Exploring treatment attendance and its relationship to outcome in a randomized controlled trial of treatment for alcohol problems: secondary analysis of the UK Alcohol Treatment Trial (UKATT)

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

Effect of a multidisciplinary approach on hospital visit continuation in the treatment of patients with alcohol dependence

AIMS

Given the high dropout rates from initial treatment for alcoholism among patients with alcohol dependence, it is highly essential to prevent alcohol-dependent patients from early dropout. This study aims to investigate whether a multidisciplinary approach can help achieve continuous hospital visits for this patient population for initial treatment.

METHODS

This is a retrospective cohort study based on the medical records of all sequential alcohol-dependent outpatients who visited Sodegaura Satsukidai Hospital for alcoholism at least once between October 2017 and March 2019. The primary outcome was the difference in the rates of patients who achieved 6 and 12 months of continuous hospital visits following the first visit with and without the multidisciplinary approach.

RESULTS

Of all the participants (n = 67), the female-to-male ratios for patients supported with and without the multidisciplinary approach were 6:30 and 5:26, respectively. It was found that the rate of alcoholic patients treated with the multidisciplinary approach (n = 33, 91.7%), who had continuous hospital visits, was significantly higher than that of those without (n = 12, 38.7%) (χ2  = 21.2, p < 0.0001) during the first 6 months of treatment. Similarly, the rate of alcoholic patients treated with the multidisciplinary approach (n = 29, 90.6%) having continuous visits was significantly higher than that of those who did not receive such support (n = 8, 25.8%) (χ2  = 27.3, p < 0.0001) during the first 12 months.

CONCLUSION

A multidisciplinary approach can be used to reduce dropout from initial treatment among outpatients with alcohol dependence.

Medications and Patient Factors Associated With Increased Readmission for Alcohol-Related Diagnoses

Objective

To investigate medication factors and patient characteristics associated with readmissions following alcohol-related hospitalizations.

Patients and Methods

Adult patients admitted from September 1, 2016, through August 31, 2019, who had an alcohol-related hospitalization were identified through electronic health records. Patient characteristics and medications of interest administered during hospitalization or prescribed at discharge were identified. Medications of interest included US Food and Drug Administration–approved medications for alcohol use disorder, benzodiazepines, barbiturates, gabapentin, opioids, and muscle relaxants. The primary outcome was to identify medications and patient factors associated with 30-day alcohol-related readmission. Secondary outcomes included medications and patient characteristics associated with multiple alcohol-related readmissions within a year from the index admission (ie, two or more readmissions) and factors associated with 30-day all-cause readmission.

Results

Characteristics of the 932 patients included in this study associated with a 30-day alcohol-related readmission included younger age, severity of alcohol withdrawal, history of psychiatric disorder, marital status, and the number of prior alcohol-related admission in the previous year. Benzodiazepine or barbiturate use during hospitalization or upon discharge was associated with 30-day alcohol-related readmission (P=.006). Gabapentin administration during hospitalization or upon discharge was not associated with 30-day alcohol-related readmission (P=.079).

Conclusion

The findings reinforce current literature identifying patient-specific factors associated with 30-day readmissions. Gabapentin use was not associated with readmissions; however, there was an association with benzodiazepine/barbiturate use.

Increased Attendance During Rapid Implementation of Telehealth for Substance Use Disorders During COVID-19 at the Largest Public Hospital System in the United States

OBJECTIVE

The objective of this study is to examine differences between; telehealth and in-person visits during COVID-19 and in a pre-COVID-19 reference period; COVID-19 televisit completion for patients with varying engagement in treatment during the reference period.

METHODS

Electronic medical record data were collected and analyzed with chi-squared or t-tests to compare patient demographics. Generalized estimating equations for estimating the odds of outcomes were used, controlling for demographics.

RESULTS

Patients were 3.34 and 1.74 times more likely to complete a telehealth visit (n = 11,839) compared with an in-person visit during (n = 7,917) and prior (n = 15,497) to COVID-19. For patients on buprenorphine, patients with no prior in-person visits during the pre-televisit period were 2.26 more likely to complete televisits compared with patients with two or more prior in-person visits. For all patients, those with two or more prior in-person visits in the reference period were 1.27 times more likely to complete a televisit compared with a patient with no in-person visits during the pre-televisit period. There was no significant difference when comparing with patients who had only one prior in-person visit to those patients with no prior visits.

CONCLUSIONS

In this study, outpatient substance use disorder (SUD) telehealth appointments were associated with higher odds of visit completion compared with in-person visits during and prior to COVID-19. Patients receiving buprenorphine, without prior in person visits, were more likely to attend if they did not have in-person visits prior to COVID-19. Regulators should consider permanently adopting telehealth flexibilities for SUD treatment once the federal emergency status has ended.

Predictors of Readmission Following Outpatient Treatment for Alcohol Use Disorder

AIMS

To identify predictors of readmission to outpatient treatment for alcohol use disorder (AUD) with a view to identifying underlying mechanisms for preventing relapse.

METHODS

A consecutive clinical cohort of 2130 AUD outpatients treated between 1 January 2006 and 1 June 2016 was studied. Data were collected by means of the Addiction Severity Index upon treatment entry and at discharge. Outcome measures were readmission to outpatient treatment and time to readmission. Potential predictors were tested for significance using Cox Proportional Hazards multivariate analysis.

RESULTS

A total of 22% were readmitted during the follow-up time. Patients readmitted within 1 year of treatment conclusion differed significantly from those not readmitted on age, cohabitation status and completion status of index treatment. Significant predictors of readmission during follow-up time were younger age (hazard ratio (HR) = 0.99, 95% confidence interval (CI), 0.98-1.00), history of psychiatric illness (HR = 1.24, 95% CI, 1.02-1.50), drop-out from index treatment (HR = 1.41, 95% CI, 1.15-1.72) and length of index treatment (HR = 1.02, 95% CI, 1.00-1.04).

CONCLUSION

Premature drop-out from treatment, a history of psychiatric illness, younger age and longer treatment episodes appear to be the most important predictors of readmission.

The Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention: Study protocol of a multi-center randomized controlled trial

INTRODUCTION

Among patients with hepatitis C virus (HCV) infection, alcohol synergistically increases the risk of cirrhosis, hepatocellular carcinoma, and death. Randomized controlled trials of integrated models of HCV-alcohol treatment have been recommended but only performed in patients with severe alcohol use disorders.

OBJECTIVES

This pragmatic randomized controlled trial seeks to compare clinical effectiveness and cost-effectiveness of integrated alcohol treatment compared to enhanced treatment as usual (TAU) on alcohol consumption and economic outcomes among patients ever infected with HCV.

METHODS

Patients recruited from three liver centers who had current or prior chronic HCV and qualifying alcohol screener scores were randomly assigned to enhanced TAU or the Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention. All patients received enhanced TAU, consisting of a patient-administered alcohol screener and care from medical providers who were trained in Screening, Brief Intervention and Referral to Treatment (SBIRT), including brief motivational interviewing counseling. The Hep ART intervention combined enhanced TAU with up to six months of integrated co-located individual and/or group therapy that provided motivational, cognitive, and behavioral strategies to reduce alcohol consumption. The Timeline Followback (TLFB) Method was used to evaluate alcohol use at baseline, 3, 6, and 12 months. Primary outcomes are alcohol abstinence and fewer heavy drinking days, and for the cost-effectiveness analysis, measures included grams of alcohol consumed.

DISCUSSION

This study will determine whether Hep ART, a six-month integrated alcohol treatment, compared to enhanced TAU, is both clinically effective and cost-effective in patients with a history of comorbid HCV and alcohol use.

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.

Who achieves low risk drinking during alcohol treatment? An analysis of patients in three alcohol clinical trials

BACKGROUND AND AIMS

There is evidence that low-risk drinking is possible during the course of alcohol treatment and can be maintained following treatment. Our aim was to identify characteristics associated with low-risk drinking during treatment in a large sample of individuals as they received treatment for alcohol dependence.

DESIGN

Integrated analysis of data from the Combined Pharmacotherapies and Behavioral Intervention (COMBINE) study, Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) and the United Kingdom Alcohol Treatment Trial (UKATT) using repeated-measures latent class analysis to identify patterns of drinking and predictors of low-risk drinking patterns during treatment.

SETTING

United States and United Kingdom.

PARTICIPANTS

Patients (n = 3589) with alcohol dependence receiving treatment in an alcohol clinical trial were primarily male (73.0%), white (82.0%) and non-married (41.7%), with an average age of 42.0 (standard deviation = 10.7).

MEASUREMENTS

Self-reported weekly alcohol consumption during treatment was assessed using the Form-90 and validated with biological verification or collateral informants.

FINDINGS

Seven patterns of drinking during treatment were identified: persistent heavy drinking (18.7% of the sample), increasing heavy drinking (9.6%), heavy and low-risk drinking (6.7%), heavy drinking alternating with abstinence (7.9%), low-risk drinking (6.8%), increasing low-risk drinking (10.5%) and abstinence (39.8%). Lower alcohol dependence severity and fewer drinks per day at baseline significantly predicted low-risk drinking patterns [e.g. each additional drink prior to baseline predicted a 27% increase in the odds of expected classification in heavy drinking versus low-risk drinking patterns; odds ratio = 1.27 (95% confidence interval (CI) = 1.10, 1.47, P = 0.002]. Greater negative mood and more heavy drinkers in the social network were significant predictors of expected membership in heavier drinking patterns.

CONCLUSIONS

Low-risk drinking is achievable for some individuals as they undergo treatment for alcohol dependence. Individuals with lower dependence severity, less baseline drinking, fewer negative mood symptoms and fewer heavy drinkers in their social networks have a higher probability of achieving low-risk drinking during treatment.

Management of Substance Use Disorder in Military Services: A Comprehensive Approach

BACKGROUND

Historically, substance misuse has been a serious problem faced by worldwide military personnel. Some research showed that military personnel have higher rates of unhealthy substance use than their age peers in the general population. These problems have serious consequences and may lead to significant military difficulties in the field of readiness, discipline, and mental or physical health. In this review, we gathered various methods for prevention, diagnosis, and treatment of substance use disorders and suggested a comprehensive plan for Iran Armed Forces to improve existing services.

MATERIALS AND METHODS

This article is a narrative review study, which was carried out on 2016. A careful literature review was performed between January 1970 and April 2016 on several national and international databases. Articles were screened according to the following inclusion criteria: (1) review articles about prevention and treatment protocols, (2) executive guidance, (3) cohort articles about risk factors of addiction, and (4) randomized controlled trials about prevention or treatment of substance use disorders in army service members. After screening by title and abstract, 130 articles selected of 832 founded articles, and after quality assessment, finally, 63 articles included in the review.

RESULTS

There is a necessity to manage substance use disorder through prevention, screening, and then referral to proper services for diagnosis and treatment. Urinalysis programs for screening are cost-effective and should be considered as a main method. Effective treatment includes both behavioral and pharmacological methods.

CONCLUSIONS

The ideal prevention program will include multiple and mutually reinforcing evidence-based universal, selective, and indicated attempts at both the individual and environmental levels. The implementation of screening and treatment strategies needs strict rules and national guideline for the comprehensive management of substance use disorders in army.

Two-year prognosis after residential treatment for patients with alcohol dependence: three chief guidelines for sobriety in Japan

BACKGROUND

In Japan, the three chief traditional guidelines for sobriety (3CGS) are regular medical checkups, participation in self-help groups, and pharmacotherapy with antidipsotropics. However, the official record of the origins of 3CGS is not clear. The aim of this current study was to assess 3CGS by an examination of the prognosis of patients with alcohol dependence 2 years after their discharge from a residential treatment program.

SUBJECTS AND METHODS

The association between subjects' abstinence from alcohol and their regular medical checkups, participation in self-help groups, and treatment with antidipsotropics were prospectively examined. Two years after discharge, the relationship between the 3CGS compliance and abstinence rates was investigated as the primary outcome. In addition, the following were examined as secondary outcomes: the time taken till the first drink after discharge, whether the participants were readmitted to residential treatment, the number of days to readmission, the number of heavy drinking days, and recovery.

RESULTS

A total of 98 patients participated. The perfect and partial abstinence rates for patients who followed all the principles of 3CGS were significantly higher than those for patients who followed no guidelines (P<0.05 and P<0.01, respectively). The perfect abstinence rates for patients who had continued attending checkup sessions (P<0.001) and who were taking antidipsotropics (P<0.05) were significantly higher than those for patients who did not follow these components of 3CGS. However, the perfect abstinence rates were not higher for patients who had continued to participate in self-help groups. In addition, the perfect abstinence rate was statistically associated with regular medical checkups (adjusted odds ratio =5.33, 95% confidence interval =1.35-21.0) and participation in self-help groups (adjusted odds ratio =3.79, 95% confidence interval =1.17-12.3).

CONCLUSION

This study, reports the effectiveness of 3CGS for the first time. The recovery rate of alcoholics 2 years after discharge from residential treatment was examined. However, due to the chronic nature of alcoholism, further studies are required to investigate the efficacy of 3CGS beyond 2 years.

Treatment Attendance Among Veterans With Depression, Substance Use Disorder, and Trauma

OBJECTIVE

Low attendance in psychotherapy, particularly among individuals with comorbid disorders, is a pervasive challenge. The present study examined predictors of treatment attendance in a sample of veterans with depression, substance use disorder, and trauma.

METHODS

This is an analysis of data collected as part of a larger clinical trial involving outpatients at a Veterans Administration dual diagnosis clinic. Individuals were excluded if they had significant memory deficits, schizophrenia, bipolar disorder, or substantial travel constraints. Participants (N = 146) received 12 weeks of group-delivered integrated cognitive behavioral therapy for depression and substance use, followed by randomization to 12 additional weeks of individually delivered cognitive behavioral therapy (n = 62) or cognitive processing therapy (n = 61) modified to address substance use and trauma. Participants, therapists, and researchers were not blinded to group assignment. For this study, we included only the 123 participants who were randomized into the second phase, analyzing predictors of treatment attendance categorized into predisposing factors, enabling factors, and need factors.

RESULTS

Participants were primarily male (89%) and Caucasian (76%) and averaged 47 years old (SD = 12). Forty-four percent had alcohol use disorder, 16% had drug use disorder, and 40% had polysubstance use disorder. Most met criteria for PTSD (82%), with 44% having combat-related trauma, 33% sexual trauma, and 28% other trauma. Treatment attendance did not differ between groups. More education was associated with increased group (r = .19, p = .04) and individual session attendance (r = .28, p = .002). Individuals with chronic housing problems attended fewer group sessions (r = -.19, p = .04), while individuals with sexual trauma, compared to those with other traumas, attended more individual sessions (r = .23, p = .01). Number of group sessions attended was positively associated with individual session attendance.

CONCLUSIONS

Few variables were significantly predictive of treatment attendance, possibly due to the complex nature of comorbid disorders. Including a focus on trauma was not associated with lower attendance. Special consideration may need to be given to education level, homelessness, and trauma when trying to engage and retain patients with comorbid disorders in treatment. This clinical trial is registered at www.clinicaltrials.gov as NCT00958217.

The role of the working alliance in treatment for alcohol problems

Little research has been done on the role of the therapeutic working alliance in treatment for alcohol problems. This longitudinal study’s objectives were (a) to identify predictors of working alliance and (b) to investigate whether client and/or therapist reports of the working alliance predicted posttreatment motivation and then later treatment outcome. Client and therapist perceptions of the working alliance were assessed after the first treatment session using a short form of the Working Alliance Inventory (WAI) among 173 clients taking part in the United Kingdom Alcohol Treatment Trial (UKATT) and randomized to motivational enhancement therapy (MET) or social behavior and network therapy (SBNT) with complete data on all measures of interest. Structural equation models were fitted to identify predictors of WAI scores and investigate the relationships between WAI and measures of drinking during treatment, posttreatment motivation, and successful treatment outcome (abstinent or nonproblem drinker), and measures of drinks per drinking day and nondrinking days, assessed 9 months after the conclusion of treatment. Motivation to change drinking when treatment began was a strong predictor of client—adjusted coefficient = 2.21 (95% confidence interval [CI] [0.36, 4.06]—but not therapist WAI. Client WAI predicted successful treatment outcome—adjusted odds ratios (OR) = 1.09 (95% CI [1.02, 1.17])—and had effects on drinking during treatment, and on posttreatment motivation to change. There was evidence for effect modification by treatment, with strong associations between WAI and posttreatment motivation, and evidence of WAI prediction of treatment outcomes in the MET group, but no evidence of associations for SBNT. Therapist WAI was not strongly associated with treatment outcome (adjusted OR = 1.05; 95% CI [0.99, 1.10]). The working alliance is important to treatment outcomes for alcohol problems, with client evaluation of the alliance strongly related to motivation to change drinking throughout treatment for MET. It was also much more important than therapist-rated alliance in this study.

A comparison of three interventions for homeless youth evidencing substance use disorders: results of a randomized clinical trial

While research on homeless adolescents and young adults evidencing substance use disorder is increasing, there is a dearth of information regarding effective interventions, and more research is needed to guide those who serve this population. The current study builds upon prior research showing promising findings of the community reinforcement approach (CRA) (Slesnick, Prestopnik, Meyers, & Glassman, 2007). Homeless adolescents and young adults between the ages of 14 to 20 years were randomized to one of three theoretically distinct interventions: (1) CRA (n = 93), (2) motivational enhancement therapy (MET, n = 86), or (3) case management (CM, n = 91). The relative effectiveness of these interventions was evaluated at 3, 6, and 12 months post-baseline. Findings indicated that substance use and associated problems were significantly reduced in all three interventions across time. Several moderating effects were found, especially for sex and history of childhood abuse. Findings show little evidence of superiority or inferiority of the three interventions and suggest that drop-in centers have choices for addressing the range of problems that these adolescents and young adults face.

Pilot study of a social network intervention for heroin users in opiate substitution treatment: study protocol for a randomized controlled trial

Background

Research indicates that 3% of people receiving opiate substitution treatment (OST) in the UK manage to achieve abstinence from all prescribed and illicit drugs within 3 years of commencing treatment, and there is concern that treatment services have become skilled at engaging people but not at helping them to enter a stage of recovery and drug abstinence. The National Treatment Agency for Substance Misuse recommends the involvement of families and wider social networks in supporting drug users’ psychological treatment, and this pilot randomized controlled trial aims to evaluate the impact of a social network-focused intervention for patients receiving OST.

Methods and design

In this two-site, early phase, randomized controlled trial, a total of 120 patients receiving OST will be recruited and randomized to receive one of three treatments: 1) Brief Social Behavior and Network Therapy (B-SBNT), 2) Personal Goal Setting (PGS) or 3) treatment as usual. Randomization will take place following baseline assessment. Participants allocated to receive B-SBNT or PGS will continue to receive the same treatment that is routinely provided by drug treatment services, plus four additional sessions of either intervention. Outcomes will be assessed at baseline, 3 and 12 months. The primary outcome will be assessment of illicit heroin use, measured by both urinary analysis and self-report. Secondary outcomes involve assessment of dependence, psychological symptoms, social satisfaction, motivation to change, quality of life and therapeutic engagement. Family members (n = 120) of patients involved in the trial will also be assessed to measure the level of symptoms, coping and the impact of the addiction problem on the family member at baseline, 3 and 12 months.

Discussion

This study will provide experimental data regarding the feasibility and efficacy of implementing a social network intervention within routine drug treatment services in the UK National Health Service. The study will explore the impact of the intervention on both patients receiving drug treatment and their family members.

Trial registration

Trial Registration Number: ISRCTN22608399

ISRCTN22608399 registration: 27/04/2012

Date of first randomisation: 14/08/2012

Predictive validity of treatment allocation guidelines on drinking outcome in alcohol-dependent patients

The purpose of this study was to establish the predictive validity of guidelines for allocating patients to outpatient or inpatient treatment for an alcohol-use disorder. It was hypothesized that patients who were matched to the recommended level of care would have (a) better outcomes than patients treated at a less intensive level of care, and (b) outcomes equivalent to those of patients treated at a more intensive level of care. Matched patients were allocated according to an algorithm based on their treatment history, addiction severity, psychiatric impairment, and social stability at baseline. Outcome was measured in terms of self-reported alcohol use 30days prior to follow-up and changes in number of abstinent and heavy drinking days between intake and follow up. Of the 2,310 patients, 65.4% were successfully followed up 9.67months after intake. Only 22% of the patients were treated according to the level of care prescribed by the guidelines; 49% were undertreated; and 29% were overtreated. The results were not in line with our hypotheses. Patients treated at a more intensive level of care than recommended had favorable outcomes compared to patients treated at the recommended level of care (55.5% vs. 43.9% success). Patients allocated to the recommended level of care did not have better outcomes than those treated at a less intensive level of care (43.9% vs. 38.3% success). Based on these results, we suggest ways to improve the algorithm for allocating patients to treatment.

Examining the interactive effect of posttraumatic stress disorder, distress tolerance, and gender on residential substance use disorder treatment retention

An extensive body of research has demonstrated that patients with a co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) diagnosis are at high risk for a wide range of negative clinical outcomes, including treatment noncompletion. However, no studies to date have explored the effect of a PTSD-SUD diagnosis on residential SUD treatment completion, as well as potential moderators of this effect. Consequently, the goal of this study was to examine the interactive effect of a PTSD diagnosis, distress tolerance (DT), and gender on residential SUD treatment retention. Participants were 214 substance-dependent patients consecutively admitted to a residential SUD treatment facility. Participants were administered diagnostic interviews, completed a laboratory-based measure of DT, and were followed throughout the course of treatment. Although no significant main effects were found, results did reveal a significant PTSD × gender × DT interaction. Post hoc analyses indicated that, among men, those with a current diagnosis of PTSD and low DT completed a significantly lower proportion of residential SUD treatment compared to all other groups. The implications of the study's findings for identifying ways to improve residential SUD treatment retention among patients with a PTSD-SUD diagnosis are discussed.