Many correlates of poor quality of life among substance users entering treatment are not addiction-specific

Treatments for chronic diseases are increasingly evaluated through subjective patient assessments on outcomes other than morbidity and mortality, and quality of life (QoL) stands out as the most common and a relevant measurement. QoL is a subjective appraisal of a patient’s life in that instant: how satisfied the patient is with their current physical health, mental health, social relationships, and environment, to use the World Health Organization’s four emphasized domains [1]. The substance use disorder (SUD) treatment field has until recently less systematically collected and prioritized the QoL of patients, in comparison with other medical fields [2]. Importantly, QoL measures add patients’ subjective assessments of the impacts that SUD and its treatment can have on their lives [3]. Such measures privilege the patient in determining whether their employment status, health, and family contact, for example, are satisfactory or not. QoL measures may also help clinicians recognize problems other than the specifics of the disorder and hence make better treatment decisions and priorities (see Frisch et al 1994 [4] and Foster et al 1999 [5] for discussions).

Individuals with SUD typically report significantly poorer QoL than the general population and as low as those with other serious psychiatric disorders [5‐8]. Poor QoL may also be a predictor of treatment readiness; two qualitative studies have shown that the desire to redress the negative effects of a SUD on a patient’s life and improve their QoL is a more explicit goal of treatment among patients than is reducing substance use itself [9, 10]. Interestingly, poor QoL has not been consistently predicted by SUD-specific characteristics, such as the types of substances used, frequencies of use, and lengths of problematic usage [7, 11]. Yet QoL plays a role in recovery from a SUD: Laudet et al. found that higher QoL at treatment discharge predicted abstinence better than traditional SUD characteristics [9]. In addition to measuring QoL for its own sake, as a subjective measure of functioning [12], exploring and addressing the dissatisfaction with various life domains that impair QoL may improve abstinence outcomes and help patients access a fuller range of health benefits after treatment.

Few consistent predictors of QoL have been found, speaking to the global nature of this measure. However, good mental health appears to be a strong protective factor among opioid dependents, alcohol dependents, and polysubstance users [11, 13, 14], dual-diagnosis patients [15], and non-SUD populations [16], perhaps because of the far-reaching effects that psychiatric symptoms and disorders exert on an individual’s life. Along with better mental health, exercise can also have an enhancing effect on QoL among healthy and clinical, non-SUD populations [17‐20]. Trials with the SUD population measuring QoL after exercise are lacking, and the mechanisms by which exercise affects QoL are still unknown. A reduction of comorbid risk factors [21], mediation of the deleterious effect of chronic physical conditions on QoL [22, 23], and improved self-efficacy and other psychological constructs [24] have been suggested as mechanisms. Interest in exercise overall among the SUD population has led to evidence suggesting exercise plays a role in improving abstinence rates and other substance outcomes such as craving, decreasing depressive and anxious symptoms, and improving physical condition (see Zschucke et al 2012 [25] for a review).

The interaction of the social environment with the development of a SUD and treatment trajectory have been of interest since the 1980’s, and the nuances of social factors progressively explored. For example, the detrimental effects of a substance-using network on abstinence appear to outweigh both the quantitative and qualitative support received in that network [26, 27]. Furthermore, the composure and impact of social networks appears to differ between genders; substance use among partners and family members has stronger negative effects on women’s treatment outcomes than on men’s [28‐30]. Women and men also have different factors, including social variables, which set them at risk for relapse or treatment drop-out [27]. Less research has been devoted to social factors’ impact on QoL, despite low QoL being another drop-out risk factor [9], and this relationship does not seem to have been investigated with a gender lens. In this article, we therefore describe the QoL of persons presenting for SUD treatment, and investigate gender differences in substance, health, and social factors associated with poorer QoL. More knowledge of these factors, which are also determinants of successful treatment outcomes, will be able to guide treatment providers towards improved and targeted clinical practices.

This analysis of incoming SUD patients in Norway shows that physical, mental and social well-being measures were of more consequence to QoL than SUD-specific indicators, with the exception of a strong protective effect of using methadone or buprenorphine. After adjusting for age and other significant variables, depressive symptoms increase women’s risk of reporting poorer QoL. Men who were not physically active more often reported poorer QoL, as did those who considered themselves underweight and those who ate most of their meals alone (a sign of limited social networks). These variables indicate vulnerabilities at treatment entry which may warrant additional attention through targeted mental health, physical health, and social support interventions, and which also contextualize SUD patients as persons susceptible to many of the same health and social concerns as other clinical and healthy populations, in addition to experiencing the serious effects of a SUD.

The significantly impaired QoL ratings of our sample were consistent with other studies [2], and our sample again shows poorer QoL than among other clinical groups [40]. The correlation of mental health problems with low QoL is also an established finding in the literature among chronic disease patients and the general population as well as among the SUD population [11, 13, 14], including in Norway [41]. The use of methadone or buprenorphine before entering treatment was associated with reporting better QoL, and their use was the only SUD-related indicator with a significant association to QoL [7]. This may reflect that these individuals were more settled, in that they did not need to “chase” illicit short-acting opiates on the street or buy from risky markets, and hence experienced more stabilized lives. Methadone and buprenorphine are prescribed in OMT in Norway, and while some of these individuals may not have been receiving formal prescription of OMT medications, use of such medicines still had positive effects on their QoL.

Few large studies have explored SUD patients’ QoL in connection with other physical well-being indicators, including exercise behavior, and our data show that being physically active improves the likelihood that male patients report higher QoL. Exercising behavior is frequently found to correlate with better QoL among other chronic disease populations and to improve QoL [19, 20]. This should prompt the SUD research field to utilize existing exercise research and QoL research from non-SUD groups when developing evidence-based treatment options, as well as to measure and exploit the potential for exercise to be used as a QoL-boosting activity within treatment. Exercise should be integrated into treatment for the very reason that this population presents with such impaired QoL. One smaller study suggests that significant QoL improvements can be seen even after modest doses of exercise [42].

As with physical inactivity, men’s concerns with broader physical self-perceptions have been negatively correlated with quality of life among other populations. For example, Pope et al. found that feeling too lean or insufficiently muscular is particularly dissatisfying for university-aged men, and we see impaired QoL among both genders in healthy and clinical groups when preoccupied with weight and other negative body images [43‐45].

“Eating alone” as a risk factor for men’s very poor QoL also points to the importance of normalizing social relationships and increasing social contact. Spending mealtimes alone can indicate low social participation and limited networks among the elderly [46], particularly for men [38], and social exclusion has been found to be correlated with poorer QoL among psychiatric patients [47]. Again, the social well-being needs of SUD patients may not be so different from other chronic disease sufferers or from the non-clinical population. Many studies have highlighted the importance of partners, families, and other elements of social settings on women’s initiation and maintenance of substance use [27, 29], and our data reminds us that social exclusion can still be a source of vulnerability for men with SUD.

Another main finding is that the negative effects of poor physical, mental, and social well-being are a pattern across this heterogeneous sample. In fact, these indicators were more decisive to our sample’s QoL than having a chronic physical condition, typical protective demographic factors such as being employed [48], and even addiction severity measures such as polysubstance use and recent injecting behavior. This finding is most clearly seen among men, where physical inactivity and a lack of social contact have a clear relationship to the worst QoL. The absence of many SUD-specific correlates shows that physical and social well-being factors, perhaps less commonly considered relevant to SUD patients by their treatment staff, are in fact burdensome and should be addressed more specifically as part of treatment. Specifically, it is important to give patients chances and support to prioritize their own needs and gain support for positive activities in order to address their bodily and social concerns.

Accessing QoL at intake can be an opportunity to learn about patient vulnerabilities which may not be uncovered through more objective questioning of various pre-determined domains, or a focus limited to substance use patterns. Our findings also support the continued measurement of QoL during treatment to guide further treatment plans as well as to be an outcome measure of treatment, which for a chronic condition must be monitored and addressed during the course of the disorder, at various phases, inclusive of during treatment [49]. Knowing the variables that influence patients’ well-being can help target treatment toward patient-identified goals, and such patient improvement may improve treatment engagement, retention and success. If treatment’s goal of recovery and improved well-being is to be achieved, services must be offered on multiple levels and empower patients to improve numerous areas of their life, without focusing only on substance-use outcomes [50, 51]. One such tool may be opportunities and support for physical activity as well as developing supportive social networks. Indeed, group-based exercise as part of treatment would likely improve both physical and social outcomes and improve QoL both directly and indirectly, thereby enhancing recovery.

Several limitations must be recognized when interpreting these results. The cross-sectional nature of this analysis prohibits drawing conclusions of causation, but the associations we found support further emphasis on improving physical and social well-being in treatment, including through investment in longitudinal studies to assess exercise’s effect on the QoL of the SUD population specifically. There may be other significant but unmeasured associations that confounded the relationships we found to QoL; for example, body mass index may explain the correlations between physical inactivity and poor QoL for men. Future studies should include larger sample sizes to thoroughly explore factors which may differentially impact women and men. The 74 % of patients who agreed to participate may not be representative of the entire incoming SUD patient population and there may have been inadvertent selection mechanisms at inclusion. However, characteristics of this sample were similar to Norwegian patient register data [37], and including patients up to twelve weeks after starting treatment prevented the de facto exclusion of patients in the worst shape. We therefore consider our estimates to be conservative rather than too large. The study involved a large geographic sample of treatment facilities, and it is to the study’s benefit that the sample provides such heterogeneity with regards to substance-related characteristics.

The characteristics that we found to be associated with poorer quality of life in this sample of substance use disorder patients – reporting depressive symptoms (for women); being physically inactive, dissatisfied with one’s physical self, and reporting some element of social isolation (for men) – are vulnerabilities that are not unique to this population. Not only do these findings highlight the importance of addressing mental health and of providing support for physical and social well-being during treatment, but they serve as a reminder that SUD patients are vulnerable to many of the same situations and conditions as those without a SUD. Treatment should therefore take care to not lose sight of such factors by prioritizing directly substance-related issues, often externally determined to be more important. Measuring quality of life, throughout the treatment trajectory, recognizes patients as sources of such important and otherwise uncollectable information.