Predictors of 12-Step Attendance and Participation for Individuals with Stimulant Use Disorders

July 18, 2016 by

group therapy orientation_174164939 - CopyFew studies have examined the effectiveness of 12-step peer recovery support programs with drug use disorders, especially stimulant use, and it is difficult to know how outcomes related to 12-step attendance and participation generalize to individuals with non-alcohol substance use disorders (SUDs).

The NIDA Clinical Trials Network study, STAGE-12, was a clinical trial of 12-step facilitation lead by the Pacific Northwest Node (N=471) focusing on individuals with cocaine or methamphetamine use disorders. It allowed for examination of four questions:

  1. To what extent do treatment-seeking stimulant users use 12-step programs and which ones?
  2. Do factors previously found to predict 12-step participation among those with alcohol use disorders also predict participation among stimulant users?
  3. What specific baseline “12-step readiness” factors predict subsequent 12-step participation and attendance?
  4. Does stimulant drug of choice differentially predict 12-step participation and attendance?

The four outcome variables, attendance, speaking, duties and 12-step meetings, and other peer recovery support activities, were not related to baseline demographic or substance problem history or severity.

Drug of choice was associated with differential days of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) attendance among those who reported attending, and cocaine users reported more days of attending AA or NA at 1-, 3-, and 6-month follow-ups than did methamphetamine users.

Pre-randomization measures of perceived benefit of 12-step groups predicted 12-step attendance at 3- and 6-month follow-ups. Pre-randomization 12-step attendance significantly predicted number of other self-help activities at end-of-treatment, 3- and 6-month follow-ups. Pre-randomization perceived benefit and problem severity both predicted number of self-help activities at end-of-treatment self-help activities at end-of-treatment and 3-month follow-up. Pre-randomization perceived barriers to 12-step groups were negatively associated with self-help activities at end-of-treatment and 3-month follow-up. Whether or not one participated in any duties was predicted at all times points by pre-randomization in self-help actitivies.

Conclusions: The primary finding of this study is one of continuity: both readiness to engage in 12-step content and specific prior attendance and active participation (defined as speaking, having duties at, or engaging in related activities) with 12-step programs were the main signs pointing to future involvement in these same areas. Based on these findings, there may be little value in continuing to explore demographic characteristics as predictors of 12-step involvement, and instead future research should focus on measures of perceptions and behaviors that are 12-step specific.

Citation: Hatch-Maillette MA, et al. Predictors of 12-Step Attendance and Participation for Individuals with Stimulant Use Disorders.  Journal of Substance Abuse Treatment 2016;68:74-82.


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Twelve-Step Facilitation Outcomes Similar for Both African Americans and Caucasians

June 14, 2016 by

blackwomanEngagement in 12-step meetings and activities has been shown to be a powerful aid to recovery from substance use disorders. However, only limited attention has been given to ethnic and racial differences in attitudes toward 12-step and involvement.

This study utilized data from CTN-0031, “Stimulant Abuser Groups to Engage in 12-Step (STAGE-12),” a large multisite trial testing the effectiveness of a 12-step facilitation therapy (Twelve-Step Facilitation (TSF)) with stimulant-dependent treatment seekers. It compared baseline differences and treatment outcomes between African American and Caucasian participants.

The Pacific Northwest Node was the lead node for this study.

Results of the analysis found select few baseline differences (i.e., African Americans reported higher levels of spirituality than Caucasians; African American participants indicated more perceived benefits of 12-step involvement; Caucasians were more likely to endorse future involvement in 12-step). However, there were no outcome differences (e.g., substance use outcomes, 12-step meeting attendance).

Conclusions: The tested intervention, TSF, produced similar outcomes for both groups, indicating that it may be useful across racial categories. This finding is promising, given that much of the previous research on TSF treatments has focused on alcohol, and stimulant use may present unique problem profiles for African American and Caucasian individuals. That TSF performed equally well among the two study groups is important information for clinicians deciding which evidence-based practice might be best applied to a particular client.

Citation: Peavy KM, et al. A Comparison of African American and Caucasian Stimulant Users in 12-Step Facilitation Treatment. Journal of Ethnicity in Substance Abuse 2016 (in press).


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Sociocultural Factors Affect Condom Use Among Black Men With Substance Use Disorders

March 7, 2016 by

shutterstock_328029845Although HIV prevention during substance abuse treatment is ideal, existing HIV risk-reduction interventions are less effective among Black and other ethnic minority substance abusers.

Though a number of recent theories have highlighted the importance of increasing our understanding of the relationship of sociocultural factors to sexual decision-making as a step towards developing more HIV prevention interventions for ethnic minorities, few studies have examined sociocultural factors in the sexual decision-making process of Black substance abusing men.

The HIV prevention intervention Real Men Are Safe (REMAS) was evaluated in a multisite, randomized clinical trial in the NIDA Clinical Trials Network (protocol CTN-0018; the Pacific Northwest Node was the lead Node on this project).

This secondary analysis aimed to examine the relation of two specific sociocultural factors (masculinity and perceived barriers to condom use) to the self-reported sexual behaviors of Black substance abusing men with their main and casual female partners.

Analyses of the baseline data of 126 Black men entering substance abuse treatment revealed that the endorsement of both personal and social masculinity predicted more unprotected sexual occasions (USO) with casual partners. The perception that condoms decreased sexual pleasure also predicted higher USO rates with casual partners.  However, fewer partner barriers was not associated with USO among casual partners as expected. Neither the endorsement of social or personal masculinity or perceived condom barriers predicted USO with main partners.

Conclusions: These findings suggest that interventions that depict condom use as both pleasurable and congruent with Black male perceptions of masculinity may be more effective with Black substance abusing men than interventions focusing solely on health beliefs or education. Future research should continue to investigate the influence of other sociocultural factors, especially those that influence the sexual decision-making process, on sexual risk behaviors among Black men, as well as other groups.

Citation: Wilson J, et al. Do Masculinity and Perceived Condom Barriers Predict Heterosexual HIV Risk Behaviors Among Black Substance Abusing Men? Journal of Health Disparities Research and Practice 2014;7(6):54-71.

Women and Men Show Different Patterns Related to Unprotected Heterosexual Anal Sex

February 2, 2016 by

genderdiffAccording to the Centers for Disease Control and Prevention (CDC), women represent approximately 20% of new HIV infections each year, with about 84% of those occurring through heterosexual contact. Heterosexual anal sex (HAS) in the absence of condom use is one of the highest risk factors for HIV and other sexually transmitted infections, and heterosexual substance-abusing individuals report higher anal sex rates compared to their counterparts in the general population.

This secondary analysis of two NIDA Clinical Trials Network studies (CTN-0018, led by the Pacific Northwest Node, and CTN-0019) evaluated the effectiveness of two gender-specific, evidence-based HIV prevention interventions (Real Men are Safe, or REMAS, for men; Safer Sex Skill Building, or SSSB, for women) against an HIV education (HIV-Ed) control condition on decreasing unprotected heterosexual anal sex (HAS) among substance abuse treatment-seeking men (n=171) and women (n=105).

Two variables, engagement in any HAS and engagement in unprotected HAS, were assessed at baseline and three months post-intervention.

Compared to the control group, women in the gender-specific intervention did not differ on rates of any HAS at follow-up but significantly decreased their rates of unprotected HAS.

Men in both the gender-specific and the control interventions reported less HAS and unprotected HAS at three-month follow-up compared to baseline, with no treatment condition effect.

Conclusions: Women and men showed different patterns when it came to unprotected HAS. For men, rates of unprotected HAS decreased overall in the sample, and patterns suggest the reduction may, at least partly, reflect their decreased rates of engaging in any HAS. On the other hand, SSSB women did show a decrease in unprotected HAS compared to controls despite no significant difference in overall HAS rates. For them, the results suggest the SSSB intervention did produce intentional action toward risk reduction.

The mechanism of action for SSSB compared to REMAS in decreasing unprotected HAS is unclear. More attention to HAS in HIV-prevention interventions for heterosexual men and women in substance abuse treatment is warranted.

Citation: Hatch-Maillette MA, et al. Heterosexual Anal Sex Among Men and Women in Substance Abuse Treatment: Secondary Analysis of Two Gender-Specific HIV-Prevention Trials. Journal of Sex Research 2016 (in press).


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CM Patients’ Incentive Preferences Contradict Current Intervention Designs

December 21, 2015 by

counselor client_138711347Despite strong support for its effectiveness, debates persist about the most effective ways to disseminate and design contingency management (CM) programs. Currently-promoted CM methods are empirically-validated, but their congruence with the actual interests and preferences of addiction treatment clients is unknown.

This study of clients in 3 community treatment programs in the Pacific Northwest Node of the NIDA Clinical Trials Network aimed to ask the question: what do clients actually want?

The study included anonymous survey completion by an aggregate sample of 358 enrollees, documenting interest in incentives and preferences for:

  • fixed-ratio vs. variable-ratio (i.e., would you rather earn $5 a week for 10 weeks, or participate in a weekly drawing in which you could earn $50 each week?), and
  • immediate vs. delayed distribution of earned incentives (i.e., would you rather earn $5 per week for 10 weeks, or save weekly points for 10 weeks to earn $50 at the end?).

Analyses ruled out site differences in survey responses, and then tested age and gender as influences.

Results found that:

  • interest in different types of $50 vouchers (e.g., retail vouchers, transportation vouchers, cash) was highly inter-correlated, with a mean sample rating of 3.49 on a 5-point scale;
  • gender did not influence client interest in incentives, but age was an inverse predictor, with youth exhibiting more interest than older clients;
  • a majority of clients preferred fixed-ratio incentives and delayed distribution (67% and 63% respectively);
  • those preferences were voiced by a majority of both men and women, but were held by a greater proportion of females.

Conclusions: This study offered a helpful glimpse into client perspectives about design features of contingency management interventions, and found that those preferences contradicted currently-promoted CM design features, which typically suggest variable-ratio (weekly drawings where you may receive more or less than the fixed amount) and immediate rewards are more effective. Future efforts to disseminate CM may be more successful if flexibly undertaken in a manner that incorporates the interests and preferences of local client populations.

Citation: Hartzler B, Garrett SB. Interest and Preferences for Contingency Management Design Among Addiction Treatment Clientele. American Journal of Drug and Alcohol Abuse 2015 (in press).


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Medication Assisted Treatment for AI/AN Populations: Free CTN Webinar Co-Presented by PN Node Researcher

February 4, 2015 by
rieckmann

Traci Rieckmann, PhD, MS

Join the NIDA Clinical Coordinating Center (CCC) for its next webinar, Medication Assisted Treatment for American Indians and Alaska Natives, Wednesday, February 11 at 12pm ET, presented by Traci Rieckmann, PhD, MS  of the Oregon Health & Science University (WS Node) and Lisa Rey Thomas, PhD of the Alcohol & Drug Abuse Institute, University of Washington (PN Node).

Remarkable progress has been made in the development of medications to treat substance use disorders, yet consistent and widespread access to such medications remains low. This gap between patient need and actual implementation of efficacious treatment is especially troubling for vulnerable populations including American Indian and Alaska Natives (AI/AN).

Lisa Rey Thomas, PhD

Lisa Rey Thomas, PhD

This one-hour course will provide an overview of organizational and provider characteristics influencing access to medication assisted treatments (MAT) for addictive disorders in AI/AN populations along with a review of results from a national survey of AI/AN substance abuse treatment program clinicians and clinical administrators regarding the incorporation of cultural, evidence-based concepts and healing techniques.

Learning objectives include:

  • Understanding organizational and provider characteristics that affect access to medication assisted treatments for American Indian and Alaska Natives (AI/AN) dealing with addictive disorders.
  • Consider implications for the design and implementation of treatment programs and services for vulnerable populations, including American Indian and Alaska Natives.
  • Discuss significant aspects of a national study on AI/AN treatment programs.

Register online at:  

https://cc.readytalk.com/r/qn649tx3zz6q&eom

Community Perspectives on Substance Use and Related Concerns in 4 WA Tribal Communities

January 14, 2015 by

0033logoCommunity-university teams from the University of Washington and the Washington State Tribal Communities investigated substance use, abuse, and dependence (SUAD) and related concerns, needs, strengths, and resources in four Washington State Tribal communities as part of National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0033-Ot-3 (“Methamphetamine: Where Does It Fit in the Bigger Picture of Drug Use of American Indian and Alaska Native Communities and Treatment Seekers?”).

One hundred and fifty-three key community members shared their perspectives through 45 semi-structured interviews and 19 semi-structured focus groups.

Qualitative data analysis revealed robust themes: prescription medications and alcohol were perceived as most prevalent and concerning, family and peer influences and emotional distress were prominent perceived risk factors, and SUAD intervention resources varied across communities.

Findings may guide future research and the development of much needed strength-based, culturally appropriate, and effective SUAD interventions for American Indians, Alaska Natives, and their communities.

Citation: Radin SM, Kutz SH, LaMarr J, et al. Community Perspectives on Drug/Alcohol Use, Concerns, Needs and Resources in Four Washington State Tribal Communities.  Journal of Ethnicity in Substance Abuse 2015 (in press).


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Lessons Learned for Follow-Up Booster Calls with ED Patients in the SMART-ED Trial

November 12, 2014 by

boostercallThis article, by Pacific Northwest Node members Dennis Donovan, Mary Hatch-Maillette, Melissa Phares, and colleagues, looked at implementation issues related to providing brief motivational interviewing-based interventions over the phone as part of CTN protocol Screening, Motivational Assessment and Referral to Treatment in Emergency Departments (SMART-ED),” and includes challenges, “lessons learned,” and recommendations for others attempting to implement adjunctive booster call sessions.

In the study, attempts were made to complete two 20-minute telephone “booster” calls within a week following an emergency department (ED) patient’s discharge, with 425 patients who screened positive for and had recent problematic substance use (other than alcohol or nicotine).

Over half (56.2%) of participants completed the initial call; 66.9% of those who received the initial call also completed the second call. It took an average of 4 attempts for the first call to connect with participants and 3 for the second.  Each completed call lasted about 22 minutes.

Common challenges/barriers identified by booster callers included:

  • Unstable housing;
  • Limited phone access;
  • Unavailability due to additional treatment;
  • Lack of compensation for booster calls;
  • Booster calls coming from unrecognized numbers/area codes or someone other than ED staff (participants found this confusing and suspicious).

Conclusions:  A team of booster interventionists and supporting staff can overcome challenges in implementing a remotely located, centralized booster call center.  Specific recommendations are presented in the article with respect to overcoming barriers and challenges. Future research needs to evaluate the incremental benefit of adjunctive booster calls on outcomes over and above that of brief motivational interventions delivered in the emergency department setting.

Citation: Donovan DM, Hatch-Maillette MA, Phares MM, et al.  Lessons learned for follow-up phone booster counseling calls with substance abusing Emergency Department patients.  Journal of Substance Abuse Treatment 2014 (in press).


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Outcomes from CTN-0047: No Significant Differences Between Treatment Groups

September 9, 2014 by

edMedical treatment settings such as emergency departments (EDs) present important opportunities to address problematic substance use. Currently, EDs do not typically intervene beyond acute medical stabilization.

This study, National Drug Abuse Institute Clinical Trials Network protocol CTN-0047 (“Screening Motivational Assessment and Referral to Treatment in Emergency Departments (SMART-ED)“) aimed to contrast the effects of a brief intervention with telephone boosters (BI-B) with those of screening, assessment, and referral to treatment (SAR) and minimal screening only (MSO) among drug-using ED patients.  The Pacific Northwest Node was the co-lead node on this project. 

Between October 2010 and February 2012, 1285 adult ED patients from 6 US academic hospitals, who scored 3 or greater on the 10-item Drug Abuse Screening Test (indicating moderate to severe problems related to drug use) and who were currently using drugs, were randomized to MSO (n=431), SAR (n=427), or BI-B (n=427).  Follow-up assessment were conducted at 3, 6, and 12 months by blinded interviewers.

Following screening, each group received:

  • MSO participants: only an informational pamphlet;
  • SAR participants: assessment plus referral to addiction treatment if indicated;
  • BI-B participants:  assessment and referral as in SAR, plus a manual-guided counseling session based on motivational interviewing principles and up to 2 “booster” sessions by telephone during the month following the ED visit.

Results found no significant differences between groups in self-reported days using the primary drug, days using any drug, or heavy drinking days at 3, 6, or 12 months. At the 3-month follow-up, participants in the SAR group had a higher rate of hair samples positive for their primary drug of abuse (265 of 280, 95%) than did participants in the MSO group (253 or 287, 88%) or the BI-B group (244 of 275, 89%). Hair analysis differences between groups at other time points were not significant.

Conclusions:  The findings of this study suggest that even a relatively robust brief intervention such as the one implemented in this trial is unlikely to be useful as a general strategy for the population recruited for this trial (ED patients with relatively severe drug problems and other life challenges).

Further research will be needed to explore more intensive interventions targeting the most severely affected patients with substance use disorder visiting the ED and to ascertain whether screening and brief interventions play a useful roll in the treatment of ED patients less severely affected by drug use disorders.

Citation: Bogenschutz MP, Donovan DM, Mandler RN, et al. Brief Intervention for Patients with Problematic Drug Use Presenting in Emergency Departments: A Randomized Clinical Trial. JAMA Internal Medicine 2014 (in press).


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Updates from STAGE-12

August 25, 2014 by

Two new articles have just been released online in-press at Psychology of Addictive Behaviors, providing the latest information about National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0031, Stimulant Abuser Groups to Engage in 12-Step (STAGE-12).

The first paper, by Suzanne Doyle and Dennis Donovan of the Pacific Northwest Node, the Lead Node for this project, describes the application of an “ensemble classification tree approach” to the prediction of completion from the 12-Step Facilitation intervention used in the study.

The application of an emsemble subsampling regressions tree method utilizes the fact that classification trees are unstable but, on average, produce an improved prediction of the completion of drug abuse treatment.  The results of this analysis support the notion that there are early indicators of treatment completion that may allow for modification of approaches more tailored to fitting the needs of individuals, and potentially provide more successful treatment engagement and improved outcomes.  For example, the number of types of self-help activity involvement prior to treatment was the predominant predictor, with other effective predictors including better coping self-efficacy, more days of prior meeting attendance, greater acceptance of the disease model, higher confidence for not resuming use following discharge, lower ASI Drug and Alcohol composite scores, negative urine screens for cocaine or marijuana, and fewer employment problems.

Citation: Doyle SR, Donovan DM. Applying an Ensemble Classification Tree Approach to the Prediction of Completion of a 12-Step Facilitation Intervention with Stimulant Abusers. Psychology of Addictive Behaviors 2014 (in press).

The second paper, by Barbara Campbell, Joseph Guydish, and colleagues, reports on an examination of associations of therapeutic alliance and treatment delivery fidelity with treatment retention in STAGE-12.  Stronger therapeutic alliance and higher therapist competence in the delivery of TSF intervention were associated with better treatment retention, whereas treatment adherence was not.  Training and fidelity monitoring of TSF should focus on general therapist skills and therapeutic alliance development to maximize treatment retention.

Notably, this was  the first study to show a relationship between therapeutic alliance and retention in TSF with substance abusers, and to identify a significant fidelity-retention relationship for manual-guided TSF treatment, a finding that has important implications for treatment delivery.

Citation: Campbell BK, Guydish JR, et al. The Relationship of Therapeutic Alliance and Treatment Delivery Fidelity with Treatment Retention in a Multisite Trial of Twelve-Step Facilitation. Psychology of Addictive Behaviors 2014 (in press).


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