20[I & c])
R EILLY , P. M ., S EES , K. L., S HO PSHIRE , M. S. et al.
(1995 ) Self-ef® cacy and illicit opioid use in a
180-day m ethadone detoxi® cation treatm ent,
Journal of Consulting and Clinical Psychology, 63, 158±
162. (22)
R ESNIC K , R. B. & W ASHTON , A. M . (1978 ) Clinical
outcom e with naltrexone, in: K ISSIN , B., L OW INSON ,
J. & M ILLM AN , R. (E ds) Recent Developments in
Chemotherapy of Narcotic A ddiction, Annals of the
New York Academ y of Sciences, 311, pp. 241 ± 247
(N ew York, New York Academ y of Sciences). (1, 4,
6, 7, 9, 10, 12, 20[I], 27[I])
R IORDAN , C. E., M EZRITZ , M , S LOBETZ , F. & K LEBER ,
H. D. (1976 ) Successful detoxi® cation from m etha-
done m aintenance: follow-up study of 38 patients,
Journal of the Am erican Medica l A ssociation, 235,
2604± 2607 . (3± 5, 17[c], 18[I & c], 20[I & c])
R OSENTH AL , R. (1991) Meta-analy tic Procedures for So-
cial Research, revised edition (N ew bury Park, CA,
Sage).
R OSZELL , D. K., C ALSYN , D. A. & C HANEY , E. F.
(1986 ) Alcohol use and psychopathology in opioid
addicts on methadone m aintenance, A merican Jour-
nal on Drug and Alcohol Abuse, 12, 269± 278. (13c )
R OU NSAVIL LE , B. J., G LAZER , W ., W ILBER , C. H .,
W EISSM AN , M . M. & K LEB ER , H . D. (1983 ) Short-
term interpersonal psychotherapy in methadone-
maintained opiate addicts, Archives of General
Psychiatry, 40, 629± 636.
R OU NSAVIL LE , B. J., K OSTEN , T. R. & K LEBER , H . D.
(1987 ) The antecedents and bene® ts of achieving
abstinence in opioid addicts: a 2.5-year follow-up

study, Am erican Journal of Drug and Alcohol Abuse,
13, 213± 229. (2, 3)
R OU NSAVILL E , B. J., K OSTEN , T . R., W EISSM AN , M . M .
& K LEBER , H. D. (1986 ) A 2.5 year follow-up of
short-term interpersonal psychotherapy in metha-
done-maintained opiate addicts, Comprehensive Psy-
chiatry, 27, 201± 210.
R OU NSAVILL E , B. J., T IERNEY , T ., C RITS- C H RISTO PH ,
K., W EISSM AN , M . M. & K LEBER , H. D. (1982 ) Pre-
dictors of outcome in treatment of opiate addicts:
evidence for the m ultidim ensional nature of addicts’
problems, Comprehensive Psychiatry, 23, 462± 478.
(13[c], 13b[c], 15[c], 17[c], 20[c], 25[c], 27[I])
S ATIJA , D. C., S H ARM A , D. K., G AU R , A. & N ATHAW AT ,
S. S. (1989 ) Prognostic signi® cance of psychopathol-
ogy in the abstinence from opiate addiction, Indian
Journal of Psychiatry, 31, 157 ± 162. (15[I])
S AVAG E , L. J. & S IM PSO N , D. D. (1981 ) Drug use and
crim e during a four-year posttreatm ent follow-up,
Am erican Journal of Drug and Alcohol Abuse, 8, 1± 16.
(2, 17[c])
S AX ON , A. J., W ELLS , E. A., F LEM ING , C., JAC KSO N , T.
R. & C ALSYN , D. A. (1996 ) Pretreatm ent characteris-
tics, program philosophy and level of ancillary ser-
vices as predictors of m ethadone m aintenance
treatm ent outcom e, Addiction, 91, 1197± 1209. (1, 2,
4, 11, 13[I], 13a[I], 13b[I], 14[I], 15[I], 19, 20[I],
25[I])
S H EEH AN , M ., O PPENHE IM ER , E. & C O LIN , T. (1993)
Opiate users and the ® rst years after treatment:
outcome analysis of the proportion of follow up tim e
spent in abstinence, Addiction, 88, 1679 ± 1689 . (2, 9,
20[c])
S IM PSO N , D. D. & JO E , G . W . (1993 ) Motivation as a
predictor of early dropout from drug abuse treat-
m ent, Psychotherapy, 30, 357± 368 .
S IM PSO N , D. D., C RANDAL L , R., S AVAG E , L. J. & P AVIA-
K RU EG ER , E. (1981 ) Leisure of opiate addicts at
posttreatm ent follow-up, Journal of Counseling Psy-
chology, 28, 36± 39.
S NARR , R. W . & B ALL , J. C. (1974 ) Involvem ent in a
drug subculture and abstinence following treatm ent
among Puerto Rican narcotic addicts, British Journal
of Addiction, 69, 233 ± 248. (10)
S TANTON , M . D., T ODD , T. C. & A SSOC IATES (1982)
The Family Therapy of Drug Abuse and Addiction
(N ew York, G uilford Press).
S TEPHEN S , R. & C OTTREL L , E. (1972 ) A follow-up
study of 200 narcotic addicts com mitted for treat-
m ent under the Narcotic Addict Rehabilitation Act
(N ARA), British Journal of Addiction, 67, 45± 53. (1,
3, 4, 9, 20[c])
S TIM M EL , B., G OLDBER G , J., R O TKOPF , E. & C OHEN , M .
(1977 ) Ability to rem ain abstinent after m ethadone
detoxi® cation: a six year study, Journal of the A meri-
can M edical A ssociation, 237, 1216± 1220. (27[I], 28)
S TIM M EL , B., G OLDBER G , J., C OHEN , M . & R OTKOPF , E.
(1978 ) Detoxi® cation from methadone m ainte-
nance: risk factors associated with relapse to narcotic
use, in: K ISSEN , B., L OW INSON , J. H. & M ILLM AN , R.
(Eds) Recen t Developments in the Chemotherapy of
Narcotic A ddiction, Annals of the New York Acad-
emy of Sciences, 311, pp. 173 ± 180 (N ew York, New
York Academ y of Sciences). (27[I], 28)
Predictors of continu ed drug use 91
S TIM M EL , B., H ANBU RY , R., S TU RIANO , V., K ORTS , D.,
JAC KSO N , G. & C O HEN , M. (1982 ) Alcoholism as a
risk factor in methadone maintenance: a random ized
controlled trial, Am erican Journal of M edicine, 73,
631 ± 636. (13c )
S TIM M EL , B. & R ABIN , J. (1974 ) The ability to remain
abstinent upon leaving m ethadone m aintenance: a
prospective study, A merican Journal of Drug and Al-
cohol A buse, 1, 379± 391 . (27[I], 28)
S U FFET , F., R EM INE , D. C., T ALEPOR OS , E. & B ROT-
M AN , R. (1978 ) Naltrexone and conventionality,
American Journal of Drug and A lcohol Abuse, 5, 221±
233.
S U RGEON G ENERAL (1988) The Health Consequences of
Smoking: nicotine addiction (Rockville, M D, U S De-
partment of H ealth and Hum an Services).
T EM PLE , M . T., F ILLM ORE , K. M ., H ARTKA , E., J OHN-
STO NE , B., L EINO , E. V. & M OTOYOS HI , M. (1991) A
meta-analysis of change in m arital and employm ent
status as predictors of alcohol consum ption on a
typical occasion, British Journal of Addiction, 86,
1269± 1281.
U NNITHA N , S., G OSSOP , M. & S TRANG , J. (1992 ) Fac-
tors associated with relapse among opiate addicts in
an out-patient detoxi® cation program me, British
Journal of Psychiatry, 161, 654± 657. (1, 2, 9, 14[c],
15[c], 20[c], 23[c])
V AILLAN T , G . E. (1966 ) A twelve-year follow-up of
New York narcotic addicts: I. The relation of treat-
ment to outcom e, American Journal of Public Health,
122 , 727± 737 . (27[I])
V AILLAN T , G. E. (1973 ) A 20-year follow-up of New
York narcotic addicts, Archives of G enera l Psychiatry,
29, 237± 241. (3, 4, 7, 9, 10, 18[I], 20[I])
W ELLS , E. A., C ATALAN O , R. F., P LOTNIC K , R.,
H AW KINS , J. D. & B RATTES ANI , K. A. (1989 ) G eneral
vs. drug-speci® c coping skills and post-treatm ent
drug use among adults, Psychology of Addictive Be-
haviors, 3, 8± 21.
W ELLS , E. A., H AW KINS , J. D. & C ATALAN O , R. F.
(1988 ) Choosing drug use m easures for treatm ent
outcom e studies. I. The in¯ uence of m easurem ent
approach on treatm ent results, International Journal
of Addictions, 23, 851± 873 .
W ESTERM EYER , J. (1989 ) Nontreatm ent factors affect-
ing treatm ent outcome in substance abuse, A merican
Journal of Drug and Alcohol Abuse, 15, 13± 29.
W ESTERM EYER , J. & B OURNE , P. (1978 ) Treatm ent out-
com e and the role of the com m unity in narcotic
addiction, Journal of Nervous and Menta l Disease,
166 , 51± 58. (1, 2, 6)
W IELAND , W . F. & N OVACK , J. L. (1973 ) A com parison
of crim inal justice and non crim inal justice-related
patients in a methadone treatm ent program , in: Pr-
oceedings of the 5th National Conference on Methadone
Treatm ent, pp. 116± 122 (N ew York, National As-
sociation for the Prevention of Addiction to Nar-
cotics). (18[c])
W ILLIAM S , H. R., M OY , W . & J OH NSTON , W . (1970)
Low and high m ethadone m aintenance in out-
patient treatment of the heroin addict, International
Journal of the Addictions, 5, 637± 644. (20[c])
W OODY , G ., L U BORSKY , L., M C L ELLAN , A. T. &
O’ B RIEN , C. P. (1989 ) Correction, American Journal
of Psychiatry, 146, 1651.
92 Devon D . Brewer et al.
W OODY , G. E., M C L ELLAN , A. T ., L U BORSKY , L. &
O’ B RIEN , C. P. (1987 ) Twelve-m onth follow-up of
psychotherapy for opiate dependence, Am erican
Journal of Psychiatry, 144, 590± 596.
W OODY , G. E., M C L ELLAN , A. T ., L U BORSKY , L. &
O’ B RIEN , C. P. (1995 ) Psychotherapy in com m unity
methadone program s: a validation study, A merican
Journal of Psychiatry, 152, 1302± 1308 .
Z AHN , M . A. & B ALL , J. C. (1972 ) Factors related to
cure of opiate addiction among Puerto Rican ad-
dicts, International Journal of the Addictions, 7, 237±
245 . (4, 9, 18[I], 20[c])