Study results from the Clinical Trials Network's first 10 years: where do they lead?

A cross-sectional survey of potential factors, motivations, and barriers influencing research participation and retention among people who use drugs in the rural USA

BACKGROUND

Despite high morbidity and mortality among people who use drugs (PWUD) in rural America, most research is conducted within urban areas. Our objective was to describe influencing factors, motivations, and barriers to research participation and retention among rural PWUD.

METHODS

We recruited 255 eligible participants from community outreach and community-based, epidemiologic research cohorts from April to July 2019 to participate in a cross-sectional survey. Eligible participants reported opioid or injection drug use to get high within 30 days and resided in high-needs rural counties in Oregon, Kentucky, and Ohio. We aggregated response rankings to identify salient influences, motivations, and barriers. We estimated prevalence ratios to assess for gender, preferred drug use, and geographic differences using log-binomial models.

RESULTS

Most participants were male (55%) and preferred methamphetamine (36%) over heroin (35%). Participants reported confidentiality, amount of financial compensation, and time required as primary influential factors for research participation. Primary motivations for participation include financial compensation, free HIV/HCV testing, and contribution to research. Changed or false participant contact information and transportation are principal barriers to retention. Respondents who prefer methamphetamines over heroin reported being influenced by the purpose and use of their information (PR = 1.12; 95% CI: 1.00, 1.26). Females and Oregonians (versus Appalachians) reported knowing and wanting to help the research team as participation motivation (PR = 1.57; 95% CI: 1.09, 2.26 and PR = 2.12; 95% CI: 1.51, 2.99).

CONCLUSIONS

Beyond financial compensation, researchers should emphasize confidentiality, offer testing and linkage with care, use several contact methods, aid transportation, and accommodate demographic differences to improve research participation and retention among rural PWUD.

Culturally tailored evidence-based substance use disorder treatments are efficacious with an American Indian Southwest tribe: an open-label pilot-feasibility randomized controlled trial

BACKGROUND AND AIMS

Many evidence-based treatments (EBTs) for substance use disorder (SUD) exist, yet few are tailored to Indigenous patients. This trial tested the efficacy of a culturally tailored EBT that combined Motivational Interviewing and the Community Reinforcement Approach (MICRA) versus treatment as usual (TAU).

DESIGN

A mixed efficacy/effectiveness randomized controlled trial of MICRA (n = 38) and TAU (n = 41) using a parallel design with follow-up assessments at 4-, 8-, and 12- months post baseline.

SETTING

United States, reservation-based outpatient, addiction specialty care treatment program.

PARTICIPANTS

79 (68% male) American Indian and Alaska Native (AI/AN) Tribal members meeting criteria for SUD and seeking SUD treatment.

INTERVENTIONS

MICRA (individual therapy sessions beginning with MI for 2-3 sessions) compared with TAU (individual and group counseling sessions in a didactic style with Twelve-Step philosophy and elements of relapse prevention).

MEASURES

Demographics, percent days abstinent (PDA; the primary outcome at 12months assessed by Form 90D), Inventory of Drug Use Consequences, Alcohol and Drug Use Self-Efficacy Scale, Native American Spirituality Scale, and SCID-DSM-IV-TR.

FINDINGS

There was no evidence for the benefit of MICRA over TAU (MICRA PDA = 72.63%, TAU = 73.62%, treatment effect: B = -4.04 (SE = 5.47); 95% CI = -14.941, 6.866; BF = 3.44) in the primary outcome. Both groups showed improvements in PDA, SUD severity, and negative consequences from baseline to the 12-month follow-up. Neither self-efficacy nor spirituality were significant mediators of MICRA.

CONCLUSIONS

There were no treatment group differences between culturally tailored evidence-based treatments for substance use disorder and treatment as usual in this randomized controlled trial with American Indian and Alaska Native participants. Nonetheless, participants improved over time on several substance-related outcomes.

A systematic scoping review of research on Black participants in the National Drug Abuse Treatment Clinical Trials Network

Black individuals experience a disproportionate burden of substance-related disabilities and premature death relative to other racial/ethnic groups, highlighting the need for additional research. The National Drug Abuse Treatment Clinical Trials Network (CTN), a research platform for multisite behavioral, pharmacological, and integrated trials designed to evaluate the effectiveness of substance use treatments in community settings with diversified patient populations, provides a wealth of research knowledge on substance use. Although CTN trials have enrolled over 5,000 Black individuals since its inception in 2000, there has been no synthesis of the findings, discussion of the implications, or suggestions for future research for Black individuals. Members of the Minority Interest Group of the CTN conducted a scoping review of published research on Black participants in CTN trials. Studies were included if the sample was more than 75% Black and/or specific findings pertaining to Black participants were reported. The review yielded 50 articles, with studies that mostly focused on baseline characteristics, followed by substance use treatment outcomes, HIV/risky sex behaviors, retention, comorbid conditions and measurement issues. This review highlighted the importance of several issues that are critical to understanding and treating substance misuse among Black people, such as the characteristics of Black people entering treatment, measurement equivalence, and engaging/retaining adolescents and young adults in treatment. There is still a continued need to identify the most effective treatments for Black individuals who use substances. The CTN offers several untapped opportunities to further advance research on Black individuals who use substances (e.g., secondary analyses of publicly available data). (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Group treatment for substance use disorder in adults: A systematic review and meta-analysis of randomized-controlled trials

BACKGROUND AND AIMS

From residential programs to outpatient services, group therapy permeates the clinical field of substance misuse. While several group interventions for substance use disorders (SUDs) have demonstrated effectiveness, the existing evidence on group therapy has not been systematically reviewed. The current meta-analysis aims to provide estimates of the efficacy of group therapy for SUDs in adults using rigorous methods.

METHODS

We included studies comparing group psychotherapy to no treatment control groups, individual psychotherapy, medication, self-help groups, and other active treatments applying no specific psychotherapeutic techniques for patients with substance use disorder. The primary outcome was abstinence, and the secondary outcomes were frequency of substance use and symptoms of substance use disorder, anxiety, depression, general psychopathology, and attrition. A comprehensive search was conducted in Medline, Web of Science, CENTRAL, and PsycINFO, complemented by a manual search. Random-effects meta-analyses were run separately for different types of control groups.

RESULTS

Thirty-three studies were included. Significant small effects of group therapy were found on abstinence compared to no treatment, individual therapy, and other treatments. Effects on substance use frequency and SUD symptoms were not significant, but significant moderately sized effects emerged for mental state when group therapy was compared to no treatment. There were no differences in abstinence rates between group therapy and control groups. These results were robust in sensitivity analyses and there was no indication of publication bias.

CONCLUSIONS

The current findings represent the best available summary analysis of group therapy for SUDs in adults, however cautious interpretation is warranted given the limitations of the available data.

Beyond Abstinence: Changes in Indices of Quality of Life with Time in Recovery in a Nationally Representative Sample of U.S. Adults

BACKGROUND

Alcohol and other drug (AOD) treatment and recovery research typically have focused narrowly on changes in alcohol/drug use (e.g., "percent days abstinent") with little attention on changes in functioning or well-being. Furthermore, little is known about whether and when such changes may occur, and for whom, as people progress in recovery. Greater knowledge would improve understanding of recovery milestones and points of vulnerability and growth.

METHODS

National, probability-based, cross-sectional sample of U.S. adults who screened positive to the question, "Did you used to have a problem with alcohol or drugs but no longer do?" (Response = 63.4% from 39,809; final weighted sample n = 2,002). Linear, spline, and quadratic regressions tested relationships between time in recovery and 5 measures of well-being: quality of life, happiness, self-esteem, recovery capital, and psychological distress, over 2 temporal horizons: the first 40 years and the first 5 years, after resolving an AOD problem and tested moderators (sex, race, primary substance) of effects. Locally Weighted Scatterplot Smoothing regression was used to explore turning points.

RESULTS

In general, in the 40-year horizon there were initially steep increases in indices of well-being (and steep drops in distress), during the first 6 years, followed by shallower increases. In the 5-year horizon, significant drops in self-esteem and happiness were observed initially during the first year followed by increases. Moderator analyses examining primary substance found that compared to alcohol and cannabis, those with opioid or other drugs (e.g., stimulants) had substantially lower recovery capital in the early years; mixed race/native Americans tended to exhibit poorer well-being compared to White people; and women consistently reported lower indices of well-being over time than men.

CONCLUSIONS

Recovery from AOD problems is associated with dynamic monotonic improvements in indices of well-being with the exception of the first year where self-esteem and happiness initially decrease, before improving. In early recovery, women, certain racial/ethnic groups, and those suffering from opioid and stimulant-related problems appear to face ongoing challenges that suggest a need for greater assistance.

Complexities with group therapy facilitation in substance use disorder specialty treatment settings

In spite of increased attention to research-based interventions for substance use disorders (SUDs), a formidable research-practice gap impedes the implementation of evidence-based treatments (EBTs). An underappreciated dimension of this gap is a mismatch in treatment modality: Whereas clinical trial and implementation research has focused primarily on individual therapy, the majority of SUD specialty treatment is in group format, with open-enrolling groups being most common. This study aims to narrow this research-practice gap by exploring clinicians' perspectives on complexities with group therapy facilitation in SUD specialty treatment settings. Semi-structured interviews were conducted with 13 group clinicians from among three outpatient SUD specialty clinics-diverse in their operational structures, treatment philosophies, clientele, and services-located in the same Midwestern U.S. metropolitan area. Interview questions addressed organizational characteristics, services provided, group therapy curricula, and use of EBTs or other structured treatments. Clinicians emphasized the importance of having flexibility in facilitating groups, through built-in group processes and clinicians' own adaptions and accommodations; this flexibility was especially emphasized for the use of EBTs or manualized interventions. Clinicians also had difficulties with group facilitation generally, as evidenced by their reported difficulty in managing complex group dynamics, their limited group therapy experience and training, and their reliance on educational groups. We discuss specific strategies for improved innovation and implementation of EBTs for SUD group therapy.

Pioglitazone, a PPARγ agonist, reduces nicotine craving in humans, with marginal effects on abuse potential

Possibly through their actions upon glia, peroxisome proliferator-activated receptor agonists (PPAR) have been shown to alter the abuse potential of addictive drugs in several preclinical models. The current study extends this research into the human laboratory as the first clinical study into the effects of the PPAR gamma agonist, pioglitazone, on the abuse potential of nicotine. Heavy smokers were recruited for this 3-week study. Upon admission, participants were randomized to either active (45mg, n=14) or placebo (0mg, n=13) PIO maintenance conditions for the duration of the study. After 5-7days of stabilization on a 7mg nicotine patch, participants began laboratory testing. On the 1st-4th test days, participants could self-administer cigarettes or receive money by making verbal choices for either option. On the 5th day, participants were administered 10 puffs of their usual brand of cigarette in the morning and later chose between smoking and money by making finger presses on a computer mouse in a progressive ratio self-administration task. Later on the 5th day participants also underwent a smoking cue exposure session. The 8th-11th test days were identical to the 1st-4th test days with the exception that during one of the test weeks de-nicotinized cigarettes were available, and during the other nicotinized cigarettes were available. Nicotinized cigarettes were always administered on the 5th and 12th days. On some measures PIO increased indicators of abuse potential, though this effect was typically not statistically significant. However, PIO did significantly reduce measures of craving.

Mortality Rates Among Substance Use Disorder Participants in Clinical Trials: Pooled Analysis of Twenty-Two Clinical Trials Within the National Drug Abuse Treatment Clinical Trials Network

BACKGROUND

Most substance use disorders (SUD) treatment clinical trials are too short and small to reliably estimate the incidence of rare events like death.

OBJECTIVE

The aim of this study is to estimate the overall mortality rates among a SUD treatment-seeking population by pooling participants from multiple clinical trials conducted through the National Institute on Drug Abuse (NIDA)-sponsored National Drug Abuse Treatment Clinical Trials Network (CTN).

PARTICIPANTS

Drug and or alcohol users (N=9866) who sought treatment and participated in one of the twenty-two CTN trials.

MEASUREMENTS

Data were collected through randomized clinical trials in national community treatment programs for SUD. Pooled analysis was performed to assess age- and gender-standardized mortality rate(s) (SM rate(s)), and mortality ratio(s) (SM ratio(s)) of CTN trial participants compared to the U.S. general population.

RESULTS

The age- and gender-SM rate among CTN trials participants was 1403 (95% CI: 862-2074) per 100,000 person years (PY) compared to 542 (95% CI: 541-543) per 100,000 PY among the U.S. general population in 2005. By gender, age-adjusted SM ratio for female CTN trial participants was over five times (SM ratio=5.35, 95% CI: 3.31-8.19)), and for male CTN trial participants, it was over three times (SM ratio=3.39, 95% CI: 2.25-4.90) higher than their gender comparable peers in the U.S. general population.

CONCLUSIONS

Age and gender-standardized mortality rates and ratios among NIDA CTN SUD treatment-seeking clinical trial participants are higher than the age and gender comparable U.S. general population. The overall mortality rates of CTN trial participants are similar to in-treatment mortality reported in large U.S. and non-U.S. cohorts of opioid users. Future analysis with additional CTN trial participants and risk times will improve the stability of estimates, especially within subgroups based on primary substance of abuse. These SUD mortality rates can be used to facilitate safety monitoring within SUD clinical trials.

Ethical and clinical safety considerations in the design of an effectiveness trial: A comparison of buprenorphine versus naltrexone treatment for opioid dependence

We examine ethical challenges encountered in the design of an effectiveness trial (CTN-0051; X:BOT), comparing sublingual buprenorphine-naloxone (BUP-NX), an established treatment for opioid dependence, to the newer extended-release injectable naltrexone (XR-NTX). Ethical issues surrounded: 1) known poor effectiveness of one possible, commonly used treatment as usual control condition-detoxification followed by counseling without medication; 2) the role of patients' preferences for treatments, given that treatments were clinically approved and available to the population; 3) differences between the optimal "usual treatment" clinical settings for different treatments making it challenging to design a fair comparison; 4) vested interest groups favoring different treatments exerting potential influence on the design process; 5) potentially vulnerable populations of substance users and prisoners; 6) potential therapeutic misconception in the implementation of safety procedures; and 7) high cost of a large trial limiting questions that could be addressed. We examine how the design features underlying these ethical issues are characteristic of effectiveness trials, which are often large trials that compare treatments with varying degrees of existing effectiveness data and familiarity to patients and clinicians, in community-based treatment settings, with minimal exclusion criteria that could involve vulnerable populations. Hence, investigators designing effectiveness trials may wish to remain alert to the possibility of similar ethical issues.

Perceptions of 'Evidence-Based Practice' among the Consumers of Adolescent Substance Use Treatment

OBJECTIVE

Several national organisations in the USA have recently developed educational materials that encourage substance use disorder treatment consumers to seek out approaches supported by scientific evidence in order to promote the use of "evidence-based practice" (EBP). This study aimed to explore how adolescents (young people age 12-17 years) with substance use disorders and their caregivers perceive, understand, and react to the concept of EBP.

METHODS

Qualitative focus groups and structured interviews were conducted with 29 caregivers and 24 adolescents with substance use disorders in the Northeastern USA. Discussions explored four themes: a) familiarity with EBP, b) assumptions about what EBP means, c) impressions of EBP after reading a common definition, and d) recommended terms to describe EBP in educational materials. Participants' responses were transcribed and qualitatively analysed by two independent coders.

RESULTS

Only two of the 53 participants had ever heard the term EBP, and only one was able to define it correctly. Common assumptions about the term "evidence-based" were that it referred to treatment based on the patient's medical history, legal evidence of substance use, or the clinician's prior experience. The misperception that EBP was associated with legal evidence was common among adolescents involved in the justice system. After reading a common definition of EBP, most participants thought that the approach sounded inflexible. Alternative terms the participants recommended to educate potential treatment consumers about EBP included proven, successful, better, and therapy that works.

CONCLUSIONS

Results suggest that future efforts to educate treatment consumers should use the phrase EBP with caution and emphasise the flexibility of the approach.

Direct-to-Consumer Marketing: A Complementary Approach to Traditional Dissemination and implementation Efforts for Mental Health and Substance Abuse Interventions

The overall chasm between those who need treatment for mental health and substance abuse (M/SU) and those who receive effective treatment consists of two, interrelated gaps: the research-to-practice gap and the treatment gap. Prior efforts to disseminate evidence-based practice (EBP) for M/SU have predominantly targeted the research-to-practice gap, by focusing efforts toward treatment providers. This article introduces direct-to-consumer (DTC) marketing that targets patients and caregivers as a complementary approach to existing dissemination efforts. Specific issues discussed include: rationale for DTC marketing based on the concept of push versus pull marketing; overview of key stakeholders involved in DTC marketing; and description of the Marketing Mix planning framework. The applicability of these issues to the dissemination of EBP for M/SU is discussed.

The forest and the trees: relational and specific factors in addiction treatment

AIMS

Increased expectations for the use of evidence-based methods in addiction treatment have fueled a debate regarding the relative importance of 'specific' versus 'common' factors in treatment outcome. This review explores the influence of these factors on addiction treatment outcome.

METHODS

The authors review and link findings from four decades of research on specific and general factors in addiction treatment outcome research.

FINDINGS

Although few would argue that what one does in addiction treatment is immaterial, outcome studies tend to find small to no difference when specific treatment methods are compared with each other or with treatment as usual. In contrast, there are usually substantial differences among therapists in client outcomes, and relational factors such as therapist empathy and therapeutic alliance can be significant determinants of addiction treatment outcome.

CONCLUSIONS

In addiction treatment, relational factors such as empathy, which are often described as common, non-specific factors, should not be dismissed as 'common' because they vary substantially across providers and it is unclear how common they actually are. Similarly they should not be relegated to 'non-specific' status, because such important relational influences can be specified and incorporated into clinical research and training.

Evaluating whether direct-to-consumer marketing can increase demand for evidence-based practice among parents of adolescents with substance use disorders: rationale and protocol

Background

Fewer than one in 10 adolescents with substance use disorders (ASUDs) will receive specialty treatment, and even fewer will receive treatment designated as evidence-based practice (EBP). Traditional efforts to increase the utilization of EBP by ASUDs typically focus on practitioners—either in substance use clinics or allied health settings. Direct-to-consumer (DTC) marketing that directly targets parents of ASUDs represents a potentially complementary paradigm that has yet to be evaluated. The current study is the first to evaluate the relevance of a well-established marketing framework (the Marketing Mix) and measurement approach (measurement of perceived service quality [PSQ]) with parents of ASUDs in need of treatment.

Methods/design

A mixed-methods design is employed across three study phases, consistent with well-established methods used in the field of marketing science. Phase 1 consists of formative qualitative research with parents (and a supplementary sample of adolescents) in order to evaluate and potentially adapt a conceptual framework (Marketing Mix) and measure of PSQ. Phase 2 is a targeted survey of ASUD parents to elucidate their marketing preferences, using the adapted Marketing Mix framework, and to establish the psychometric properties of the PSQ measure. The survey will also gather data on parents’ preferences for different targeted marketing messages. Phase 3 is a two-group randomized controlled trial comparing the effectiveness of targeted marketing messages versus standard clinical information. Key outcomes will include parents’ ratings of PSQ (using the new measure), behavioral intentions to seek out information about EBP, and actual information-seeking behavior.

Discussion

The current study will inform the field whether a well-established marketing framework and measurement approach can be used to increase demand for EBP among parents of ASUDs. Results of this study will have the potential to immediately inform DTC marketing efforts by professional organizations, federal agencies, clinicians, and clinical researchers.

Impact of research network participation on the adoption of buprenorphine for substance abuse treatment

There is a growing body of research supporting the use of buprenorphine and other medication assisted treatments (MATs) for the rapidly accelerating opioid epidemic in the United States. Despite numerous advantages of buprenorphine (accessible in primary care, no daily dosing required, minimal stigma), implementation has been slow. As the field progresses, there is a need to understand the impact of participation in practitioner-scientist research networks on acceptance and uptake of buprenorphine. This paper examines the impact of research network participation on counselor attitudes toward buprenorphine addressing both counselor-level characteristics and program-level variables using hierarchical linear modeling (HLM) to account for nesting of counselors within treatment programs. Using data from the National Treatment Center Study, this project compares privately funded treatment programs (N=345) versus programs affiliated with the National Institute on Drug Abuse Clinical Trials Network (CTN) (N=198). Models included 922 counselors in 172 CTN programs and 1203 counselors in 251 private programs. Results of two-level HLM logistic (Bernoulli) models revealed that counselors with higher levels of education, larger caseloads, more buprenorphine-specific training, and less preference for 12-step treatment models were more likely to perceive buprenorphine as acceptable and effective. Furthermore, buprenorphine was 50% more likely to be perceived as effective among counselors working in CTN-affiliated programs as compared to private programs. This study suggests that research network affiliation positively impacts counselors' acceptance and perceptions of buprenorphine. Thus, research network participation can be utilized as a means to promote positive attitudes toward the implementation of innovations including medication assisted treatment.

Toward empirical identification of a clinically meaningful indicator of treatment outcome: features of candidate indicators and evaluation of sensitivity to treatment effects and relationship to one year follow up cocaine use outcomes

BACKGROUND

Selection of an appropriate indictor of treatment response in clinical trials is complex, particularly for the various illicit drugs of abuse. Most widely used indicators have been selected based on expert group recommendation or convention rather than systematic empirical evaluation. Absence of an evidence-based, clinically meaningful index of treatment outcome hinders cross-study evaluations necessary for progress in addiction treatment science.

METHOD

Fifteen candidate indicators used in multiple clinical trials as well as some proposed recently are identified and discussed in terms of relative strengths and weaknesses (practicality, cost, verifiability, sensitivity to missing data). Using pooled data from five randomized controlled trials of cocaine dependence (N=434), the indicators were compared in terms of sensitivity to the effects of treatment and relationship to cocaine use and general functioning during follow-up.

RESULTS

Commonly used outcome measures (percent negative urine screens; percent days of abstinence) performed relatively well in that they were sensitive to the effects of the therapies evaluated. Others, including complete abstinence and reduction in frequency of use, were less sensitive to effects of specific therapies and were very weakly related to cocaine use or functioning during follow-up. Indicators more strongly related to cocaine use during follow-up were those that reflected achievement of sustained periods of abstinence, particularly at the end of treatment.

CONCLUSIONS

These analyses did not demonstrate overwhelming superiority of any single indicator, but did identify several that performed particularly poorly. Candidates for elimination included retention, complete abstinence, and indicators of reduced frequency of cocaine use.

The relationship between Clinical Trial Network protocol involvement and quality of substance use disorder treatment

The National Institute on Drug Abuse's Clinical Trials Network (CTN) is a practice-based research network that partners academic researchers with community based substance use disorder (SUD) treatment programs designed primarily to conduct effectiveness trials of promising interventions. A secondary goal of the CTN is to widely disseminate results of these trials and thus improve the quality of SUD treatment in the US. Drawing on data from 156 CTN programs, this study examines the association between involvement in CTN protocols and overall treatment quality measured by a comprehensive index of 35 treatment services. Negative binomial regression models show that treatment programs participating in a greater number of CTN protocols had significantly higher levels of treatment quality, an association that held after controlling for key organizational characteristics. These findings contribute to the growing body of research on the role of practice-based research networks in promoting health care quality.

Selection and utilization of assessment instruments in substance abuse treatment trials: the National Drug Abuse Treatment Clinical Trials Network experience

Based on recommendations from a US Institute of Medicine report, the National Institute on Drug Abuse established the National Drug Abuse Treatment Clinical Trials Network (CTN) in 1999, to accelerate the translation of science-based addiction treatment research into community-based practice, and to improve the quality of addiction treatment, using science as the vehicle. One of the CTN's primary tasks is to serve as a platform to forge bi-directional communications and collaborations between providers and scientists, to enhance the relevance of research, which generates empirical results that impact practice. Among many obstacles in moving research into real-world settings, this commentary mainly describes challenges and iterative experiences in regard to how the CTN develops its research protocols, with focus on how the CTN study teams select and utilize assessment instruments, which can reasonably balance the interests of both research scientists and practicing providers when applied in CTN trials. This commentary also discusses the process by which the CTN further selects a core set of common assessment instruments that may be applied across all trials, to allow easier cross-study analyses of comparable data.

Primary outcome indices in illicit drug dependence treatment research: systematic approach to selection and measurement of drug use end-points in clinical trials

AIMS

Clinical trials test the safety and efficacy of behavioral and pharmacological interventions in drug-dependent individuals. However, there is no consensus about the most appropriate outcome(s) to consider in determining treatment efficacy or on the most appropriate methods for assessing selected outcome(s). We summarize the discussion and recommendations of treatment and research experts, convened by the US National Institute on Drug Abuse, to select appropriate primary outcomes for drug dependence treatment clinical trials, and in particular the feasibility of selecting a common outcome to be included in all or most trials.

METHODS

A brief history of outcomes employed in prior drug dependence treatment research, incorporating perspectives from tobacco and alcohol research, is included. The relative merits and limitations of focusing on drug-taking behavior, as measured by self-report and qualitative or quantitative biological markers, are evaluated.

RESULTS

Drug-taking behavior, measured ideally by a combination of self-report and biological indicators, is seen as the most appropriate proximal primary outcome in drug dependence treatment clinical trials.

CONCLUSIONS

We conclude that the most appropriate outcome will vary as a function of salient variables inherent in the clinical trial, such as the type of intervention, its target, treatment goals (e.g. abstinence or reduction of use) and the perspective being taken (e.g. researcher, clinical program, patient, society). It is recommended that a decision process, based on such trial variables, be developed to guide the selection of primary and secondary outcomes as well as the methods to assess them.

Re-envisioning Addiction Treatment: A Six-Point Plan

This article is focused on improving the quality of addiction treatment. Based on observations that patients are leaving treatment too early and/or are continuing to use substances during their care, the authors propose six actions that could help reorient and revitalize this kind of clinical work: (1) conceptualize and treat addictive disorders within a psychiatric/mental health framework; (2) make the creation of a strong therapeutic alliance a core part of the healing process; (3) understand patients' addictions and other problems using models based on multiple internal parts, voices, or modes; (4) make contingency management and the use of positive reinforcement systems a standard and central practice in all treatment settings; (5) envision long-term change and healing through the lens of identity theory; and (6) integrate the growing developments in recovery culture with formal treatment.

Relation of study design to recruitment and retention in CTN trials

BACKGROUND

Recruitment and retention in randomized clinical trials are difficult in general and particularly so in trials of substance abuse treatments. Understanding trial design characteristics that could affect recruitment and retention rates would help in the design of future trials.

OBJECTIVE

To test whether any of the following factors are associated with recruitment or retention: type of intervention, type of therapy, duration of treatment, total duration of trial, number of treatment sessions, number of follow-up visits, number of primary assessments, timing of primary assessments, number of case report form (CRF) pages at baseline, and number of CRF pages for the entire trial.

METHODS

Recruitment and retention data from 24 Clinical Trials Network (CTN) trials conducted and completed between 2001 and 2010 were analyzed using single-factor analysis of variance and single-predictor regression methods to test their association with trial design characteristics.

RESULTS

Almost all of the analyses performed did not show statistically significant patterns between recruitment and retention rates and the trial design characteristics considered.

CONCLUSION

In CTN trials, the relationship between assessment burden on participants and length of trial, on the one hand, and recruitment and retention, on the other, is not as strong and direct as expected. Other factors must impinge on the conduct of the trial to influence trial participation.

SCIENTIFIC SIGNIFICANCE

Researchers may deem slightly more justifiable to permit inclusion of some of the design features that previously were assumed to have a strong, negative influence on recruitment and retention, and should consider other strategies that may have a stronger, more direct effect on trial participation.

Gender research in the National Institute on Drug Abuse National Treatment Clinical Trials Network: a summary of findings

BACKGROUND

The National Institute of Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (CTN) was established to foster translation of research into practice in substance abuse treatment settings. The CTN provides a unique opportunity to examine in multi-site, translational clinical trials, the outcomes of treatment interventions targeting vulnerable subgroups of women; the comparative effectiveness of gender-specific protocols to reduce risk behaviors; and gender differences in clinical outcomes.

OBJECTIVES

To review gender-related findings from published CTN clinical trials and related studies from January 2000 to March 2010.

METHODS

CTN studies were selected for review if they focused on treatment outcomes or services for special populations of women with substance use disorders (SUDs) including those with trauma histories, pregnancy, co-occurring eating and other psychiatric disorders, and HIV risk behaviors; or implemented gender-specific protocols. The CTN has randomized 11,500 participants (41% women) across 200 clinics in 24 randomized controlled trials in community settings, of which 4 have been gender-specific.

RESULTS

This article summarizes gender-related findings from CTN clinical trials and related studies, focusing on trauma histories, pregnancy, co-occurring eating and other psychiatric disorders, and HIV risk behaviors.

CONCLUSIONS

These published studies have expanded the evidence base regarding interventions for vulnerable groups of women with SUDs as well as gender-specific interventions to reduce HIV risk behaviors in substance-using men and women. The results also underscore the complexity of accounting for gender in the design of clinical trials and analysis of results.

SCIENTIFIC SIGNIFICANCE

To fully understand the relevance of gender-specific moderators and mediators of outcome, it is essential that future translational studies adopt more sophisticated approaches to understanding and measuring gender-relevant factors and plan sample sizes that are adequate to support more nuanced analytic methods.

Rates and influences of alcohol use disorder comorbidity among primary stimulant misusing treatment-seekers: meta-analytic findings across eight NIDA CTN trials

BACKGROUND

There is need to improve treatment effectiveness for stimulant misusers, and one means of doing so is by tailoring services to account for common diagnostic comorbidities and psychosocial challenges they face.

OBJECTIVES

Using its publicly available datasets, this CTN-approved secondary analysis project examined prevalence of alcohol use disorders (AUDs) among primary stimulant misusing treatment-seekers as well as impact of AUD comorbidity on their pre-treatment psychosocial functioning.

METHODS

Upon identifying a primary stimulant misuser subsample (N = 1133) from among aggregated treatment-seekers across eight CTN trials, diagnostic data were used to document lifetime AUD rates. Paired comparisons, stratified by stimulant drug type (e.g., amphetamine, cocaine) then tested the influence of AUD comorbidity on psychosocial indices from the Addiction Severity Index - Lite.

RESULTS

A high AUD rate (45%) was found in this client population. Among primary cocaine misusers, those with AUD were more likely to: (i) show elevated Addiction Severity Index composite scores, (ii) perceive greater importance of drug treatment, and (iii) endorse psychiatric symptoms and perceived need for their treatment. Among primary amphetamine misusers, those with AUD were more likely to endorse specific psychiatric symptoms.

CONCLUSION

Study findings document AUD comorbidity as a fairly common diagnostic feature of primary stimulant misusers, and suggest it is a pervasive influence on the pre-treatment psychosocial functioning of cocaine misusers.

SCIENTIFIC SIGNIFICANCE

This study demonstrates the utility of CTN common assessment battery for secondary analysis projects, though challenges noted during its conduct highlight the value of consistent data collection and documentation within and across CTN trials.

Addiction treatment trials: how gender, race/ethnicity, and age relate to ongoing participation and retention in clinical trials

Introduction

Historically, racial and ethnic minority populations have been underrepresented in clinical research, and the recruitment and retention of women and ethnic minorities in clinical trials has been a significant challenge for investigators. The National Drug Abuse Treatment Clinical Trials Network (CTN) conducts clinical trials in real-life settings and regularly monitors a number of variables critical to clinical trial implementation, including the retention and demographics of participants.

Purpose

The examination of gender, race/ethnicity, and age group differences with respect to retention characteristics in CTN trials.

Methods

Reports for 24 completed trials that recruited over 11,000 participants were reviewed, and associations of gender, race/ethnicity, and age group characteristics were examined along with the rate of treatment exposure, the proportion of follow-up assessments obtained, and the availability of primary outcome measure(s).

Results

Analysis of the CTN data did not indicate statistical differences in retention across gender or race/ethnicity groups; however, retention rates increased for older participants.

Conclusion

These results are based on a large sample of patients with substance use disorders recruited from a treatment-seeking population. The findings demonstrate that younger participants are less likely than older adults to be retained in clinical trials.

Ten take home lessons from the first 10 years of the CTN and 10 recommendations for the future

BACKGROUND

The first 10 years of the National Institute on Drug Abuse's Clinical Trials Network (CTN) yielded a wealth of data on the effectiveness of a number of behavioral, pharmacological, and combined approaches in community-based settings.

METHODS

We summarize some of the methodological contributions and lessons learned from the behavioral trials conducted during its first ten years, including the capacity and enormous potential of this national research infrastructure.

RESULTS

The CTN made contributions to the methodology of effectiveness research; new insights from secondary analyses; the extent to which approaches with strong evidence bases, such as contingency management, extend their effectiveness to real world clinical settings; new data on 'standard treatment' as actually practiced in community programs, the extent to which retention remains a major issue in the field; important data on the safety of specific behavioral therapies for addiction; and heightened the importance of continued sustained attention to bridging the gap between treatment and research.

CONCLUSIONS

Areas of focus for the CTN's future include defining common outcome measures to be used in treatment outcome studies for illicit drugs; incorporating performance indicators and measures of clinical significance; conducting comparative outcome studies; contributing to the understanding of effective treatments of comorbidity; reaching underserved populations; building implementation science; understanding long-term outcomes of current treatments and sustaining treatment effects; and conducting future trials more efficiently.

Strategies for safety reporting in substance abuse trials

BACKGROUND

Reporting all adverse events (AEs) and serious adverse events (SAEs) in substance use disorder (SUD) clinical trials has yielded limited relevant safety information and has been burdensome to research sites.

OBJECTIVE

This article describes a new strategy utilizing standard data elements for AE and SAEs that defines a threshold to reduce unnecessary safety reporting burden in SUD clinical trials and describes retrospective review and prospective preliminary data on the strategy's safety reporting impact.

METHODS

We developed a new strategy to standardize safety reporting and tailor reporting to the trial intervention risk. Protocols and safety data from 17 SUD clinical trials were reviewed. Retrospective analysis of five of these studies and prospective application to new studies is described.

RESULTS

Across the 17 previously completed trials, a total of 11,220 AEs and 1330 SAEs were reported in the 6737 participants. Wide variability in AE and SAE reporting rates were noted based on trial type and inconsistent reporting strategies. Application of the new, tailored safety strategy retrospectively and prospectively reduces reporting burden of irrelevant safety events.

CONCLUSION

Comparison of the previous reporting strategies used in SUD trials to the new strategy demonstrates a more consistent safety system with a reduction in safety reporting burden while maintaining appropriate safety monitoring.

SCIENTIFIC SIGNIFICANCE

Safety assessments should be tailored to the participant risks based on the trial intervention. The current strategies could be applied to safety assessments across all clinical trials in SUDs.

The Appalachian Tri-State Node Experiences with the National Institute on Drug Abuse Clinical Trials Network

The National Institute on Drug Abuse (NIDA)-sponsored Clinical Trial Network (CTN) recently celebrated 10 years of conducting "real world" research into the treatment of addiction. This article reviews the history and results of the most recent CTN studies and describes the experiences of one of the 13 participating research affiliates, the Appalachian Tri-State (ATS) Node. We discuss our "bidirectional" collaboration with multiple community treatment programs (CTPs) on research and dissemination activities and include their experiences as a member of our ATS Node.Results of CTN clinical trials have found unexpectedly that treatment as usual (TAU) is often almost as good as evidence-based interventions such as Motivational Interviewing (MI), possibly due to the difficulty in implementing evidence-based practices most effectively among divergent treatment sites and heterogeneous clinical populations. Some expected findings from the reviewed research are that severity of addiction and comorbidity moderate treatment outcomes and must be accounted for in future CTN-sponsored studies. Notwithstanding these results, much has been learned and recommendations are suggested for changes in CTN research designs that will address methodological limitations and increase treatment effectiveness in future CTN studies.

The National Drug Abuse Treatment Clinical Trials Network: forging a partnership between research knowledge and community practice

The National Drug Abuse Treatment Clinical Trials Network (CTN) has faced many challenges over its first eleven years. This review explores some of these challenges and the paths the CTN took to meet these challenges, including: designing clinical trials that reflect the CTN's mission and changing public health needs, finding the synergies in the varied expertise of clinical treatment providers and academic researchers, promoting evidence-based practices and expanding the Network into mainstream medical practices to reach a broader patient population. Included in this exploration are specific examples from CTN clinical trials.