Stressful life events prior to seeking substance use disorder treatment

Ansiedad y Estrés, (2025), 31(1), 30-37
https://doi.org/10.5093/anyes2025a5
https://www.ansiedadyestres.es
Bibliography reference

Psychological Intervention in Adults with Difficult-to-Treat Migraine: Benefits of Applying MIDITRA Protocol

INFO ARTICLE

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Received 18 October 2024
Accepted 25 April 2025

 

ABSTRACT

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Background: There is never an ideal time for people with a substance use disorder (SUD) to seek help. Several studies suggest that ‘hitting rock bottom’ is one of the reasons for entering treatment. However, little is known about the reasons for entering SUD treatment. The aims of this study were 1) to assess the occurrence of stressful life events (SLEs) in the 6 months prior to starting SUD treatment, 2) to explore the relationship between SLEs and addiction severity, and 3) to consider the effect of sex on this relationship. Methods: In this cross-sectional study, the sample consisted of 200 (167 men and 33 women) participants from two clinical centres for the treatment of SUD. Results: The prevalence of having at least one SLE was 79.5% (79.0% in men and 81.1% in women). Men had a greater number of SLEs than women. Moderate correlations were found between different SLEs and addiction severity domains in both men and women. Men with > 2 SLEs had more severe problems in the employment, drug, family/social and psychiatric domains of the EuropASI, more problems controlling violent behaviour and more previous psychopharmacological treatments than men with = 2 SLEs. Conclusions: The results of this study are novel and relevant. There is a high prevalence of SLEs among people with SUD. Addiction treatment may be an opportunity to address SLEs.

 

KEYWORDS

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Stressful life events
Substance use disorder
Treatment
Admission

Ansiedad y Estrés, (2025), 31(1), 30-37
https://doi.org/10.5093/anyes2025a5
https://www.ansiedadyestres.es
Bibliography reference

RESUMEN

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Antecedentes: Nunca hay un momento ideal para que las personas con un trastorno por consumo de sustancias (TCS) busquen ayuda. Varios estudios sugieren que «tocar fondo» es una de las razones para iniciar un tratamiento. Sin embargo, se sabe poco sobre las razones para iniciar el tratamiento de los TCS. Los objetivos de este estudio fueron 1) evaluar la ocurrencia de acontecimientos vitales estresantes (AVEs) en los 6 meses previos al inicio del tratamiento de los TCS, 2) explorar la relación entre los AVEs y la gravedad de la adicción, y 3) considerar el efecto del sexo en esta relación. Métodos: En este estudio transversal, la muestra estuvo compuesta por 200 (167 hombres y 33 mujeres) individuos de dos centros clínicos para el tratamiento del TCS. Resultados: La prevalencia de tener al menos un AVE fue del 79,5% (79,0% en hombres y 81,1% en mujeres). Los hombres presentaban un mayor número de AVEs que las mujeres. Se encontraron correlaciones moderadas entre los distintos AVEs y los dominios de gravedad de la adicción, tanto en hombres como en mujeres. Los hombres con > 2 AVEs tenían problemas más graves en los dominios de empleo, drogas, familiar/social y psiquiátrico del EuropASI, más problemas para controlar la conducta violenta y más tratamientos psicofarmacológicos previos que los hombres con = 2 AVEs. Conclusiones: Los resultados de este estudio son novedosos y relevantes. Existe una alta prevalencia de AVEs entre las personas con TCS. El tratamiento de las adicciones puede ser una oportunidad para abordar los AVEs.

 

PALABRAS CLAVE

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Acontecimientos vitales estresantes
Trastorno por consumo de sustancias
Tratamiento
Admisión
 

Introduction

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Patients with substance use-related problems are socially stigmatized. Society still finds it difficult to understand that substance use may indicate a disorder (Ahern et al., 2007; Rey et al., 2019; Zwick et al., 2020). Moreover, addiction is a maladaptive behaviour sustained by negative reinforcement, wherein an individual tends to continue using a substance despite its negative consequences. This implies that, from the perspective of people with addiction, there may never be an opportune moment to initiate or maintain abstinence (Meyers et al., 2014).

Two major problems have been identified in substance use disorder (SUD) treatment programmes. First, there is a high rate of early treatment dropout (Lappan et al., 2020; López-Goñi et al., 2012a; Simsek et al., 2019), and second, there is a high incidence of relapse during treatment (Andersson et al., 2019; López-Goñi et al., 2017). These problems may reflect a lack of motivation for treatment and/or the fact that people may not voluntarily agree to treatment. Considering a gender perspective, women with SUD usually experience more severe impacts in the medical, work, family, social and psychiatric areas than men. In contrast, men have more severe legal problems than women (Fernández-Montalvo et al., 2014). Moreover, women present worst results in SUD treatment programmes: They are less likely to seek treatment (from 15% to 20% in almost all studies about SUD), and more likely to dropout than men (Fernández-Montalvo et al., 2017; Green, 2006; Greenfield et al., 2007; Walitzer & Dearing, 2006).

The clinical impression of professionals in SUD treatment programmes suggests that patients frequently decide to enter treatment programmes following the experience of significant stressful life events (SLEs), such as job loss, the loss of significant relationships, intense interpersonal conflicts, legal problems or health problems, among others, in the line of the results found in previous studies (Cruz-Feliciano et al., 2017; Matzger et al., 2005; Taylor et al., 2012). These events have a significant impact on patients' lives and may trigger acute stress responses (Schepis et al., 2015). Little is known about the influence of events that occur prior to seeking treatment for SUD. They could not only lead to increased substance consumption but also provide the impetus to seek help for SUD treatment. In this regard, the study by Cruz-Feliciano et al. (2017) found that those patients who reported a greater number of recent SLEs were more likely to use SUD treatment services than those who did not report SLEs. In addition, these authors found that each cumulative SLE increased the likelihood of being in treatment by 11%.

Few studies have assessed the reasons why patients enter SUD treatment programmes and none have focused specifically on women. One of the main problems in SUD population is the lack of motivation for treatment (Brooke et al., 1992; Meyers et al., 2014; Wild et al., 2016). Meyers et al. (2014) assessed the feelings and reasons for treatment entry in a sample of 36 people participating in the CRAFT (Community Reinforcement and Family Training) programme. This programme trains family members of people with SUD who are resistant to treatment in behavioural strategies and skills to reinforce non-substance-related behaviours and increase an individual’s motivation to start treatment. The most common feelings reported were “relieved” and “hopeful”, and the most common reasons for entering treatment were “I want to stop using drugs”, “I am tired of living the way I have been” and “I want to feel good about myself”. Other studies propose the notion of 'hitting rock bottom' as a predictive event for treatment adherence (i.e., starting and completing SUD treatment) (Cunningham et al., 1994; Matzger et al., 2005; Vepsa, 2020). They also argue that recovery from SUD usually begins with a crisis or series of negative events that somehow force a person to realize the seriousness of their problems. However, the lack of more recent studies makes it impossible to compare results and to obtain consistent conclusions about this issue. Therefore, the aims of the present study were 1) to explore the occurrence of SLEs in the 6 months prior to admission to SUD treatment programmes, 2) to explore the relationship between the nature of SLEs and SUD severity, and 3) to consider the effect of sex on this relationship. In relation to these objectives, the first hypothesis was that SLEs in the 6 months prior to treatment admission would be prevalent in people with SUD. The second hypothesis was that people who reported experiencing SLEs in the 6 months prior to admission would have greater SUD severity than those who did not report experiencing these events. Finally, the third hypothesis was that women would have more SLEs in the 6 months prior to admission than men.

Method

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Participants

The sample consisted of 200 consecutive patients (n = 167, 83.5% men and n = 33, 16.5% women) who voluntarily sought treatment for SUD from the Proyecto Hombre Navarra Foundation and ANTOX Association (Spain) between 2021 and 2023. The mean ages were 42.5 years in the total sample (SD = 11.5), 41.8 years (SD = 11.4) in men and 46.5 years (SD =11.0) in women (Table 1). The main substance that motivated treatment was alcohol (47.0%; 43.7% of men vs. 63.6% of women), followed by other substances (27.0%; 28.2% vs. 21.2%) and cocaine (26.0%; 28.1% vs. 15.2%).

INSERT HERE TABLE 1

The sample inclusion criteria were as follows: a) to meet the DSM-5 diagnostic criteria for alcohol and/or substance use disorder; b) to be older than 18 years; c) to be receiving treatment for SUD; d) to sign the informed consent form to participate in the study after being properly informed; and e) to complete the assessments.

Assessment measures

The EuropASI (Kokkevi & Hartgers, 1995) is the European version of the Addiction Severity Index scale (ASI) (McLellan et al., 1980). In this study, the Spanish version of this scale was used (Bobes et al., 1996). This interview assesses a patient’s need for treatment based on seven different domains: 1) general medical condition; 2) employment and financial situations; 3) alcohol consumption; 4) use of other drugs; 5) legal problems; 6) family and social relationships; and 7) psychiatric state. After the interview is concluded, the intervention team assesses the patient’s need for treatment regarding each of these domains. The interviewer severity rating (ISR), which has shown good predictive validity in different studies conducted in the treatment context (López-Goñi et al., 2012b), was used for this assessment. The ISR score is calculated based on a series of critical items in each of the domains considering a patient’s own self-evaluation and the interviewer’s judgement. The score for each domain ranges from 0 (no problems) to 9 (extreme problems). The higher the score is, the greater the addiction severity and the greater the need for treatment. Additional questions from the EuropASI were used to obtain information about psychological symptoms (psychiatric scale: questions 3, 4, 6, 7, 8, 9 and 10). The one-week test-retest reliabilities of the seven different domains on the Spanish version of this instrument range from .67 to .96 (González et al., 2002).

The List of Threatening Experiences (LTE) (Brugha et al., 1985) is a brief questionnaire consisting of 12 stressful life events; personal serious illness, injury, or assault; serious illness, injury, or assault happened to a close relative; death of a partner, parent, or child; death of close friend or relative; separation due to marital difficulties; breaking off a steady relationship; a serious problem with a close friend, neighbour, or relative; unemployed or seeking work unsuccessfully for more than 1 month; fired from job; major financial crisis; problem with the police and a court appearance and something valuable was a lost or stolen. In this study, the Spanish version of this questionnaire was used (Motrico et al., 2013). Responses are dichotomous, with the options of “Yes/Present” or “No/Absent”. This instrument can be applied both across the lifespan and within the last 6 months. In this study, data from the last 6 months were used.

Procedure

The Proyecto Hombre Navarra Foundation and the ANTOX Association offer cognitive behavioural interventions with two different modalities (outpatient and inpatient treatment) aimed at abstinence, which have been shown to be effective in SUD treatment (Aguilar et al., 1998; Fernández-Montalvo & López-Goñi, 2010; Fernández-Montalvo et al., 2008). These programmes are financed by public health institutions and serve people older than 18 years old throughout the Navarra region. These patients are representative of Spanish people with SUD.

The assessment of the sample was performed at the beginning of the SUD treatment programme. All people were interviewed face-to-face in two sessions by a clinical psychologist trained in this research. In the first session, data related to sociodemographic characteristics were collected, and the List of Threatening Experiences was completed. In the second session, the EuropASI was applied. After the assessment sessions, the participants continued the standard treatment for SUD. All participants signed informed consent forms prior to the assessment sessions.

Data analysis

Descriptive analyses were conducted for all variables. A point-biserial correlation test was conducted to determine the relationships among the different variables studied. For the valuation of correlations, scores above 0.3 were considered moderate, and those above 0.5 were considered high (Cohen, 1988). The sample was divided into the following two groups depending on the number of SLEs reported in the past 6 months: = 2 SLEs and > 2 SLEs. The reason for this division was that the mean number of SLEs in the sample was 2.3. Bivariate analyses were performed using the ?2 test, Student’s t test or the Mann-Whitney U test for independent samples, depending on the nature of the variables analysed. Variance homogeneity was assessed by Levene’s test. Depending on the result, the corresponding correction was used (Glass & Stanley, 1970). The statistical analyses were two-sided. Effect sizes (Cohen’s d or Phi) for the analyses were provided. Cohen´s d was interpreted as follows: d < 0.20 (no effect size), 0.20 = d < 0.50 (small effect size), 0.50 = d < 0.80 (medium effect size) and d = 0.80 (large effect size) (Cohen, 1988).

A difference of p < .05 was considered significant. Statistical analyses were performed using SPSS software (version 27.0).

Ethical Considerations

The ethics committees of the Universidad Publica de Navarra (PI-014/21), Proyecto Hombre Navarra Foundation (PHN2016-01) and ANTOX Association (AN2016-01) approved the protocol for this study. All participants signed informed consent forms.

Results

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Prevalence of SLEs in the 6 Months Prior to Entering SUD Treatment Programmes

The prevalence of SLEs in the 6 months prior to entering SUD treatment was 79.5% in the total sample (n = 159), 79.0% in men (n = 132) and 81.8% in women (n = 27). No statistically significant differences were found between men and women (Table 2).

(INSERT TABLE 2 HERE)

The most prevalent SLE in the total sample was having a personal serious illness, injury or assault (33.5%; 35.3% in men vs. 24.2% in women), followed by having a major financial crisis (29.5%; 30.5% in men vs. 24.2% in women) and having a serious problem with a close friend, neighbour, or relative (27.0%; 29.3% in men vs. 15.2% in women).

A statistically significant difference in the number of SLEs was found between men and women. Men experienced a greater number of SLEs in the past 6 months than women did (mean 2.5 vs. 1.7). Moreover, men reported a greater likelihood of being fired from a job than women did (10.8% vs. 0%).

Correlations between SUD Severity and Each Type of SLE in Men

The results of the correlations between SUD severity and each type of SLE in men are shown in Table 3. All correlations found were low, except for one moderate correlation. Having a problem with the police and a court appearance showed a moderate correlation with having a higher score on the legal domain of the EuropASI.

(INSERT TABLE 3 HERE)

Correlations between SUD Severity and Each Type of SLE in Women

Most of the correlations between each type of SLE and SUD severity in the EuropASI in women were low (Table 3). Seven correlations were moderate. Having suffered a personal serious illness, injury or assault correlated with having a higher score on the medical area. Having experienced a personal serious illness, injury or assault, the death of a close friend or relative and having suffered a major financial crisis in the past 6 months correlated with a higher score in the employment/support area. Having experienced a major financial crisis and having a problem with the police and a court appearance correlated with a higher score in the psychiatric area. Having experienced a serious problem with a close friend, neighbour or relative with a higher score in the drug area.

Comparisons of SUD Severity and Psychological Symptoms between the Groups of Men and Women with = 2 SLEs and > 2 SLEs

The results of the comparisons of SUD severity and psychological symptoms between the groups of men and women with = 2 SLEs and > 2 SLEs are shown in Table 4. Statistically significant differences between groups were found only for men.

(INSERT TABLE 4 HERE)

Regarding SUD severity, the group of men with > 2 SLEs had significantly greater scores on the employment/support, drug, family/social and psychiatric domains of the EuropASI than did the group of men with = 2 SLEs. With respect to the occurrence of psychological symptoms in the past 30 days, the group of men with > 2 SLEs had significantly greater rates of violent problems and a greater number of prior psychopharmacological treatments than did the group of men with = 2 SLEs.

Discussion

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This study was aimed at exploring the presence of SLEs in the 6 months prior to seek treatment for SUD, as well of analysing the relationship between the nature of SLEs and SUD severity. All analyses were conducted considering the effect of sex. Two of the proposed hypotheses were confirmed. First, 79.5% of the people entering SUD treatment programmes had experienced at least one SLE in the past 6 months, and 39.5% had experienced two or more SLEs, which confirms that recent SLEs are prevalent among people seeking SUD treatment. Second, people with two or more SLEs had greater treatment needs at the start of SUD treatment in terms of employment, maintenance of abstinence from drug use, family and social relationships and psychopathological symptomatology. The third hypothesis was not confirmed. Men reported a greater number of SLEs in the 6 months prior to admission than women did. The main strengths of this study are the novelty and relevance of the findings. In particular, few studies to date have specifically assessed the occurrence of SLEs prior to SUD treatment initiation and none using the LTE.

Clinical implications

The most prevalent SLE was having a personal serious illness, injury or assault followed by having a major financial crisis and having a serious problem with a close friend, neighbour, or relative. One possible explanation could be the effect of the SUD itself. The effect of substance use in the short term is often positive, as it alleviates people's suffering, but in the long term, the consequences can be very negative. SUD can affect vital organs, leading to medical illness; the continued need and lack of control over substance consumption can lead to an economic crisis; and being under the influence of substances can lead to loss of control over behaviour, leading to serious problems with others. These findings are in line with other previous studies that provide information about the most frequent SLEs presented in patients who seek SUD treatment (Cruz-Feliciano et al., 2017; Taylor et al., 2012). The presence of these SLEs indicates that SUD affects all areas of a person’s life and that it is therefore important to assess and treat all problems (Fernández-Montalvo et al., 2015; Leza et al., 2025; McLellan et al., 1980).

The correlations found between the severity of SUD and each type of SLE in men appear consistent. Each type of SLE was directly related to its corresponding SUD area. These correlations emphasize the need to consider stressful experiences in the assessment of the SUD population. It is critical to provide medical, employment and legal support in SUD treatment programmes (National Institute on Drug Abuse, 2014). Moreover, other correlations show that addictive behaviour negatively affects the relationships of affected patients and probably limits the possibility of receiving help. Family and social support must be key components of SUD treatment programmes (Birkeland et al., 2021).

Specifically, in women, several more diverse associations were found. For example, having a personal illness, injury, or assault, experiencing the death of a close friend or relative and having a major financial crisis correlated with a higher score in the employment domain. Women suffer more severe consequences than men, probably due to gender roles and the stigmatization of addiction in society (Agterberg et al., 2020). Although women did not have a greater number of SLEs in the 6 months prior to admission to treatment compared to men, they did appear to have a greater severity profile. In fact, they had more employment, more family and social and mental health problems, and more depressive symptoms than men. These findings are similar to those of Fernández-Montalvo et al. (2014), who reported that women who entered SUD treatment programmes had a greater severity profile in terms of addiction and associated psychopathological symptomatology than men. In addition, the number of women in this sample was relatively small, which may indicate that they had greater difficulty seeking help (Agterberg et al., 2020).

In the comparisons according to the number of SLEs experienced, statistically significant differences were found only for men. Men with > 2 SLEs had more employment problems, more substance use problems, more family and social problems, more mental health problems and more psychopathological symptoms than men with = 2 SLEs. These results may indicate that as the number of SLEs increases, the severity of symptoms also increases. These findings once again highlight the importance of addressing people´s needs at the start of treatment. In addition to the cessation of substance use, there is a need to intervene in other problems that are undoubtedly directly related to SUD.

Furthermore, the consequences of SUD are not limited to the people with the disorder but also affect the physical and mental health of those around them (Olafsdottir et al., 2020; Sarno et al., 2021). As a result, these people may decide to withdraw after becoming overwhelmed by the situation. The fact that a person with a disorder is lonely can also be a trigger for seeking help.

In short, these findings may be related to the motivation and, more importantly, the decision of these people to seek help. The fact that the group with the greatest number of SLEs in the 6 months prior to treatment had greater severity of both addiction and the associated psychopathological symptomatology supports the idea of “hitting rock bottom” proposed by various studies (Bellaert et al., 2022; Matzger et al., 2005; Vepsa, 2020). The accumulation of stressful events over a period of time may lead to a sense of having hit rock bottom and provide the motivation to seek help and start treatment.

Limitations

The results of this study should be interpreted with caution. Due to the nature of the study, causal associations cannot be established. This study did not ask directly about the reason for starting treatment, so the association is uncertain. In addition, the lack of such a study makes it impossible to compare our results and draw solid conclusions. The configuration of the sample itself is another issue that should be considered. Because few women were included in the sample, the results obtained can mainly be generalized to male-addicted patients. It is true that almost all studies about SUD include largely male samples, but it should nevertheless be considered when generalizing the obtained results. These aspects should be considered in future research.

Future lines of research

An interesting line of research will be to determine what motivates people with SUD to seek treatment. “Hitting rock bottom” may be a reason for seeking treatment and may influence the course of treatment. It is generally assumed that the greater the severity of SUD is, the greater the likelihood of early withdrawal. However, it remains to be seen whether “hitting rock bottom” increases the likelihood of treatment completion.

Conclusion

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SUD treatment programmes should consider and address the conditions of the people they serve, including serious personal illness, injury, or assault, financial ruin, and serious problems involving a close friend, neighbour, or relative, among others. Awareness of these events by treatment programme staff should consider additional interventions to meet the needs of people in crisis.

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