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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Higher Exposure to STAGE-12 Sessions Resulted in Improved Outcomes for Stimulant Use

June 19, 2014 by

Psychotherapie - Die Selbsthilfegruppe blau schwarzThis ancillary investigation of data from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0031 (“Stimulant Abuser Groups to Engage in 12-Step (STAGE-12)“), by Pacific Northwest Node members Elizabeth Wells, Dennis Donovan, Suzanne Doyle, Sharon Garrett, Michelle Ingalsbe, Mary Hatch-Maillette, and colleagues examined whether level of exposure to the STAGE-12 intervention, a 12-step facilitative therapy, is related to treatment outcome.

The original study compared STAGE-12 combined with treatment-as-usual (TAU) to TAU alone; however, these analyses include only those randomized to STAGE-12 (n=234).

“High-exposure” patients (n=158; attended at least 2 of 3 individual and 3 of 5 group sessions in the STAGE-12 intervention), compared to those with less exposure, demonstrated:

  1. Higher odds of self-reported abstinence from, and lower rates of, stimulant and non-stimulant drug use;
  2. Lower probabilities of stimulant-positive urine screens;
  3. More days of attending and lower odds of not attending 12-Step meetings;
  4. Greater likelihood of reporting no drug problems;
  5. More days of duties at meetings;
  6. More types of 12-Step activities.

Many of these differences declined over time, but several were still significant by the last follow-up (180 days following randomization).

Conclusions:  Although outpatient substance use disorder treatment is thought to be characterized by high drop-out rates and low rates of treatment completion, exposure to STAGE-12 was relatively high for this 8-session intervention.  Those achieving high exposure to STAGE-12 demonstrated more positive outcomes, though the design of this secondary analysis cannot demonstrate a causal relationship there. However, it does demonstrate that it is feasible to interest people entering intensive outpatient treatment in a 12-Step oriented intervention and that individuals who agree to participate can be retained at relatively high rates.

Citation: Wells EA, Donovan DM, Daley DC, et al. Is Level of Exposure to a 12-Step Facilitation Therapy Associated with Treatment Outcome? Journal of Substance Abuse Treatment 2014 (in press).


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Raters Unaffiliated with the Tested Treatment May Have Most Objective Fidelity Feedback

June 18, 2014 by

HAQThis ancillary investigation of data from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0031 (“Stimulant Abuser Groups to Engage in 12-Step (STAGE-12)“), by Pacific Northwest Node members Michelle Peavy and Sharon Garrett, as well as Joseph Guydish, Jennifer Knapp Manuel, and colleagues, investigated the correspondence among four groups of raters on adherence to STAGE-12, a manualized 12-step facilitation (TSF) group and individual treatment targeting stimulant abuse.

The four rater groups compared included the study therapists, their supervisors, study-related (“TSF expert”) raters, and non-project-related (“external”) raters.

Results indicated that external raters rated most critically Mean Adherence — the mean of all the adherence items — and global performance. External raters also demonstrated the highest degree of reliability with the designated expert. Therapists rated their own adherence lower, on average, than did supervisors and TSF expert raters, but therapist ratings also had the poorest reliability.

Conclusions:  Findings highlight the challenge in developing practical, but effective methods of fidelity monitoring for evidence-based practice in clinical settings. While funding and licensing agencies increasingly call for use of evidence-based treatments, community-based organizations implementing them will seek the simplest, most reliable and cost-effective ways of monitoring their delivery.

These results suggest that there may be a role for on-site therapists or supervisors rating adherence, and that raters unaffiliated with the treatment being tested may provide the most objective ratings.

Citation: Peavy KM, Guydish JR, Manuel JK,et al. Treatment Adherence and Competency Ratings Among Therapists, Supervisors, Study-Related Raters and External Raters in a Clinical Trial of 12-Step Facilitation for Stimulant Users. Journal of Substance Abuse Treatment 2014 (in press).


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Residence XII Announces New CEO, Eve Ruff

May 29, 2014 by

res12Residence XII announces the selection of Eve Ruff, MS, CDP as their new Chief Executive Officer, beginning in July 2014.    Eve is currently Executive Director of Edgewood Seattle Addiction Services. She has extensive leadership experience and worked in acute care, inpatient and outpatient chemical dependency treatment settings.  Residence XII’s Board of Directors is impressed with her passion for gender-specific treatment and Residence XII’s mission to provide the highest quality treatment programs and services to meet the unique needs of women and their families. Ms. Rufff is highly respected in the chemical dependency field and has presented at the U.S. Fundamentals of Addiction Medicine and NAADAC conferences.

Margaret Jones returned to Residence XII as CEO in late 2012 for a temporary appointment.  About her replacement she says “Eve is also passionate about research  and will be a great addition to the PNW Node.  I look forward to Residence XII’s  participation in future research projects.”

Methadone or Buprenorphine Treatment for Opioid Dependence Reduces HIV Risk Behaviors

April 28, 2014 by

riskResearch over the past 20 years has shown that methadone maintenance (MET) reduces opioid use and is an effective HIV risk reduction intervention as well. Like methadone, treatment with buprenorphine-naloxone (BUP) also appears to reduce HIV risk.

To date, only one study has compared HIV risk in patients receiving MET vs. BUP. This article, currently in-press in JAIDS, reports on a similar comparison of a much larger sample in a secondary analysis of data from the National Drug Abuse Treatment Clinical Trials Network (CTN) protocol, “Starting Treatment with Agonist Replacement Therapies (START).”

The Pacific Northwest Node was one of the original nodes involved in the START study, and Dr. Andrew Saxon from the VA Puget Sound Health Care was one of the authors of this ancillary investigation.

START was a randomized, open-label phase 4 study in participants entering opioid agonist treatment programs throughout the country that aimed to compare the effect of BUP and MET on liver function. The Risk Behavior Survey (RBS) was administered to participants, measuring past 30-day HIV risk, at baseline and weeks 12 and 24. Among the 529 patients randomized to MET, 391 (74%) were completers; for BUP, 740 were randomized and 340 completed (46%).

Analysis of the survey results found significant reductions in injecting risk with no differences between groups in mean number of times reporting injecting heroin, speedball, other opiates, and number of injections. There were also no differences between groups in terms of percent who shared needles, did not clean shared needles with bleach, shared cookers, or engaged in front/back loading of syringes.

The percent having multiple sex partners decreased equally in both groups. However, for males on BUP, the sex risk composite increased, while for males on MET, the sex risk decreased, resulting in significant group differences over time. For females, there was a significant reduction in sex risk with no group differences.

Conclusions: Among MET and BUP patients who remained in treatment, HIV injecting risk was equally and markedly reduced, however MET retained more patients. Sex risk was equally and significantly reduced among females in both treatment conditions, but increased for males on BUP and decreased for males on MET. Overall, these findings further support the importance of expanding availability of evidence-based medical treatments for opioid addiction.

Citation: Woody GE, Bruce RD, Korthuis PT, et al. HIV Risk Reduction with Buprenorphine-Naloxone or Methadone: Findings from A Randomized Trial. Journal of Acquired Immune Deficiency Syndromes 2014 (in press).


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