Clinical Trials Network Research

Attitudes Toward the Integration of Smoking Cessation Treatment into Drug Abuse Clinics

This article examines the variables associated with the presence of smoking cessation interventions in drug abuse treatment units, as well as staff attitudes toward the integration of smoking cessation services as a component of care. Surveys were administered to 106 organizations, 348 treatment clinics, and 3,786 employees in agencies that participated in the National Drug Abuse Treatment Clinical Trials Network. Use of smoking cessation interventions was associated with the number of additional services offered at clinics, residential detoxification services, and attitudes of the staff toward smoking cessation treatment. Staff attitudes toward integrating smoking cessation services in drug treatment were influenced by the number of pregnant women admitted, the number of ancillary services provided, the attitudes of staff toward evidence-based practices, and whether smoking cessation treatment was offered as a component of care. Fuller, B.E., Guydish, J., Tsoh, J., Reid, M.S., Resnick, M., Zammarelli, L., Ziedonis, D.M., Sears, C., and McCarty, D. Attitudes Toward the Integration of Smoking Cessation Treatment into Drug Abuse Clinics. J Subst Abuse Treat. 32(1), pp. 53-60, 2007. Epub September 26, 2006.

Substance Abuse Treatment Entry, Retention, and Outcome in Women: A Review of the Literature

A search of the English language literature from 1975 to 2005 using Medline and PsycInfo databases found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. Gender-specific predictors of outcome do exist, and individual characteristics and treatment approaches can differentially affect outcomes by gender. While women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field. Greenfield, S.F., Brooks, A.J., Gordon, S.M., Green, C.A., Kropp, F., McHugh, R.K., Lincoln, M., Hien, D., and Miele, G.M. Substance Abuse Treatment Entry, Retention, and Outcome in Women: A Review of the Literature. Drug Alcohol Depend. 86(1), pp. 1-21, 2007. Epub June 8, 2006.

Direct Care Workers in the National Drug Abuse Treatment Clinical Trials Network: Characteristics, Opinions, and Beliefs

Individuals with direct care responsibilities in 348 drug abuse treatment units were surveyed to obtain a description of the workforce and to assess support for evidence-based therapies. Surveys were distributed to 112 programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN). Descriptive analyses characterized the workforce. Women made up two-thirds of the CTN workforce. One-third of the workforce had a master's or doctoral degree. Responses from 1,757 counselors, 908 support staff, 522 managers-supervisors, and 511 medical staff (71% of eligible participants) suggested that the variables that most were most consistently associated with responses were job category and education. Managers-supervisors were the most supportive of evidence-based therapies, and support staff were the least supportive. Generally, individuals with graduate degrees had more positive opinions about evidence-based therapies. Support for using medications and contingency management was modest across job categories. The relatively traditional beliefs of support staff could inhibit the introduction of evidence-based practices. Programs initiating changes in therapeutic approaches may benefit from including all employees in change efforts. McCarty, D., Fuller, B.E., Arfken, C., Miller, M., Nunes, E.V., Edmundson, E., Copersino, M., Floyd, A., Forman, R., Laws, R., Magruder, K.M., Oyama, M., Prather, K., Sindelar, J., and Wendt, W.W. Direct Care Workers in the National Drug Abuse Treatment Clinical Trials Network: Characteristics, Opinions, and Beliefs. Psychiatr Serv. 58(2), pp. 181-190, 2007.

Training and Fidelity Monitoring of Behavioral Interventions in Multi-site Addictions Research

Methods for the training and fidelity monitoring of behavioral interventions in multi-site addictions research were reviewed, including five published studies and seven ongoing studies sponsored by the National Institute on Drug Abuse-funded Clinical Trials Network. Topics include: therapist selection, training, certification, and supervision; selection, training, and certification of supervisors; scales and processes used for monitoring of the quality of treatment; and processes followed to provide new training for replacement staff once trials have begun. The review reveals both a wide array of procedures and emerging standards for multi-site trials. Methodological weakness was observed with respect to limited empirical support for many adherence scales, little or no evaluation of supervisory processes, and no evaluation of re-training practices. Methods used in multi-site trials are important not only to ensure validity of those trials, but also to inform the wider dissemination of empirically based treatment into community agencies. Training and fidelity models that delegate responsibility to participating sites appear most relevant for establishing best practices for dissemination of behavioral interventions. The effectiveness of these distributed training and supervision models should be subjected to empirical study at a level of rigor comparable to the evaluation of their corresponding treatments. Baer, J.S., Ball, S.A., Campbell, B.K., Miele, G.M., Schoener, E.P., and Tracy, K. Training and Fidelity Monitoring of Behavioral Interventions in Multi-site Addictions Research. Drug Alcohol Depend. 87(2-3), pp. 107-118, 2007. Epub October 4, 2006.

Cost-effectiveness of Prize-based Incentives for Stimulant Abusers in Outpatient Psychosocial Treatment Programs

This cost-effectiveness analysis is based on a randomized clinical trial implemented within the National Drug Abuse Treatment Clinical Trials Network. The trial was conducted at eight community-based outpatient psychosocial drug abuse treatment clinics. Four hundred and fifteen stimulant abusers were assigned to usual care (N=206) or usual care plus abstinence-based incentives (N=209) for 12 weeks. Participants randomized to the incentive condition earned the chance to draw for prizes for submitting substance negative samples; the number of draws earned increased with continuous abstinence time. Incremental cost-effectiveness ratios were estimated to compare prize-based incentives relative to usual care. The primary patient outcome was longest duration of confirmed stimulant abstinence (LDA). Unit costs were obtained via surveys administered at the eight participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Acceptability curves are presented to illustrate the uncertainty due to the sample and to provide policy relevant information. The incremental cost to lengthen the LDA by 1 week was US$ 258 (95% confidence interval, US$ 191-401). Sensitivity analyses on several key parameters show that this value ranges from US$ 163 to 269. Compared with the usual care group, the incentive group had significantly longer LDAs and significantly higher costs. Olmstead, T.A., Sindelar, J.L., and Petry, N.M. Cost-effectiveness of Prize-based Incentives for Stimulant Abusers in Outpatient Psychosocial Treatment Programs. Drug Alcohol Depend. 87(2-3), pp. 175-182, 2007. Epub September 12, 2006.

'Tweaking 12-Step': The Potential Role of 12-Step Self-Help Involvement in Methamphetamine Recovery

The authors reviewed the literature on outcomes associated with 12-Step meeting attendance and involvement in 12-Step activities among substance abusers, particularly those who abuse stimulants. There are few if any data available on methamphetamine abusers and their use of 12-Step approaches. Evidence derived from work with alcohol-and cocaine-dependent individuals indicates that involvement in 12-Step self-help groups, both attending meetings and engaging in 12-Step activities, is associated with reduced substance use and improved outcomes. Although involvement in 12-Step fellowship improves outcome, many individuals do not engage on their own in 12-Step activities, and there are high rates of dropout from such groups. There are a number of evidence-based therapies available to assist clinicians in facilitating 12-Step involvement; however, these have not been used with methamphetamine abusers. More actively integrating 12-Step approaches into the treatment process may provide low-or no-cost options for methamphetamine abusers and increase the capacity for providing treatment. Further research and evaluation are necessary to determine the extent to which methamphetamine abusers do engage in 12-Step self-help programs, whether they prefer more general (e.g. Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous) or drug-specific (e.g. Crystal Meth Anonymous) meetings, the rate of dropout and the outcomes associated with their involvement. Donovan, D.M., and Wells, E.A. 'Tweaking 12-Step': The Potential Role of 12-Step Self-Help Involvement in Methamphetamine Recovery. Addiction, 102 (Suppl.1), pp. 121-129, 2007.