Research Findings - CTN-Related Research

Adverse Events in an Integrated Trauma-focused Intervention for Women in Community Substance Abuse Treatment

A substantial number of women who enter substance abuse treatment have a history of trauma and meet criteria for posttraumatic stress disorder (PTSD). Fear regarding the extent to which PTSD treatment can evoke negative consequences remains a research question. This study explored adverse events related to the implementation of an integrated treatment for women with trauma and substance use disorder (Seeking Safety) compared with a nontrauma-focused intervention (Women's Health Education). Three hundred fifty-three women enrolled in community substance abuse treatment were randomized to 1 of the 2 study groups and monitored weekly for adverse events. There were no differences between the two intervention groups in the number of women reporting study-related adverse events (28 [9.6%] for the Seeking Safety group and 21[7.2%] for the Women's Health Education group). Implementing PTSD treatment in substance abuse treatment programs appears to be safe, with minimal impact on intervention-related adverse psychiatric and substance abuse symptoms. More research is needed on the efficacy of such interventions to improve outcomes of PTSD and substance use. Killeen, T., Hien, D., Campbell, A., Brown, C., Hansen, C., Jiang, H., Kristman--Valente, A., Neuenfeldt, C., Rocz-de la Luz, N., Sampson, R., Suarez-Morales, L., Wells, E., Brigham, G., and Nunes, E. Adverse Events in an Integrated Trauma-focused Intervention for Women in Community Substance Abuse Treatment. J. Subst. Abuse Treat. 2008 Feb 20. [E-pub ahead of print].

Using a Standardized Patient Walk-through to Improve Implementation of Clinical Trials

This report describes a standardized patient (SP) walk-through to facilitate implementation of a clinical trial within the National Drug Abuse Treatment Clinical Trials Network (CTN). SPs are actors trained to portray a set of symptoms consistently across interactions with multiple clinicians. The Oregon/Hawaii Node of the CTN employed one SP to pilot participant screening processes in a study testing a combined pharmacological and behavioral therapy for women and men dependent on prescription opioid analgesics. The SP mimicked an individual seeking treatment and "walked" through study intake processes. Findings such as study staff members' inadequacy in describing issues of patient confidentiality and problems explaining the Health Insurance Portability and Accountability Act led to modifications to the clinical implementation of the study. Research coordinators and the staff found the use of an SP to be highly effective. The node is now making routine use of SPs in the implementation of CTN protocols. Fussell, H.E., Kunkel, L.E., Lewy, C.S., McFarland, B.H., McCarty, D.. J. Subst. Abuse Treat. 2008 May 28. [E-pub ahead of print].

States and Substance Abuse Treatment Programs: Funding and Guidelines for Infection-Related Services

Community-based substance abuse treatment programs provide HIV, hepatitis C virus, and sexually transmitted infection services. To explore how state funding and guidelines affect practice, the authors surveyed state agency administrators and substance abuse treatment program administrators and clinicians regarding 8 infection-related services. Although state funding for infection-related services is widely available, substance abuse treatment programs do not always access it. Substance abuse treatment program guidelines are clearer in states that have written guidelines. Improved communication between state agencies and substance abuse treatment programs may enhance service. Kritz, S., Brown, L.S. Jr, Goldsmith, R.J., Bini, E.J., Robinson, J., Alderson, D., Novo, P., and Rotrosen, J. States and Substance Abuse Treatment Programs: Funding and Guidelines for Infection-Related Services. Am. J. Public Health. 98(5), pp. 824-826, E-pub 2008 Apr 1, May 2008.

Smoking Cessation Treatment in Community-based Substance Abuse Rehabilitation Programs

Nicotine dependence is highly prevalent among drug- and alcohol-dependent patients. A multisite clinical trial of smoking cessation (SC) treatment was performed at outpatient community-based substance abuse rehabilitation programs affiliated with the National Drug Abuse Treatment, Clinical Trials Network. Cigarette smokers (N=225) from five methadone maintenance programs and two drug and alcohol dependence treatment programs were randomly assigned in a 2:1 ratio to receive either (1) SC treatment as an adjunct to substance abuse treatment-as-usual (TAU) or (2) substance abuse TAU. Smoking cessation treatment consisted of 1 week of group counseling before the target quit date and 8 weeks of group counseling plus transdermal nicotine patch treatment (21 mg/day for Weeks 1-6 and 14 mg/day for Weeks 7 and 8) after the target quit date. Smoking abstinence rates in SC, 10%-11% during treatment and 5%-6% at the 13- and 26-week follow-up visits, were significantly better than those in TAU during treatment (p< .01). In addition, SC was associated with significantly greater reductions as compared with TAU in cigarettes smoked per day (75% reduction, p< .001), exhaled carbon monoxide levels (p< .001), cigarette craving (p< .05), and nicotine withdrawal (p< .05). Smoking cessation did not differ from TAU on rates of retention in substance abuse treatment, abstinence from primary substance of abuse, and craving for primary substance of abuse. Compliance with SC treatment, moderate at best, was positively associated with smoking abstinence rates. Smoking cessation treatment resulted in significant reductions in daily smoking and modest smoking abstinence rates without having an adverse impact on substance abuse rehabilitation when given concurrently with outpatient substance abuse treatment. Substance abuse treatment programs should not hesitate to implement SC for established patients. Reid, M.S., Fallon, B., Sonne, S., Flammino, F., Nunes, E.V., Jiang, H., Kourniotis, E., Lima, J., Brady, R., Burgess, C., Arfken, C., Pihlgren, E., Giordano, L., Starosta, A., Robinson, J., and Rotrosen, J. J. Subst. Abuse Treat. 35(1), pp. 68-77, E-pub 2007 Oct 24, July 2008.

Infrequent Illicit Methadone Use Among Stimulant-using Patients in Methadone Maintenance Treatment Programs: A National Drug Abuse Treatment Clinical Trials Network Study

The authors sought to determine the prevalence, patterns, and correlates of past-month illicit methadone use and history of regular illicit use among stimulant-using methadone maintenance treatment patients. They obtained self-reported information on illicit methadone use from 383 participants recruited from six community-based methadone maintenance programs. Overall, 1.6% of participants reported illicit use in the past month, and 4.7% reported a history of regular use. Younger age and history of outpatient psychological treatment were associated with increased odds of past-month illicit use. Illicit methadone use among patients in maintenance programs is infrequent; however, a number of factors may increase risk of illicit use. Wu, L.T., Blazer, D.G., Stitzer, M.L., Patkar, A.A., and Blaine, J.D. Am. J. Addict. 17(4), pp. 304-311, Jul-Aug 2008.

Motivational Enhancement Therapy to Improve Treatment Utilization and Outcome in Pregnant Substance Users

Pregnant substance users can benefit significantly from substance abuse treatment, but treatment retention can be challenging. Two hundred pregnant substance users entering outpatient substance abuse treatment at one of four treatment programs were randomized to receive either three individual sessions of Motivational Enhancement Therapy for pregnant substance users (MET-PS) or the first three individual sessions normally provided by the program. All participants were encouraged to participate in all other treatment offered by the program. Outcome measures included treatment utilization according to clinic records, qualitative urine toxicology measures, and self-report of substance use. One hundred sixty-two (81%) participants completed the 1-month active phase. Participants attended 62% of scheduled treatment on average and reported decreased substance use during the first month of treatment, with no differences between MET-PS and treatment-as-usual (TAU) participants. There was some evidence that the efficacy of MET-PS varied between sites and that MET-PS might be more beneficial than TAU in decreasing substance use in minority participants. These results suggest that MET-PS is not more effective than TAU for pregnant substance users in general but that there might be particular subgroups or treatment programs for which MET-PS might be more or less effective than TAU. Winhusen, T., Kropp, F., Babcock, D., Hague, D., Erickson, S.J., Renz, C., Rau, L., Lewis, D., Leimberger, J., and Somoza, E.. J. Subst. Abuse Treat. 35(2), pp. 161-73, Epub 2008 Feb 20, September 2008.

NIDA CTN Membership is Diverse, But Due to the Need For Large Samples, Over Represents Larger Facilities

Programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN) completed Organizational Surveys (n=106 of 112; 95% response rate) and Treatment Unit Surveys (n=348 of 384; 91% response rate) to describe the levels of care, ancillary services, patient demographics, patient drug use and co-occurring conditions. Analyses describe the corporations participating in the CTN and provide an exploratory assessment of variation in treatment philosophies. A diversity of treatment centers participates in the CTN; not for profit organizations with a primary mission of treating alcohol and drug disorders dominate. Compared to National Survey of Substance Abuse Treatment Services (N-SSATS), programs located in medical settings are over-represented and centers that are mental health clinics are under-represented. Outpatient, methadone, long-term residential and inpatient treatment units differed on patients served and services provided. Larger programs with higher counselor caseloads in residential settings reported more social model characteristics. Programs with higher social model scores were more likely to offer self-help meetings, vocational services and specialized services for women. Conversely, programs with accreditation had less social model influence. The CTN is an ambitious effort to engage community-based treatment organizations into research and more fully integrate research and practice. McCarty, D., Fuller, B., Kaskutas, L., Wendt, W., Nunes, E., Miller, M., Forman, R., Magruder, K., Arfken, C., Copersino, M., Floyd, A., Sindelar, J., and Edmundson, E. Treatment Programs In the National Drug Abuse Treatment Clinical Trials Network. Drug Alcohol Depend., 92(1-3), pp. 200-207, 2008.

Staff Perceptions of Need to Improve Treatment are More Open to Implementing New Practices

Program administrators and staff in 249 treatment programs participating in the National Drug Abuse Treatment Clinical Trials Network completed surveys (95% response rate) to characterize participating programs and practitioners. A two-level random-effects regression model assessed the influence of Organizational Readiness for Change (ORC) and organizational attributes on opinions toward the use of four evidence-based practices (manualized treatments, medication, integrated mental health services, and motivational incentives) and practices with less empirical support (confrontation and noncompliance discharge). The ORC scales suggested greater support for evidence-based practices in programs where staff perceived more program need for improvement, better Internet access, higher levels of peer influence, more opportunities for professional growth, a stronger sense of organizational mission, and more organizational stress. Support for confrontation and noncompliance discharge, in contrast, was strong when staff saw less opportunity for professional growth, weaker peer influence, less Internet access, and perceived less organizational stress. The analysis provides evidence of the ORC's utility in assessing agency strengths and needs during the implementation of evidence-based practices. Fuller, B., Rieckmann, T., Nunes, E., Miller, M., Arfken, C., Edmundson, E., and McCarty, D. Organizational Readiness for Change and Opinions Toward Treatment Innovations. J. Subst. Abuse Treat. 33(2), pp. 183-192, 2007.