A randomized comparison of 4 vs. 16 weeks of psychosocial treatment for stimulant users

Project RETAIN: Providing Integrated Care for People With HIV Who Use Cocaine

Background

People with HIV (PWH) who use cocaine are less likely to achieve virologic suppression (<200 copies/mL) because of poor engagement in care. We tested the efficacy of an integrated substance use treatment and outpatient HIV care intervention on improving viral suppression in nonsuppressed PWH who use cocaine.

Methods

Project RETAIN recruited 360 cocaine-using PWH who were not virologically suppressed in Miami, FL, and Atlanta, GA. Patients were randomized to treatment as usual (TAU) or the intervention, which included patient navigation and substance use treatment with motivational enhancement therapy and cognitive-behavioral therapy. The primary outcome assessed viral suppression at 6- and 12-month follow-up.

Results

There was no difference in viral suppression by group (TAU = 17.1%, intervention = 15.6%, P = .897). The intervention group had significantly more participation in substance use treatment (87.0%) than TAU (7.2%, P < .001). There were significant decreases in stimulant use in both groups, but oxycodone use decreased more in the intervention group. Severe psychological distress (32% of the baseline sample) declined differentially at 6 months (TAU = 24.5%, intervention = 16.1%, P = .0492).

Conclusions

Only a minority of PWH who used cocaine became virally suppressed over the 12-month study, with no effect of the integrated intervention. Patients in the intervention did have reduced psychological distress postintervention. Despite more substance use treatment in the intervention, both groups declined equally in substance use. Interventions that improve retention in care and viral suppression are needed for this vulnerable population, including those that address their other complex medical and psychosocial needs.

ClinicalTrialsgov

NCT01614106.

California's Recovery Incentives Program: Implementation strategies

INTRODUCTION

Due to the increasing role of psychostimulants in the US drug poisoning crisis, there is an increasing need to effectively implement evidence-based treatment for individuals with stimulant use disorder (StimUD). Contingency management is a behavioral strategy with robust evidence of support for the treatment of StimUD. In 2023, California initiated a large-scale effort to implement CM as a treatment for individuals with a stimulant use disorder (cocaine, methamphetamine, amphetamine) called the Recovery Incentives Program: California's Contingency Management Benefit.

METHODS

The Recovery Incentives Program is being systematically implemented using the Becker et al. Science to Service Lab (SSL) implementation approach with several augmentations for this project. The SSL features three core components: didactic training, performance feedback, and external facilitation. We have augmented this approach with a readiness assessment process for sites prior to CM service launch, and an ongoing fidelity monitoring and feedback component post-launch.

RESULTS

The present paper is a preliminary report describing the use of this augmented SSL strategy for CM implementation in a large-scale implementation effort. Data are presented to describe the implementation activities during the first ten months of the Recovery Incentives Program.

CONCLUSION

The California Recovery Incentives Program has been systematically implemented and appears to be receiving a positive response from treatment program staff and enrolled members. Future papers and evaluation reports will continue to document member response to the Program and report on the ongoing training and implementation process.

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

Providing substance use disorder treatment in correctional settings: knowledge gaps and proposed research priorities-overview and commentary

This manuscript is the product of the authors' discussions, literature overview, and consultation with experts in the field, and identifies important gaps in the evidence base for substance use disorder (SUD) treatment effectiveness within criminal justice (CJ) settings. Lacking from the extant literature are longitudinal investigations of treatment related outcomes during and after incarceration. Such studies could provide rich contextual data about treatment delivery and effectiveness across the CJ continuum, and would provide important insight into individual characteristics (e.g., motivation, treatment modality preferences, treatment completion rates, etc.) as well as institutional and environmental factors (e.g., appropriate staffing, space limitations for individual treatment sessions, distribution of medications, etc.). We also identified the importance of reproducibility within CJ research, and the unfortunate reality of too many single studies conducted in single (or relatively few) correctional facilities. Some of this has been because the studies designed to produce that evidence are not prioritized for funding, which has continually placed researchers in a position where we cannot make firm conclusions or recommendations based on available evidence. The importance of replicating the foundational studies in this field cannot be overstated. We hope this article spurs other researchers to join in the healthy process of questioning the existing state of the CJ-based SUD treatment research, what should be re-examined, and how we can lay a stronger foundation for the future.

Retention in treatment and therapeutic adherence: How are these associated with therapeutic success? An analysis using real-world data

INTRODUCTION

Treatment retention and adherence are used as outcomes in numerous randomized clinical trials and observational studies conducted in the addiction field. Although usual criteria are 3/6 months of treatment retention or number of sessions attended, there is not a methodological support for conclusions using these criteria. This study analyzed the usefulness of retention and adherence to predict therapeutic success.

METHODS

Retrospective observational study using real-world data from electronic health records of 11,907 patients in treatment diagnosed with cocaine, alcohol, cannabis and opiate use disorders or harmful use.

RESULTS

Moderate effect size relations were found between the different type of clinical discharge and months in retention (η2  = 0.12) and proportion of attendance (η2  = 0.10). No relationship was found with the number of sessions attended. Using cut-off points (i.e., 3 or 6 months in treatment or attending 6 therapy sessions) worsens the ability to predict the type of discharge.

DISCUSSIONS/CONCLUSION

Treatment retention and adherence are indicators moderately related to therapeutic success. Research using these indicators to assess the effectiveness of therapies should complement their results with other clinical indicators and quality of life measures.

Goofballing of Opioid and Methamphetamine: The Science Behind the Deadly Cocktail

Globally, millions of people suffer from various substance use disorders (SUD), including mono-and polydrug use of opioids and methamphetamine. Brain regions such as the cingulate cortex, infralimbic cortex, dorsal striatum, nucleus accumbens, basolateral and central amygdala have been shown to play important roles in addiction-related behavioral changes. Clinical and pre-clinical studies have characterized these brain regions and their corresponding neurochemical changes in numerous phases of drug dependence such as acute drug use, intoxication, craving, withdrawal, and relapse. At present, many studies have reported the individual effects of opioids and methamphetamine. However, little is known about their combined effects. Co-use of these drugs produces effects greater than either drug alone, where one decreases the side effects of the other, and the combination produces a prolonged intoxication period or a more desirable intoxication effect. An increasing number of studies have associated polydrug abuse with poorer treatment outcomes, drug-related deaths, and more severe psychopathologies. To date, the pharmacological treatment efficacy for polydrug abuse is vague, and still at the experimental stage. This present review discusses the human and animal behavioral, neuroanatomical, and neurochemical changes underlying both morphine and methamphetamine dependence separately, as well as its combination. This narrative review also delineates the recent advances in the pharmacotherapy of mono- and poly drug-use of opioids and methamphetamine at clinical and preclinical stages.

Substance use referral, treatment utilization, and patient costs associated with problematic substance use in people living with HIV in Cape Town, South Africa

Introduction

Despite efforts to detect and treat problematic substance use (SU) among people living with HIV (PLWH) in South Africa, integration of HIV and SU services is limited. We sought to understand whether PLWH and problematic SU were: (a) routinely referred to SU treatment, a co-located Matrix clinic, (b) used SU treatment services when referred, and (c) the individual amount spent on SU.

Methods

Guided by the RE-AIM implementation science framework, we examined patient-level quantitative screening and baseline data from a pilot clinical trial for medication adherence and problematic SU. Qualitative data came from semi-structured interviews with HIV care providers (N = 8), supplemented by patient interviews (N = 15).

Results

None of the screened patient participants (N = 121) who were seeking HIV care and had problematic SU were engaged in SU treatment, despite the freely available co-located SU treatment program. Only 1.5% of the enrolled patient study sample (N = 66) reported lifetime referral to SU treatment. On average, patients with untreated SU spent 33.3% (SD=34.5%) of their monthly household income on substances. HIV care providers reported a lack of clarity about the SU referral process and a lack of direct communication with patients about patients' needs or interest in receiving an SU referral.

Discussion

SU treatment referrals and uptake were rare among PLWH reporting problematic SU, despite the high proportion of individual resources allocated to substances and the co-located Matrix site. A standardized referral policy between the HIV and Matrix sites may improve communication and uptake of SU referrals.