Non-attendance at counselling therapy in cocaine-using methadone-maintained patients: lessons learnt from an abandoned randomised controlled trial

Adding quality to quantity in randomized controlled trials of addiction prevention and treatment: a new framework to facilitate the integration of qualitative research

BACKGROUND AND AIMS

Randomized controlled trials (RCTs) are important for evaluating interventions, and qualitative research is increasingly recognized as being crucial to the success of this enterprise. We aimed to describe and demonstrate a temporal parallel purpose framework to help researchers understand how to make optimum use of qualitative research before, during and after RCTs. This framework sets out specific rationales for conducting qualitative research at each stage of a trial, where the rationales presented relate to both the intervention and evaluation methodology.

METHOD AND RESULTS

We conducted a scoping review of published qualitative studies undertaken alongside RCTs focusing on illicit drug use. We then used the temporal parallel purpose framework to present key findings to demonstrate how qualitative studies can add value to addiction RCTs by enhancing understanding of the intervention being trialled and/or the RCT itself. In so doing, we highlight the missed opportunities for addiction science when qualitative research is overlooked. We also explain why barriers to combining qualitative research and RCTs are neither inevitable nor insurmountable.

CONCLUSIONS

The temporal parallel purpose framework provides a tool for assessing when and why to combine qualitative research with addiction treatment and prevention RCTs. Our paper and framework can help researchers formulate key questions that qualitative research can address. This can potentially save resources by reducing the number of poorly designed interventions and trials and prevent morbidity, mortality, and other addiction-related harms by facilitating the identification and implementation of interventions that are most likely to be effective.

Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months

BACKGROUND

Opioid dependence is a major health concern across the world and does also occur in adolescents. While opioid substitution treatment (OST) has been thoroughly evaluated in adult populations, very few studies have examined its use in adolescents. There are concerns that OST is underutilised in adolescents with heroin dependence. We sought to measure changes in drug use among adolescents receiving OST and also to examine treatment attrition during the first 12 months of this treatment.

METHODS

We included all heroin dependent patients aged under 18.5 years commencing OST at one outpatient multidisciplinary adolescent addiction treatment service in Dublin, Ireland. Psycho-social needs were also addressed during treatment. Drug use was monitored by twice weekly urine drugs screens (UDS). Change in the proportion of UDS negative for heroin was examined using the Wilcoxon signed rank test. Attrition was explored via a Cox Regression multivariate analysis.

RESULTS

OST was commenced by 120 patients (51% female and mean age 17.3 years). Among the 39 patients who persisted with OST until month 12, heroin abstinence was 21% (95% confidence interval [CI] = 9-36%) at month three and it was 46% (95% CI = 30-63%) at month 12. Heroin use declined significantly from baseline to month three (p < 0.001) and from month three to month 12 (p = 0.01). Use of other drugs did not change significantly. People using cocaine during month 12 were more likely to be also using heroin (p = 0.02). Unplanned exit occurred in 25% patients by 120 days. The independent predictors of attrition were having children, single parent family of origin, not being in an intimate relationship with another heroin user and evidence of cocaine use just before treatment entry.

CONCLUSIONS

We found that heroin dependent adolescent patients achieved significant reductions in heroin use within three months of starting OST and this improved further after a year of treatment, about half being heroin abstinent at that stage. Patient drop out from treatment remains a challenge, as it is in adults. Cocaine use before and during treatment may be a negative prognostic factor.

A pilot feasibility randomised controlled trial of an adjunct brief social network intervention in opiate substitution treatment services

BACKGROUND

Approximately 3% of people receiving opioid substitution therapy (OST) in the UK manage to achieve abstinence from prescribed and illicit drugs within three years of commencing treatment. Involvement of families and wider social networks in supporting psychological treatment may be an effective strategy in facilitating recovery, and this pilot study aimed to evaluate the impact of a social network-focused intervention for patients receiving OST.

METHODS

A two-site, open feasibility trial randomised patients receiving OST for at least 12 months but still reporting illicit opiate use in the past 28 days to one of three treatments: 1) treatment as usual (TAU), 2) Brief Social Behaviour and Network Therapy (B-SBNT) + TAU, or 3) Personal Goal Setting (PGS) + TAU. The two active interventions consisted of 4 sessions. There were 3 aims: 1) test the feasibility of recruiting OST patients to a trial of B-SBNT, and following them up over 12 months; 2) test the feasibility of training clinicians to deliver B-SBNT; 3) test whether B-SBNT reduces heroin use 3 and 12 months after treatment, and to explore potential mediating factors. The primary outcome for aim 3 was number of days of heroin use in the past month, and a range of secondary outcome measures were specified in advance (level of drug dependence, mental health, social satisfaction, therapist rapport, treatment satisfaction, social network size and support).

RESULTS

A total of 83 participants were randomised, and 70 (84%) were followed-up at 12 months. Fidelity analysis of showed that B-SBNT sessions were clearly distinguishable from PGS and TAU sessions, suggesting it was possible to train clinical staff to an adequate level of competence. No significant differences were found between the 3 intervention arms in the primary or secondary outcome measures. Attendance at psychosocial treatment intervention sessions was low across all three arms (44% overall).

CONCLUSIONS

Patients receiving OST can be recruited into a trial of a social network-based intervention, but poor attendance at treatment sessions makes it uncertain whether an adequate dose of treatment was delivered. In order to achieve the benefits of psychosocial interventions, further work is needed to overcome poor engagement.

TRIAL REGISTRATION

ISRCTN Trial Registration Number: ISRCTN22608399 . Date of registration: 27/04/2012. Date of first randomisation: 14/08/2012.

Psychosocial interventions in opiate substitution treatment services: does the evidence provide a case for optimism or nihilism?

BACKGROUND AND AIMS

Clinical guidelines from around the world recommend the delivery of psychosocial interventions as part of routine care in opiate substitution treatment (OST) programmes. However, although individual studies demonstrate benefit for structured psychosocial interventions, meta-analytical reviews find no benefit for manual-based treatments beyond 'routine counselling'.

ANALYSIS

We consider the question of whether OST medication alone is sufficient to produce the required outcomes, or whether greater efforts should be made to provide high-quality psychosocial treatment alongside medication. In so doing, we consider the nuances and limitations of the evidence and the organizational barriers to transferring it into routine practice.

CONCLUSION

The evidence base for psychosocial interventions in opiate substitution treatment (OST) services can be interpreted both positively and negatively. Steering a path between overly optimistic or nihilistic interpretations of the value of psychosocial treatment in OST programmes is the most pragmatic approach. Greater attention should be paid to elements common to all psychological treatments (such as therapeutic alliance), but also to the sequencing and packaging of psychosocial elements and their linkage to peer-led interventions.

Correlates of cocaine use during methadone treatment: implications for screening and clinical management (ANRS Methaville study)

Background

Cocaine use is frequent in patients receiving methadone maintenance treatment (MMT) and can jeopardize their treatment response. Identifying clinical predictors of cocaine use during methadone treatment can potentially improve clinical management. We used longitudinal data from the ANRS Methaville trial both to describe self-reported occasional and regular cocaine use during MMT and to identify clinical predictors.

Methods

We selected 183 patients who had data on cocaine (or crack) use at months 0 (M0), M6, and/or M12, accounting for 483 visits. The outcome was “cocaine use” in three categories: “no,” “occasional,” and “regular” use. To identify factors associated with the outcome over time, we performed a mixed multinomial logistic regression.

Results

Time on methadone was significantly associated with a decrease in occasional but not in regular cocaine use from 14.7 % at M0 to 7.1 % at M12, and from 10.7 % at baseline to 6.5 % at M12, respectively. After multiple adjustments, opiate injection, individuals screening positive for attention deficit hyperactivity disorder (ADHD) symptoms, and those presenting depressive symptoms were more likely to regularly use cocaine.

Conclusions

Although time on MMT had a positive impact on occasional cocaine use, it had no impact on regular cocaine use. Moreover, regular cocaine users were more likely to report opiate injection and to present ADHD and depressive symptoms. Early screening of these disorders and prompt tailored pharmacological and behavioral interventions can potentially reduce cocaine use and improve response to MMT.

Trial registration

The trial is registered with the French Agency of Pharmaceutical Products (AFSSAPS) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials, number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397, and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.

Beginning and end of treatment of patients who dropped out of psychoanalytic psychotherapy

INTRODUCTION

Even though it is expected that patients and therapist will agree on when to terminate psychotherapy, quite often patients discontinue treatment on their own. This study aims to better understand dropout in psychoanalytic psychotherapy (PP).

METHOD

Baseline and post-treatment interviews were conducted with six adult women classified by their therapists as dropout patients at a PP outpatient clinic. Results were analyzed using Bardin's content analysis.

RESULTS

Content analysis generated five categories (reasons for treatment, goals, readiness to change, previous treatment, transference) for the baseline interviews and three categories (change process, results, interruption) for post-treatment interviews. Unclear treatment goals, low readiness to change, early signs of negative transference and resistance, and absence of recognition of their own participation in problems emerged in baseline interviews. In most cases, the patient's evaluation of the therapeutic relationship was not determinant of dropout. Therapeutic gains, dissatisfaction, and resistance during the psychotherapeutic process seemed to be associated with noncompliance.

CONCLUSIONS

Decisions to initiate, continue, or quit PP depend on multiple factors, such as initial goals, readiness to change, insight capacity, awareness of personal problems, resistance, and transference. However, these factors should be considered in view of the methodological limitations of this study. Further investigation of PP dropout is still necessary.