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Ruglass LM, Shevorykin A, Zhao Y, Killeen TK, Bauer AG, Morgan-López AA, Back SE, Fitzpatrick S, López-Castro T, Norman SB, Saavedra LM, Hien DA. Self-report and urine drug screen concordance among women with co-occurring PTSD and substance use disorders participating in a clinical trial: Impact of drug type and participant characteristics. Drug Alcohol Depend 2023; 244:109769. [PMID: 36696843 PMCID: PMC9987239 DOI: 10.1016/j.drugalcdep.2023.109769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/17/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Self-report measures are important in substance use assessment, yet they are susceptible to reporting errors. Urine drug screens (UDS) are often considered a more valid alternative. However, collecting in-person UDS may not always be feasible, contributing to the need to understand factors that influence the validity of self-reported substance use. METHODS In this secondary analysis of data from 295 women with co-occurring PTSD and substance use disorders (SUD) who participated in a clinical trial testing behavioral interventions, we examined concordance and discordance between self-reported drug use and associated UDS results. Generalized linear mixed models were used to examine the impact of treatment type and participant characteristics on the associations between self-reported drug use and UDS results. RESULTS Findings revealed higher disagreement between self-report and UDS for opioids and sedatives (ranging from.77 to.90) and lower disagreement rates for cannabis and cocaine (ranging from.26 to.33). Treatment type was not a significant moderator of the associations between self-report and UDS across all drugs. Among those with a positive opioid UDS, those who reported employment in the past three years were more likely to self-report no opioid use compared to their counterparts without employment in the past three years. CONCLUSIONS Findings add to the literature that supports the validity of self-reported cannabis and cocaine use. The greater discrepancies between self-report and UDS test results of opioids and sedatives suggest adjunctive UDS may be required, although a variety of factors other than inaccurate self-report may be associated with this discrepancy.
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Affiliation(s)
- L M Ruglass
- Department of Psychology, The City College of New York, CUNY, USA; Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, USA.
| | - A Shevorykin
- Department of Health Behavior, Roswell Comprehensive Cancer Center, USA
| | - Y Zhao
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, USA; School of Nursing, Columbia University, USA; Department of Psychiatry, Yale University School of Medicine, USA
| | - T K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, USA
| | - A G Bauer
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, USA
| | | | - S E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, USA
| | | | - T López-Castro
- Department of Psychology, The City College of New York, CUNY, USA
| | - S B Norman
- National Center for PTSD, White River Junction, VT, USA; Department of Psychiatry, University of California, San Diego, USA
| | | | - D A Hien
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, USA
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Acute and long-term cannabis use among stimulant users: Results from CTN-0037 Stimulant Reduction Intervention using Dosed Exercise (STRIDE) Randomized Control Trial. Drug Alcohol Depend 2019; 200:139-144. [PMID: 31129484 PMCID: PMC6863445 DOI: 10.1016/j.drugalcdep.2019.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 02/04/2019] [Accepted: 02/09/2019] [Indexed: 11/22/2022]
Abstract
AIMS The aim of this study was to examine the impact of vigorous intensity, high dose exercise (DEI) on cannabis use among stimulant users compared to a health education intervention (HEI) using data from the Stimulant Reduction Intervention using Dosed Exercise, National Institute of Drug Abuse National Drug Treatment Clinical Trials Network Protocol Number 0037 (STRIDE). METHODS Adults (N = 302) enrolled in the STRIDE randomized clinical trial were randomized to either the DEI or the HEI. Interventions included supervised sessions three times a week during the Acute phase (12 weeks) and once a week during the Follow-up phase (6 months). Cannabis use was measured at each assessment via Timeline Follow Back and urine drug screens. Cannabis use was compared between the groups during the Acute and Follow-up phases using both the intent-to-treat sample and a complier average causal effects (CACE) analysis. FINDINGS Approximately 43% of the sample reported cannabis use at baseline. The difference in cannabis use between the DEI and HEI groups during the Acute phase was not significant. During the Follow-up phase, the days of cannabis use was significantly lower among those in the DEI group (1.20 days) compared to the HEI group (2.15 days; p = 0.04). CONCLUSIONS For those who adhered to the exercise intervention, vigorous intensity, high dose exercise resulted in less cannabis use. Results suggest that there were no significant short-term differences in cannabis use between the groups. Further study on the long-term impact of exercise as a treatment to reduce cannabis use should be considered.
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Carmody T, Greer TL, Walker R, Rethorst CD, Trivedi MH. A Complier Average Causal Effect Analysis of the Stimulant Reduction Intervention using Dosed Exercise Study. Contemp Clin Trials Commun 2018; 10:1-8. [PMID: 29682627 PMCID: PMC5898532 DOI: 10.1016/j.conctc.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective Exercise is a promising treatment for substance use disorders, yet an intention-to-treat analysis of a large, multi-site study found no reduction in stimulant use for exercise versus health education. Exercise adherence was sub-optimal; therefore, secondary post-hoc complier average causal effects (CACE) analysis was conducted to determine the potential effectiveness of adequately dosed exercise. Method The STimulant use Reduction Intervention using Dosed Exercise study was a randomized controlled trial comparing a 12 kcal/kg/week (KKW) exercise dose versus a health education control conducted at nine residential substance use treatment settings across the U.S. that are affiliated with the National Drug Abuse Treatment Clinical Trials Network. Participants were sedentary but medically approved for exercise, used stimulants within 30 days prior to study entry, and received a DSM-IV stimulant abuse or dependence diagnosis within the past year. A CACE analysis adjusted to include only participants with a minimum threshold of adherence (at least 8.3 KKW) and using a negative-binomial hurdle model focused on 218 participants who were 36.2% female, mean age 39.4 years (SD = 11.1), and averaged 13.0 (SD = 9.2) stimulant use days in the 30 days before residential treatment. The outcome was days of stimulant use as assessed by the self-reported TimeLine Follow Back and urine drug screen results. Results The CACE-adjusted analysis found a significantly lower probability of relapse to stimulant use in the exercise group versus the health education group (41.0% vs. 55.7%, p < .01) and significantly lower days of stimulant use among those who relapsed (5.0 days vs. 9.9 days, p < .01). Conclusions The CACE adjustment revealed significant, positive effects for exercise. Further research is warranted to develop strategies for exercise adherence that can ensure achievement of an exercise dose sufficient to produce a significant treatment effect.
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Affiliation(s)
| | | | | | | | - Madhukar H. Trivedi
- Corresponding author. Julie K. Hersh Chair for Depression Research and Clinical Care, Betty Jo Hay Distinguished Chair in Mental Health, Director, Center for Depression Research and Clinical Care, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9119, USA.
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Psychosocial relationship status and quality as predictors of exercise intervention adherence and substance use outcomes: Results from the STRIDE (CTN-0037) study. Psychiatry Res 2017; 254:332-339. [PMID: 28525788 PMCID: PMC5563976 DOI: 10.1016/j.psychres.2017.04.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 04/12/2017] [Accepted: 04/27/2017] [Indexed: 11/24/2022]
Abstract
Social/intimate relationship status and quality are associated with health-promoting behaviors, while living alone or being isolated are adversely associated with physical and mental health outcomes. Limited work has investigated how particular components of one's social environment - usual living arrangements, satisfaction with those arrangements, and global social and family discord - are related to substance use reduction and intervention adherence. We investigated these questions in 270 individuals receiving study intervention for stimulant abuse/dependence through the multi-site Stimulant Reduction Intervention using Dosed Exercise (CTN-0037) trial. Using mixed effects modeling, results indicated that individuals with baseline social discord used stimulants on more days throughout the intervention period than those without social discord (d=0.39). An interaction between gender, usual living arrangements, and satisfaction with those arrangements indicated that women who lived alone and were dissatisfied with that arrangement reported greater days of stimulant use compared to several other groups (d≥1.46). Finally, individuals who reported usually living with a non-partner over the past three years attended a greater percentage of intervention sessions compared to those usually living with a partner (d=0.34). These results identify sample subgroups with adverse stimulant use and intervention adherence outcomes and suggest areas for future inquiry/intervention.
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Trivedi MH, Greer TL, Rethorst CD, Carmody T, Grannemann BD, Walker R, Warden D, Wilson KS, Stoutenberg M, Oden N, Silverstein M, Hodgkins C, Love L, Seamans C, Stotts A, Causey T, Szucs-Reed RP, Rinaldi P, Myrick H, Straus M, Liu D, Lindblad R, Church T, Blair SN, Nunes EV. Randomized Controlled Trial Comparing Exercise to Health Education for Stimulant Use Disorder: Results From the CTN-0037 STimulant Reduction Intervention Using Dosed Exercise (STRIDE) Study. J Clin Psychiatry 2017; 78:1075-1082. [PMID: 28199070 PMCID: PMC5683711 DOI: 10.4088/jcp.15m10591] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/29/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate exercise as a treatment for stimulant use disorders. METHODS The STimulant Reduction Intervention using Dosed Exercise (STRIDE) study was a randomized clinical trial conducted in 9 residential addiction treatment programs across the United States from July 2010 to February 2013. Of 497 adults referred to the study, 302 met all eligibility criteria, including DSM-IV criteria for stimulant abuse and/or dependence, and were randomized to either a dosed exercise intervention (Exercise) or a health education intervention (Health Education) control, both augmenting treatment as usual and conducted thrice weekly for 12 weeks. The primary outcome of percent stimulant abstinent days during study weeks 4 to 12 was estimated using a novel algorithm adjustment incorporating self-reported Timeline Followback (TLFB) stimulant use and urine drug screen (UDS) data. RESULTS Mean percent of abstinent days based on TLFB was 90.8% (SD = 16.4%) for Exercise and 91.6% (SD = 14.7%) for Health Education participants. Percent of abstinent days using the eliminate contradiction (ELCON) algorithm was 75.6% (SD = 27.4%) for Exercise and 77.3% (SD = 25.1%) for Health Education. The primary intent-to-treat analysis, using a mixed model controlling for site and the ELCON algorithm, produced no treatment effect (P = .60). In post hoc analyses controlling for treatment adherence and baseline stimulant use, Exercise participants had a 4.8% higher abstinence rate (78.7%) compared to Health Education participants (73.9%) (P = .03, number needed to treat = 7.2). CONCLUSIONS The primary analysis indicated no significant difference between exercise and health education. Adjustment for intervention adherence showed modestly but significantly higher percent of abstinent days in the exercise group, suggesting that exercise may improve outcomes for stimulant users who have better adherence to an exercise dose. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01141608.
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Affiliation(s)
- Madhukar H. Trivedi
- University of Texas Southwestern Medical Center, Dallas, TX,Address Correspondence to: Madhukar H. Trivedi, M.D. Professor of Psychiatry, Betty Jo Hay Distinguished Chair in Mental Health, Director, Center for Depression Research and Clinical Care UT Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX 75390-9119, Ph: 214-648-0188,
| | - Tracy L. Greer
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Thomas Carmody
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Robrina Walker
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Diane Warden
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Neal Oden
- The EMMES Corporation, Rockville, MD
| | | | | | - Lee Love
- Gibson Recovery Center, Cape Girardeau, MO
| | | | - Angela Stotts
- University of Texas Health Science Center at Houston, Houston, TX
| | - Trey Causey
- Morris Village Alcohol and Drug Addiction Treatment Center, Columbia, SC
| | | | | | - Hugh Myrick
- Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Michele Straus
- National Institutes of Health, National Institute on Drug Abuse, Bethesda, MD
| | - David Liu
- National Institutes of Health, National Institute on Drug Abuse, Bethesda, MD
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Ling W, Hillhouse MP, Saxon AJ, Mooney LJ, Thomas CM, Ang A, Matthews AG, Hasson A, Annon J, Sparenborg S, Liu DS, McCormack J, Church S, Swafford W, Drexler K, Schuman C, Ross S, Wiest K, Korthuis PT, Lawson W, Brigham GS, Knox PC, Dawes M, Rotrosen J. Buprenorphine + naloxone plus naltrexone for the treatment of cocaine dependence: the Cocaine Use Reduction with Buprenorphine (CURB) study. Addiction 2016; 111:1416-27. [PMID: 26948856 PMCID: PMC4940267 DOI: 10.1111/add.13375] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/19/2015] [Accepted: 02/26/2016] [Indexed: 11/28/2022]
Abstract
AIMS To examine the safety and effectiveness of buprenorphine + naloxone sublingual tablets (BUP, as Suboxone(®) ) provided after administration of extended-release injectable naltrexone (XR-NTX, as Vivitrol(®) ) to reduce cocaine use in participants who met DSM-IV criteria for cocaine dependence and past or current opioid dependence or abuse. METHODS This multi-centered, double-blind, placebo-controlled study, conducted under the auspices of the National Drug Abuse Treatment Clinical Trials Network, randomly assigned 302 participants at sites in California, Oregon, Washington, Colorado, Texas, Georgia, Ohio, New York and Washington DC, USA to one of three conditions provided with XR-NTX: 4 mg/day BUP (BUP4, n = 100), 16 mg/day BUP (BUP16, n = 100, or no buprenorphine (placebo; PLB, n = 102). Participants received pharmacotherapy for 8 weeks, with three clinic visits per week. Cognitive behavioral therapy was provided weekly. Follow-up assessments occurred at 1 and 3 months post-intervention. The planned primary outcome was urine drug screen (UDS)-corrected, self-reported cocaine use during the last 4 weeks of treatment. Planned secondary analyses assessed cocaine use by UDS, medication adherence, retention and adverse events. RESULTS No group differences were found between groups for the primary outcome (BUP4 versus PLB, P = 0.262; BUP16 versus PLB, P = 0.185). Longitudinal analysis of UDS data during the evaluation period using generalized linear mixed equations found a statistically significant difference between BUP16 and PLB [P = 0.022, odds ratio (OR) = 1.71] but not for BUP4 (P = 0.105, OR = 1.05). No secondary outcome differences across groups were found for adherence, retention or adverse events. CONCLUSIONS Buprenorphine + naloxone, used in combination with naltrexone, may be associated with reductions in cocaine use among people who meet DSM-IV criteria for cocaine dependence and past or current opioid dependence or abuse.
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Measures of outcome for stimulant trials: ACTTION recommendations and research agenda. Drug Alcohol Depend 2016; 158:1-7. [PMID: 26652899 PMCID: PMC4698050 DOI: 10.1016/j.drugalcdep.2015.11.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/06/2015] [Accepted: 11/07/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND The development and approval of an efficacious pharmacotherapy for stimulant use disorders has been limited by the lack of a meaningful indicator of treatment success, other than sustained abstinence. METHODS In March, 2015, a meeting sponsored by Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) was convened to discuss the current state of the evidence regarding meaningful outcome measures in clinical trials for stimulant use disorders. Attendees included members of academia, funding and regulatory agencies, pharmaceutical companies, and healthcare organizations. The goal was to establish a research agenda for the development of a meaningful outcome measure that may be used as an endpoint in clinical trials for stimulant use disorders. RESULTS AND CONCLUSIONS Based on guidelines for the selection of clinical trial endpoints, the lessons learned from prior addiction clinical trials, and the process that led to identification of a meaningful indicator of treatment success for alcohol use disorders, several recommendations for future research were generated. These include a focus on the validation of patient reported outcome measures of functioning, the exploration of patterns of stimulant abstinence that may be associated with physical and/or psychosocial benefits, the role of urine testing for validating self-reported measures of stimulant abstinence, and the operational definitions for reduction-based measures in terms of frequency rather than quantity of stimulant use. These recommendations may be useful for secondary analyses of clinical trial data, and in the design of future clinical trials that may help establish a meaningful indicator of treatment success.
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Mooney LJ, Nielsen S, Saxon A, Hillhouse M, Thomas C, Hasson A, Stablein D, McCormack J, Lindblad R, Ling W. Cocaine use reduction with buprenorphine (CURB): rationale, design, and methodology. Contemp Clin Trials 2012; 34:196-204. [PMID: 23159524 DOI: 10.1016/j.cct.2012.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 11/07/2012] [Accepted: 11/09/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND Effective medications to treat cocaine dependence have not been identified. Recent pharmacotherapy trials demonstrate the potential efficacy of buprenorphine (BUP) (alone or with naltrexone) for reducing cocaine use. The National Institute on Drug Abuse Clinical Trials Network (CTN) launched the Cocaine Use Reduction with Buprenorphine (CURB) investigation to examine the safety and efficacy of sublingual BUP (as Suboxone®) in the presence of extended-release injectable naltrexone (XR-NTX, as Vivitrol®) for the treatment of cocaine dependence. This paper describes the design and rationale for this study. METHODS This multi-site, double-blind, placebo-controlled study will randomize 300 participants across 11 sites. Participants must meet the DSM-IV criteria for cocaine dependence and past or current opioid dependence or abuse. Participants are inducted onto XR-NTX after self-reporting at least 7 days of abstinence from opioids and tolerating a naloxone challenge followed by oral naltrexone and are then randomly assigned to one of three medication conditions (4 mg BUP, 16 mg BUP, or placebo) for 8 weeks. Participants receive a second injection of XR-NTX 4 weeks after the initial injection, and follow-up visits are scheduled at 1 and 3 months post-treatment. Participants receive weekly cognitive behavioral therapy (CBT). Recruitment commenced in September, 2011. Enrollment, active medication, and follow-up phases are ongoing, and recruitment is exceeding targeted enrollment rates. CONCLUSIONS This research using 2 medications will demonstrate whether BUP, administered in the presence of XR-NTX, reduces cocaine use in adults with cocaine dependence and opioid use disorders and will demonstrate if XR-NTX prevents development of physiologic dependence on BUP.
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Affiliation(s)
- Larissa J Mooney
- UCLA Integrated Substance Abuse Programs, Los Angeles, CA 90025, USA.
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Trivedi MH, Greer TL, Grannemann BD, Church TS, Somoza E, Blair SN, Szapocznik J, Stoutenberg M, Rethorst C, Warden D, Ring KM, Walker R, Morris DW, Kosinski AS, Kyle T, Marcus B, Crowell B, Oden N, Nunes E. Stimulant reduction intervention using dosed exercise (STRIDE) - CTN 0037: study protocol for a randomized controlled trial. Trials 2011; 12:206. [PMID: 21929768 PMCID: PMC3191354 DOI: 10.1186/1745-6215-12-206] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 09/19/2011] [Indexed: 11/20/2022] Open
Abstract
Background There is a need for novel approaches to the treatment of stimulant abuse and dependence. Clinical data examining the use of exercise as a treatment for the abuse of nicotine, alcohol, and other substances suggest that exercise may be a beneficial treatment for stimulant abuse, with direct effects on decreased use and craving. In addition, exercise has the potential to improve other health domains that may be adversely affected by stimulant use or its treatment, such as sleep disturbance, cognitive function, mood, weight gain, quality of life, and anhedonia, since it has been shown to improve many of these domains in a number of other clinical disorders. Furthermore, neurobiological evidence provides plausible mechanisms by which exercise could positively affect treatment outcomes. The current manuscript presents the rationale, design considerations, and study design of the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) CTN-0037 Stimulant Reduction Intervention using Dosed Exercise (STRIDE) study. Methods/Design STRIDE is a multisite randomized clinical trial that compares exercise to health education as potential treatments for stimulant abuse or dependence. This study will evaluate individuals diagnosed with stimulant abuse or dependence who are receiving treatment in a residential setting. Three hundred and thirty eligible and interested participants who provide informed consent will be randomized to one of two treatment arms: Vigorous Intensity High Dose Exercise Augmentation (DEI) or Health Education Intervention Augmentation (HEI). Both groups will receive TAU (i.e., usual care). The treatment arms are structured such that the quantity of visits is similar to allow for equivalent contact between groups. In both arms, participants will begin with supervised sessions 3 times per week during the 12-week acute phase of the study. Supervised sessions will be conducted as one-on-one (i.e., individual) sessions, although other participants may be exercising at the same time. Following the 12-week acute phase, participants will begin a 6-month continuation phase during which time they will attend one weekly supervised DEI or HEI session. Clinical Trials Registry ClinicalTrials.gov, NCT01141608 http://clinicaltrials.gov/ct2/show/NCT01141608?term=Stimulant+Reduction+Intervention+using+Dosed+Exercise&rank=1
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Affiliation(s)
- Madhukar H Trivedi
- The University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9119, USA.
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Nunes EV. The design and analysis of multisite effectiveness trials: a decade of progress in the National Drug Abuse Clinical Trials Network. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2011; 37:269-72. [PMID: 21854267 PMCID: PMC3232468 DOI: 10.3109/00952990.2011.604109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Edward V Nunes
- Department of Psychiatry, Columbia University, New York, NY, USA.
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