Clinical Trials Network Research

Abstinence-Based Incentives in Methadone Maintenance: Interaction with Intake Stimulant Test Results

Baseline drug use detected in urine toxicology has been shown to predict drug abuse treatment outcome, including response to contingency management interventions with drug abstinence as their target. This study examined the association between baseline urine test result and treatment outcome in stabilized methadone maintenance patients with ongoing stimulant use to determine whether abstinence incentives were differentially effective in those testing stimulant negative versus positive at study entry. Participants were 386 methadone-maintained patients who took part in a National Drug Abuse Treatment Clinical Trials Network multisite study aimed at reducing stimulant abuse during treatment (J.M. Peirce et al., 2006). At study intake, 24% of participants tested stimulant negative and 76% tested positive. Those testing negative at entry submitted 82% negative urines during the study versus 36% for those testing positive at entry (odds ratio [OR] = 8.67; confidence interval [CI] = 5.81-12.94). Compared with those receiving usual care, the addition of abstinence incentives resulted in a significant increase in stimulant-negative urine samples submitted during the study both for those testing negative at study entry (OR = 2.27; CI = 1.13-4.75) and for those testing positive (OR = 1.84; CI = 1.25-2.71). These findings suggest that abstinence incentives have significant clinical benefits independent of initial drug use severity among methadone maintenance patients with ongoing stimulant drug use. Stitzer, M.L., Peirce, J., Petry, N.M., Kirby, K., Roll, J., Krasnansky, J., Cohen, A., Blaine, J., Vandrey, R., Kolodner, K., Li, R. APA Exp. Clin. Psychopharmacol. 15(4), pp. 344-350, 2007.

Implementation of a Smoking Cessation Treatment Study at Substance Abuse Rehabilitation Programs: Smoking Behavior and Treatment Feasibility Across Varied Community-based Outpatient Programs

Cigarette smoking is widely prevalent among individuals in treatment for drug or alcohol dependence; however, the treatment of nicotine addiction in this population has numerous obstacles at both programmatic and patient levels. Despite these difficulties, recent studies have demonstrated moderate success in implementing smoking cessation treatment in drug rehabilitation programs. The National Drug Abuse Treatment Clinical Trials Network sponsored a smoking cessation study in 13 community-based outpatient substance abuse rehabilitation programs across the country. The study evaluated the effectiveness of smoking cessation treatment provided as an adjunct to substance abuse treatment-as-usual. This report summarizes the practical and clinical experiences encountered at each of the study sites with regard to implementing the smoking cessation treatment intervention. Smoking behavior of the treatment clientele was assessed by anonymous survey at each site. In addition, sites were systematically characterized by using program review and assessment tools completed by the respective staff and program directors at the site. Survey and recruitment data indicated that cigarette smoking is more prevalent and that smoking cessation treatment is more feasible, in methadone maintenance treatment programs. Other factors associated with smoking behavior and with the recruitment of drug- and alcohol-dependent individuals into the smoking cessation treatment study are described. Reid, M.S., Fallon, B., Sonne, S., Nunes, E.V., Lima, J., Jiang, H., Tyson, C., Hiott, R., Arfken, C., Bohs, R., Orr, D., Muir, J., Pihlgren, E., Loree, A., Fuller, B.E., Giordano, L., Robinson, J., Rotrosen, J. J Addict. Med. 1(3), pp. 154-160, September 2007.

A Feasibility Study of a Web Based Performance Improvement System for Substance Abuse Treatment Providers

Authors report here on the feasibility of implementing a semiautomated performance improvement system-Patient Feedback (PF)-that enables real-time monitoring of patient ratings of therapeutic alliance, treatment satisfaction, and drug/alcohol use in outpatient substance abuse treatment clinics. The study was conducted in six clinics within the National Institute on Drug Abuse Clinical Trials Network. It involved a total of 39 clinicians and 6 clinic supervisors. Throughout the course of the study (consisting of five phases: training period [4 weeks], baseline [4 weeks], intervention [12 weeks], postintervention assessment [4 weeks], sustainability [1 year]), there was an overall collection rate of 75.5% of the clinic patient census. In general, the clinicians in these clinics had very positive treatment satisfaction and alliance ratings throughout the study. However, one clinic had worse drug use scores at baseline than other participating clinics and showed a decrease in self-reported drug use at postintervention. Although the implementation of the PF system proved to be feasible in actual clinical settings, further modifications of the PF system are needed to enhance any potential clinical usefulness. Forman, R., Crits-Christoph, P., Kaynak, O., Worley, M., Hantula, D.A., Kulaga, A., Rotrosen, J., Chu, M., Gallop, R., Potter, J., Muchowski, P., Brower, K., Strobbe, S., Magruder, K., Chellis, A.H., Clodfelter, T., and Cawley, M. J. Subst. Abuse Treat. 33(4), pp. 363-371, December 2007. (e-pub May 11, 2007).

Telephone Enhancement of Long-term Engagement (TELE) in Continuing Care for Substance Abuse Treatment: A NIDA Clinical Trials Network (CTN) Study

The TELE study examined the feasibility and potential efficacy of phone calls to patients after discharge from short- term inpatient and residential substance abuse treatment programs to encourage compliance with continuing care plans. After review of their continuing care plans, 339 patients from four programs were randomized either to receive calls or to have no planned contact. Ninety-two percent of patients randomized to receive calls received at least one call. No difference was found between groups in self-reported attendance at one or more outpatient counseling sessions after discharge (p = .89). When program records of all participants were examined, those receiving calls had a greater likelihood of documented attendance (48%) than those not called (37%). Results were not statistically significant (p < .003) because of the Hochberg correction for multiple tests. While the phone calls were feasible, the lack of clear evidence of efficacy of the calls suggests the need for further investigation of the role of telephone intervention to encourage compliance and improve outcomes. Hubbard, R.L., Leimberger, J.D., Haynes, L., Patkar, A.A., Holter, J., Liepman, M.R., Lucas, K., Tyson, B., Day, T., Thorpe, E.A., Faulkner, B., and Hasson, A. Am. J. Addict. 16, pp. 495-502, 2007.

Treatment Programs in the National Drug Abuse Treatment Clinical Trials Network

Drug abuse treatment programs and university-based research centers collaborate to test emerging therapies for alcohol and drug disorders in the National Drug Abuse Treatment Clinical Trials Network (CTN). Programs participating in the 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 participate 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.A., Wendt, W.W., Nunes, E.V., Miller, M., Forman, R., Magruder, K.M., Arfken, C., Copersino, M., Floyd, A., Sindelar, J., and Edmundson, E. Drug Alcohol Depend. 92(1-3), pp. 200-207, January 1, 2008. (e-pub September 17, 2007).

Prize-based Contingency Management in MMT Programs Estimated to Cost $141 for Each 1 Week Increase in LDA

Data on 388 participants in the National Drug Abuse Treatment Clinical Trials Network Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR) study were used to examine the cost-effectiveness of prize-based contingency management in six methadone programs. Compared to usual care, the incremental cost of using prize-based CM to lengthen the longest duration abstinent (LDA) by 1 week was $141 [95% confidence interval (CI), $105-$193]. The incremental cost to obtain an additional stimulant-negative urine sample was $70 (95% CI, $53-$117). These incremental costs were lower than those computed for non-methadone programs in a related study, but the difference was due to less overall abstinence among MMT clients compared with other clients. In either case, whether the additional cost is worthwhile depends on the value placed on the outcomes produced. Sindelar, J., Olmstead, T., and Peirce, J. Cost-Effectiveness of Prize-Based Contingency Management in Methadone Maintenance Treatment Programs. Addiction, 102(9), pp. 1463-1471, 2007.