Substance use-related continuing education course objectives: Alignment with professional competencies

Background: Novel educational efforts are needed to prepare the current and future interprofessional health care workforce to address the range of substance use-related health problems. A 6-module massive open online course (MOOC) was developed to provide education to health professionals of various disciplines on the fundamentals of substance use-related treatment. The purpose of this project was to match course objectives to substance use-related competencies for 5 disciplines: nurses, pharmacists, physicians, physician assistants (PA), and social workers. Methods: Content expert raters within each discipline determined what Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) core competencies were matched to each objective for the 6 modules of the MOOC. The number of objectives across the 6 modules was summated. Results: All nursing and social work competencies were mapped to the course objectives. For physicians, PAs, and pharmacists, the proportions of knowledge-based competencies that mapped to the course objective were 58%, 76%, and 80%, respectively, and proportions of skill-based competencies that mapped to the course objective were 88%, 83%, and 75%, respectively. For those 3 groups, 100% of attitude-based competencies mapped to the course objective. Conclusions: The competency-based mapping with the MOOC objectives supports the interprofessional design of the course and discipline-specific competencies needed to promote the best outcomes for patients.

PTSD / substance use disorder comorbidity: Treatment options and public health needs

Purpose of Review

Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings.

Recent Findings

Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD.

Summary

There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.

Longitudinal Findings from a Randomized Clinical Trial of Varenicline for Alcohol Use Disorder with Comorbid Cigarette Smoking

BACKGROUND

This study is the first to examine longitudinal posttreatment outcomes of a placebo-controlled trial of varenicline for alcohol use disorder (AUD) with comorbid cigarette smoking.

METHODS

Participants were 131 adults (n = 39 female) seeking alcohol treatment in a randomized, double-blind, parallel group, placebo-controlled, 16-week multisite trial of varenicline combined with medical management (MM). Timeline follow-back assessments of alcohol and smoking behavior were conducted at the end of treatment (4 months), with follow-ups at 6, 9, and 12 months. Outcomes were percentage of heavy drinking days (PHDD), percent of participants with no heavy drinking days (NHDD), cotinine-confirmed prolonged smoking abstinence (PA), and good clinical outcome on either NHDD or PA.

RESULTS

Treatment improvements were maintained posttreatment. For the sample overall, PHDD or NHDD did not differ significantly by treatment condition (ps > 0.13), but varenicline produced higher rates of PA versus placebo at 4, 9, and 12 months (p < 0.05). Significant differences were observed by sex: Males had higher rates of NHDD with varenicline (28.9%) versus placebo (6.4%) at the end of treatment (p = 0.004), and these effects were maintained at 12 months (varenicline: 40.0% vs. placebo: 19.2%, p = 0.03). Higher rates of PA were seen for varenicline in both males (8.9%) and females (21.1%) versus placebo (males/females: 0%) at the end of treatment (p = 0.05), and this effect was maintained at 12 months for females (varenicline: 21.1% vs. placebo, 0.0%, p = 0.05).

CONCLUSIONS

Varenicline treatment combined with MM appears to have enduring benefits for patients with co-occurring AUD and cigarette smoking, and these effects may differ by sex.

Effect of Varenicline Combined With Medical Management on Alcohol Use Disorder With Comorbid Cigarette Smoking: A Randomized Clinical Trial

IMPORTANCE

Individuals with alcohol use disorder have high rates of cigarette smoking. Varenicline tartrate, an approved treatment for smoking cessation, may reduce both drinking and smoking.

OBJECTIVES

To test the efficacy of varenicline with medical management for patients with alcohol use disorder and comorbid smoking seeking alcohol treatment, and to evaluate the secondary effects on smoking abstinence.

DESIGN, SETTING, AND PARTICIPANTS

This phase 2, randomized, double-blind, parallel group, placebo-controlled trial was conducted at 2 outpatient clinics from September 19, 2012, to August 31, 2015. Eligible participants met alcohol-dependence criteria and reported heavy drinking (≥5 drinks for men and ≥4 drinks for women) 2 or more times per week and smoking 2 or more times per week; 131 participants were randomized to either varenicline or placebo stratified by sex and site. All analyses were of the intention-to-treat type. Data analysis was conducted from February 5, 2016, to September 29, 2017.

INTERVENTIONS

Varenicline tartrate, 1 mg twice daily, and matching placebo pills for 16 weeks. Medical management emphasized medication adherence for 4 weeks followed by support for changing drinking.

MAIN OUTCOMES AND MEASURES

Percentage of heavy drinking days (PHDD) weeks 9 to 16, no heavy drinking days (NHDD) weeks 9 to 16, and prolonged smoking abstinence weeks 13 to 16.

RESULTS

Of 131 participants, 39 (29.8%) were women and 92 (70.2%) were men, the mean (SD) age was 42.7 (11.7) years, and the race/ethnicity self-identified by most respondents was black (69 [52.7%]). Sixty-four participants were randomized to receive varenicline, and 67 to receive placebo. Mean change in PHDD between varenicline and placebo across sex and site was not significantly different. However, a significant treatment by sex by time interaction for PHDD (F1,106 = 4.66; P = .03) revealed that varenicline compared with placebo resulted in a larger decrease in log-transformed PHDD in men (least square [LS] mean difference in change from baseline, 0.54; 95% CI, -0.09 to 1.18; P = .09; Cohen d = 0.45) but a smaller decrease in women (LS mean difference, -0.69; 95% CI, -1.63 to 0.25; P = .15; Cohen d = -0.53). Thirteen of 45 men (29%) had NHDD taking varenicline compared with 3 of 47 men (6%) taking placebo (Cohen h = 0.64; 95% CI, 0.22-1.03), whereas 1 of 19 women (5%) had NHDD compared with 5 of 20 women (25%) taking placebo (Cohen h = -0.60; 95% CI, -1.21 to 0.04). Taking varenicline, 8 of 64 participants (13%) achieved prolonged smoking abstinence; no one (0 of 67) quit smoking taking placebo (P = .003; Cohen h = 0.72; 95% CI, 0.38-1.07).

CONCLUSIONS AND RELEVANCE

Varenicline with medical management resulted in decreased heavy drinking among men and increased smoking abstinence in the overall sample. Varenicline could be considered to promote improvements in men with these dual behavioral health risks.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01553136.

The clinical utility of the Medication Adherence Questionnaire (MAQ) in an alcohol pharmacotherapy trial

BACKGROUND

Medication nonadherence is a ubiquitous problem in pharmacology treatment for alcohol use disorders. Unintentional and purposeful nonadherence as measured by the Medication Adherence Questionnaire (MAQ) has been shown to predict problems with medication adherence; however, feedback from the MAQ has never been incorporated into a behavioral intervention to facilitate medication adherence. We assessed the integration of the MAQ into medical management (MM), a counseling approach frequently employed in conjunction with alcohol pharmacotherapy, to determine whether prior patterns of nonadherence could be addressed effectively to promote medication adherence.

METHODS

We conducted a post-hoc analysis of data from 131 alcohol dependent smokers who participated in a double blind, placebo controlled study of varenicline for the treatment of alcohol dependence. At baseline, participants completed a single administration of the MAQ, which asks 2 questions about unintentional nonadherence (e.g., forgetting) and 2 questions about purposeful nonadherence (e.g., stopping because feeling good or feeling bad). Based on these responses, participants were divided into 1 of 3 three categories. Adherent (n=60), Unintentional or Purposeful Nonadherent (n=50) and Unintentional and Purposeful Nonadherent (n=21). Over the course of the 16-week treatment period, patients were expected to participate in 12 medical management (MM) sessions; a brief psychosocial treatment. Feedback based on the MAQ responses was integrated into the MM sessions to facilitate medication and treatment adherence.

RESULTS

The 3 adherence groups were compared on baseline characteristics, medication adherence, treatment attendance and end-of-treatment patient ratings of treatment helpfulness. Baseline demographics and characteristics were not significantly different among the three categories. We found no statistically significant differences among the three groups with respect to pill adherence, treatment attendance, and treatment satisfaction ratings.

CONCLUSIONS

The findings suggest that the incorporation of MAQ feedback into the MM approach could be effective in mitigating risks associated with prior patterns of nonadherence suggesting that further testing of the integrated behavioral approach is warranted.

Sustaining motivational interviewing: a meta-analysis of training studies

BACKGROUND AND AIMS

Previous research indicates that motivational interviewing (MI) skills decline over time among participants in training workshops when post-workshop feedback and coaching are not provided. This study explored moderators of skill retention among trainees learning MI mainly for substance use disorder treatment in real-world treatment settings, including workshop enhancements and type and dose of post-workshop feedback and coaching.

METHODS

A meta-analysis of training studies was conducted with studies that reported MI skills using observational measures and that included trainees from real-world agency settings. Standardized change scores were calculated to indicate the magnitude of pre-post training change in MI skills; standardized change scores from post-training to 3 and 6+ months follow-up were calculated to indicate the sustainability of training gains over time. Effect sizes were aggregated using random effects models.

RESULTS

Twenty-one papers that reported the effects of MI training on agency staff were included in this review. Across studies, training yielded gains in MI skills (d = 0.76). Studies that did not include feedback and/or coaching reported eroding skills over a 6-month follow-up (d = -0.30), whereas post-workshop feedback/coaching sustained skills (d = 0.03). Effects of post-workshop feedback/coaching were moderated by frequency, duration and length of training. Moreover, studies reporting low levels of attrition from training protocols showed small increases in skills over the 6-month follow-up period (d = 0.12), whereas studies with high attrition showed skill erosion (d = -0.29).

CONCLUSIONS

On average, three to four feedback/coaching sessions over a 6-month period sustain skills among trainees for motivational interviewing, mainly for substance use disorder treatment. However, high rates of attrition from feedback/coaching contributes to post-workshop skill erosion.

Commentary on the adding individual psychotherapy after relapse in a pharmacotherapy trial: commentary on the PREDICT study

BACKGROUND

With few exceptions there has been a dearth of research evaluating the independent and combined effects of a promising medication and an effective behavioral intervention for alcohol problems. Few studies have incorporated both theory and empirical findings to ascertain how the combination of medication and behavioral intervention interact or work synergistically to produce better outcomes or why a particular combination of pharmacological and behavioral treatment works better than another combination or either of the interventions employed alone.

METHODS

The PREDICT Study is one of the few pharmacotherapy trials that has utilized a behavioral intervention to reduce/delay relapse to heavy drinking. The findings in the PREDICT Study were reviewed to gain a better understanding of how the combination of pharmacotherapy and behavioral intervention can be employed to manage the course of recovery for individuals with alcohol use disorders (AUDs).

RESULTS

Findings in the PREDICT Study show that behavioral interventions and pharmacotherapies have complementary functions that can be utilized to address the differential needs, capabilities, and resources associated with AUDs. However, researchers were forced to rely mainly on their own clinical experiences rather than an overarching conceptual model in determining how the approach should be employed with AUD patients, thereby limiting the conclusions that could be drawn from the study findings.

CONCLUSIONS

Different vulnerabilities underlying AUDs should be considered in determining what kinds of behavioral interventions should be paired with particular medications. At the same time, we need to have a better understanding of the clinical course of pharmacobehavioral treatment to deal with the array of problems/situations that arise over the course of combination therapy.

Does session attendance by a supportive significant other predict outcomes in individual treatment for alcohol use disorders?

BACKGROUND

A significant amount of research has supported the efficacy of couple versus individual treatment for alcohol use disorders, yet little is known about whether involving a significant other during the course of individual treatment can improve outcomes. Likewise, several barriers to couple treatment exist and a more flexible approach to significant other involvement may be warranted.

METHODS

This study constituted secondary analyses of the COMBINE data, a randomized clinical trial that combined pharmacotherapy and behavioral intervention for alcohol dependence. Data were drawn from the 16-week individual combined behavioral intervention (CBI), which had 776 participants, 31% of which were female, and 23% were non-white. The current study examined whether attendance by a supportive significant other (SSO) during CBI sessions would predict better outcomes. It was further hypothesized that active SSO involvement, defined by attendance during drink refusal or communication skills training sessions, would predict better outcomes.

RESULTS

SSOs attended at least 1 session for 26.9% of clients. Clients with SSOs who attended at least 1 session had significantly fewer drinking days and fewer drinking-related problems at the end of treatment. The presence of an SSO during a drink refusal training session predicted significantly better outcomes, as compared to SSO attendance at other sessions and drink refusal training without an SSO present. SSO attendance at a communication training session did not predict better outcomes.

CONCLUSIONS

These results suggest that specific types of active involvement may be important for SSO-involved treatment to have greater efficacy than individual treatment.

Effective Strategies for Maintaining Research Participation in Clinical Trials

Achieving high protocol adherence is essential for ensuring the overall success and scientific merit of clinical trials. Strategies for maximizing recruitment and treatment adherence have been previously explored in the literature. There has been less focus, however, on effective methods for maintaining participants in research follow-up. This article examines factors associated with poor follow-up rates as well as strategies for facilitating research commitment and addressing sources of nonadherence. Special attention is devoted to alcohol- and substance-dependent populations, groups known to have poor adherence rates. Examples are drawn from the COMBINE Study, an NIAAA-funded, nationwide, multisite, combined behavioral and pharmacotherapy trial for alcohol problems that achieved high one-year follow-up rates. The important role of coordinating centers in facilitating research retention is also discussed.

Alcohol treatment effects on secondary nondrinking outcomes and quality of life: the COMBINE study

OBJECTIVE

To evaluate the full range of alcohol treatment effectiveness, it is important to assess secondary nondrinking outcome dimensions in addition to primary alcohol consumption outcomes.

METHOD

We used a large sample (n=1,226) of alcohol-dependent participants entering the National Institute on Alcohol Abuse and Alcoholism-sponsored COMBINE (Combining Medications and Behavioral Interventions) Study, a multisite clinical trial of pharmacological (naltrexone [ReVia] and acamprosate [Campral]) and behavioral interventions, to examine the effects of specific treatment combinations on nondrinking functional outcomes. We assessed the outcomes at baseline and at the end of 16 weeks of alcohol treatment and again at the 26-week and/or 52-week postrandomization follow-ups.

RESULTS

(1) Drinking and secondary outcomes were significantly related, especially at the follow-up periods. A higher percentage of heavy drinking days, more drinks per drinking day, and lower percentage of days abstinent were associated with lower quality-of-life measures. (2) All nondrinking outcomes showed improvement at the end of 16 weeks of treatment and most maintained improvement over the 26-week and 52-week follow-ups. Only two measures returned to pretreatment levels at 52 weeks: percentage of days paid for work and physical health. Improvements of nondrinking outcomes remained even after adjusting for posttreatment heavy drinking status. (3) Although nondrinking outcomes showed overall improvement, specific pharmacological and behavioral treatment combinations were not differentially effective on specific secondary outcomes.

CONCLUSIONS

In the current study, changes that resulted from treatment were multidimensional, and improvements in nondrinking outcomes reflected the overall significant improvement in drinking but they were not differentiated between treatment combination groups. Findings from this study support the importance of including secondary nondrinking outcomes in clinical alcohol-treatment trials.

Relationship between medication adherence and treatment outcomes: the COMBINE study

BACKGROUND

Within the alcoholism field, there is mounting evidence supporting an important relationship between medication adherence and drinking outcomes. Little is known however, about the complex relationships between medication and treatment variables and drinking outcomes. The present paper reports on the differential impact of medication adherence and treatment factors on drinking outcomes. Data derived from the COMBINE Study was used to investigate the interrelationships between medication adherence, combination treatments and drinking outcomes.

METHODS

Twelve hundred and twenty-six patients were randomized to 1 of 8 different combination treatments involving 2 medications--naltrexone and acamprosate and placebo, and 2 behavioral treatments--medical management (MM) and combined behavioral intervention (CBI). Two primary drinking outcomes were percent days abstinent (PDA) and time to first heavy drinking day. Medication adherence was defined as a proportion that reflects the number of pills taken by the maximum number of pills expected to be taken over the course of the trial. A generalized linear mixed model was used to estimate the effects of adherence on PDA while proportional hazards model was used to examine similar co-variate effects on time to first heavy drinking day.

RESULTS

Concerning time to first heavy drinking day, a significant three-way interaction was found between medication adherence, CBI and naltrexone (p = 0.0160). Within the MM only plus placebo group (no CBI), significant differences were found in "recovery" (i.e., no heavy drinking days) rates between adherers and nonadherers (40% vs. 10%, p < 0.0001). Such differences became nonsignificant (p = 0.12) when CBI was introduced into the relationship. CBI did not add any such advantage to naltrexone-treated patients.

CONCLUSIONS

CBI might serve a protective function for nonadherers in the placebo group; the median relapse time was reduced when these nonadherers were exposed to the alcohol specialty intervention. CBI offered little additional benefit to nonadherers in the naltrexone group. Among nonadherers in the naltrexone group, relapse rates appear to be more a function of inadequate exposure to the active medication and less influenced by CBI.

Addressing substance abuse in health care settings

This article summarizes the proceedings of a roundtable discussion at the 2005 annual meeting of the Research Society on Alcoholism in Santa Barbara, California. The chair was William R. Miller. The presentations were as follows: (1) Screening and Brief Intervention for Alcohol Problems, by Allen Zweben; (2) Three Intervention Models and Their Impact on Medical Records, by Denise Ernst; (3) Pharmacotherapies for Managing Alcohol Dependence in Health Care Settings, by Roger D. Weiss; (4) The Trauma Center as an Opportunity, by Carol R. Schermer; (5) Motivational Interviewing by Telephone and Telemedicine, by Catherine Baca; (6) Health Care as a Context for Treating Drug Abuse and Dependence, by Wilson M. Compton; and (7) Interventions for Heavy Drinking in Health Care settings: Barriers and Strategies, by Mark L. Willenbring.

Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial

CONTEXT

Alcohol dependence treatment may include medications, behavioral therapies, or both. It is unknown how combining these treatments may impact their effectiveness, especially in the context of primary care and other nonspecialty settings.

OBJECTIVES

To evaluate the efficacy of medication, behavioral therapies, and their combinations for treatment of alcohol dependence and to evaluate placebo effect on overall outcome.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial conducted January 2001-January 2004 among 1383 recently alcohol-abstinent volunteers (median age, 44 years) from 11 US academic sites with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses of primary alcohol dependence.

INTERVENTIONS

Eight groups of patients received medical management with 16 weeks of naltrexone (100 mg/d) or acamprosate (3 g/d), both, and/or both placebos, with or without a combined behavioral intervention (CBI). A ninth group received CBI only (no pills). Patients were also evaluated for up to 1 year after treatment.

MAIN OUTCOME MEASURES

Percent days abstinent from alcohol and time to first heavy drinking day.

RESULTS

All groups showed substantial reduction in drinking. During treatment, patients receiving naltrexone plus medical management (n = 302), CBI plus medical management and placebos (n = 305), or both naltrexone and CBI plus medical management (n = 309) had higher percent days abstinent (80.6, 79.2, and 77.1, respectively) than the 75.1 in those receiving placebos and medical management only (n = 305), a significant naltrexone x behavioral intervention interaction (P = .009). Naltrexone also reduced risk of a heavy drinking day (hazard ratio, 0.72; 97.5% CI, 0.53-0.98; P = .02) over time, most evident in those receiving medical management but not CBI. Acamprosate showed no significant effect on drinking vs placebo, either by itself or with any combination of naltrexone, CBI, or both. During treatment, those receiving CBI without pills or medical management (n = 157) had lower percent days abstinent (66.6) than those receiving placebo plus medical management alone (n = 153) or placebo plus medical management and CBI (n = 156) (73.8 and 79.8, respectively; P<.001). One year after treatment, these between-group effects were similar but no longer significant.

CONCLUSIONS

Patients receiving medical management with naltrexone, CBI, or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy, with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management. Placebo pills and meeting with a health care professional had a positive effect above that of CBI during treatment. Naltrexone with medical management could be delivered in health care settings, thus serving alcohol-dependent patients who might otherwise not receive treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00006206.

Quality of life as an outcome measure in alcoholism treatment research

OBJECTIVE

The present article reviews the literature to date dealing with quality of life (QoL) as it relates to drinking behavior, alcohol use disorders and treatment outcome.

METHOD

Articles using the term "quality of life" to describe a status or outcome construct for individuals diagnosed with or being treated for alcohol use disorders or that used one or more instruments considered to reflect patients' QoL were identified primarily through Psychological Abstracts, MEDLINE and the National Institute on Alcohol Abuse and Alcoholism's ETOH archival database.

RESULTS

Thirty-six studies, published between 1993 and 2004, met these criteria. Twelve different QoL measures were used. Frequent heavy drinking or episodic heavy drinking (e.g., five or more drinks per occasion) patterns were associated with reduced QoL. Alcoholics had lower levels of QoL compared with general population norms or with other chronic health conditions. This relationship appears to be moderated by a number of sociodemographic and client characteristics, such as age, education, gender and co-occurring psychiatric disorders. Alcohol-dependent individuals experience improvements in QoL across treatment and with both short-term and long-term abstinence. Despite these improvements, many alcoholic individuals' QoL is unlikely to equal or exceed that of normative groups. Also, among hazardous and harmful drinkers, achieving and maintaining a marked reduction in drinking, even without complete abstinence, is associated with significant increases in QoL.

CONCLUSIONS

QoL represents an important area to consider in assessing individuals with alcohol use disorders and in evaluating alcoholism treatment outcome.

Origins, issues and options in the development of the combined behavioral intervention

OBJECTIVE

The aim of the investigators was to develop a moderate intensity comprehensive behavioral treatment based on the principles of motivational interviewing and Cognitive Behavioral Therapy that, within the confines of a standardized abstinence-oriented treatment, would provide a broad spectrum of modules to assist those seeking treatment to achieve reduction of problematic drinking.

METHOD

The core issue of how to deliver a flexible therapy tailored to the needs of individual clients while at the same time providing a standardized treatment protocol for a randomized clinical trial provided the dilemma out of which this unique standardized protocol arose. By using a single decision tree, client choice, combined with limited options, we were able to reconcile these conflicting demands.

RESULTS

Key decisions that were made in developing the treatment protocol and the thinking leading to these decisions are described.

CONCLUSIONS

Understanding these key issues and the factors that led to the decisions made will assist would-be users in their own clinical and/or clinical research needs.

When worlds collide: blending the divergent traditions of pharmacotherapy and-psychotherapy outcome research

OBJECTIVE

The multisite COMBINE Study brought together a team of alcoholism investigators who varied in whether their expertise was primarily in pharmacotherapy research or in studying psychotherapy. The process of designing a single trial that tested combinations of psychotherapy and pharmacotherapy highlighted the differences in these two research traditions and necessitated a number of compromises that are the focus of this article.

METHOD

The COMBINE trial was designed to investigate the efficacy, separately and in combination, of two medications (i.e., naltrexone, acamprosate) with Medical Management and a state-of-the-art psychotherapy, known as the Combined Behavioral Intervention.

RESULTS

Pharmacotherapy researchers favored studying outcome during the treatment period when medications were administered, viewing behavioral intervention as a means for minimizing variance during treatment and providing ethical care in placebo-controlled studies. In contrast, psychotherapy researchers focused on assessment of outcomes after treatment, regarding the behavioral intervention as a source of long-lasting change, necessitating careful training and monitoring of its implementation. The two traditions also differed on variables of interest in studying treatment process and secondary outcomes and methods of data collection and analysis. Some of the solutions reached by the COMBINE Study Research Group included studying both the short-term and long-term effects of treatment and selective inclusion of measures designed to evaluate processes specific to medications and to behavioral interventions.

CONCLUSIONS

The successful compromises reached by the COMBINE Study Research Group may be helpful to other transdisciplinary research teams undertaking a combined evaluation of promising medications and behavioral interventions for alcoholism.

Applying Clinical Significance Methodology to Alcoholism Treatment Trials: Determining Recovery Outcome Status with Individual- and Population-Based Measures

BACKGROUND

The current analysis applies clinical significance methodology to alcoholism treatment outcome research using data available from Project MATCH. Because of its high internal validity and its inclusion of multiple measures assessing multiple outcome dimensions, MATCH was considered an ideal study to explore the utility of this methodology.

METHODS

Data reported here are from a total of 1,726 participants enrolled in either aftercare (n = 774) or outpatient (n = 952) arms of the study. First, a cutoff score was determined differentiating functional versus dysfunctional status on three outcome measures: percent days abstinent (PDA), mean drinks per drinking day (DDD) and negative consequences of alcohol use. Second, the reliable change in pre- to post-treatment scores on these three measures was calculated.

RESULTS

The results reported herein support the importance of distinguishing between statistical and clinical significance of outcomes. During three months post-treatment, approximately one-half of the treated patients were "recovered" (i.e., both functional and reliably changed) with respect to both PDA (i.e., 51%) and negative consequences of drinking (i.e., 47%); however, only about one-third of individuals remained recovered throughout the full one-year follow-up period (i.e., 33% on PDA and 35% on negative consequences). These individual-based change outcomes compared similarly to a population-based indicator of heavy drinking. Alternatively, only about one-quarter of participants were recovered using two distinct criteria for mean DDD (i.e., 23-29%), and even fewer participants remained recovered on mean DDD over the full one-year follow-up period (i.e., about 14-18%).

CONCLUSIONS

Based on study limitations, more work is required to make clinical significance methodology practically useful to alcoholism treatment trials including more precise definitions of functional status and relative change as well as better interpretation of the inter-relationship between multiple measures assessing multiple outcome domains.

Recruiting and retaining participants in a combined behavioral and pharmacological clinical trial

OBJECTIVE

This article focuses on the practical and methodological considerations that went into recruiting and retaining participants in a complex clinical trial. It describes multiple recruitment strategies that were employed to meet stringent eligibility criteria and manage efficiently the flow of participants to fulfill recruitment goals. Both study-wide and site-specific methods that were employed to maximize retention rates are discussed. Also discussed is how the coordinating center worked together with study investigators to improve recruitment and retention.

METHOD

A multidimensional perspective on recruitment and retention is discussed. Details are provided on how barriers to recruitment and retention were addressed. Intervention strategies designed by the coordinating center to meet performance goals are described. Data are presented to support the utility of recruitment and retention methods. The COMBINE Study served as a case illustration for various issues addressed in the article.

RESULTS

As a result of the combined efforts of the coordinating center and study sites, there was steady improvement in recruitment and retention rates over the course of the trial. The recruitment goal of 1,375 participants was surpassed by September 2003. Also, improvement in data completeness rates improved by 18-27 percentage points over a 3-year period, culminating in follow-up rates meeting or exceeding performance goals by 2004.

CONCLUSIONS

Various strategies and procedures designed to address recruitment and retention problems in large, complex combination pharmacotherapy and behavioral trials were effective in meeting recruitment and retention goals. The lessons learned may be of value to investigators not only involved in multisite, combination trials but in monotherapy and/or single-site studies as well.

Use of a "psychotherapy with no pills" treatment condition as part of a combined pharmacotherapy-psychotherapy research study of alcohol dependence

OBJECTIVE

The purpose of this article is to review issues related to the use of placebo medication in a study examining combined pharmacotherapy and psychotherapy for alcohol dependence.

METHOD

Little is known about the strength of the placebo effect in alcohol-dependent patients. One way to study this is to compare placebo to no pharmacological treatment. The multisite National Institute on Alcohol Abuse and Alcoholism COMBINE Study is examining optimal combinations of two medications (acamprosate and naltrexone) and two behavioral treatments (a moderate-intensity treatment called Combined Behavioral Intervention [CBI] and a low-intensity treatment called Medical Management [MM]) for alcohol-dependent patients. The study initially included a 2 x 2 x 2 eight-cell design. This article relates our experience adding a ninth treatment condition (Cell 9), consisting of CBI alone, with no pills or MM. By comparing patients receiving CBI alone to patients receiving two placebos, MM and CBI, we can examine the strength of the placebo effect for these two medications in alcohol-dependent patients. Moreover, we can study CBI in the context in which it is frequently delivered clinically, that is, in the absence of pharmacotherapy and certainly in the absence of placebo medication.

RESULTS

This article explains the background and rationale behind the decision to include Cell 9 in COMBINE. Recruitment challenges faced as a result of adding this condition are reviewed, as is the experience implementing this condition in a pilot feasibility study.

CONCLUSIONS

The use of a "psychotherapy with no pills" treatment condition as part of a combined pharmacotherapy-psychotherapy study of alcohol dependence is feasible and can help enrich the results of this research.

A multi-site dose ranging study of nalmefene in the treatment of alcohol dependence

The opiate antagonist nalmefene has been shown in 2 single-site studies to reduce alcohol consumption and relapse drinking in alcohol-dependent individuals. This safety and preliminary multisite efficacy study evaluated 3 doses of nalmefene (5, 20, or 40 mg) in a double-blind comparison to placebo over a 12-week treatment period in 270 recently abstinent outpatient alcohol-dependent individuals. Participants concomitantly received 4 sessions of a motivational enhancement therapy (with a medication compliance component) delivered from trained counselors. Although more subjects in the active medication groups terminated the study early secondary to adverse events, the rates did not differ significantly from that of placebo. The 20-mg/d group experienced more insomnia, dizziness, and confusion, while the 5-mg group also had more dizziness and the 40-mg group had more nausea than the placebo group. Most of these symptoms were mild and improved over time. Although all subjects had a reduction in heavy drinking days, craving, gamma-glutamyl transferase, and carbohydrate-deficient transferrin concentrations over the course of the study, there was no difference between the active medication and placebo groups on these measures. The time to first heavy drinking day was also not significantly different between the placebo and the active treatment groups. This relatively small multisite trial showed that nalmefene was reasonably well tolerated in recently abstinent alcoholics. However, possibly because of variation among the sites or the comparatively small sample size, there was no evidence of superior efficacy outcomes with nalmefene treatment.

Clinical and methodological utility of a composite outcome measure for alcohol treatment research

BACKGROUND

How to capture different response patterns resulting from alcohol treatment has been a troublesome issue for alcohol researchers. A composite measure is one approach to capturing multiple treatment outcomes among diverse client populations. This article provides the rationale, development, and work conducted thus far on the composite outcome index and discusses the clinical utility of the measure.

METHODS

With the use of Project MATCH data, the composite outcome measure was examined in relation to self-reported alcohol consumption and alcohol problems and biological markers as well as in relation to other areas of functioning, such as psychiatric dysfunction and quality of life. Also, for assessing the stability of the measure, different composite outcomes statuses were assessed over time.

RESULTS

Individuals with better scores on composite outcome index had fewer percent days abstinent, consumed more alcohol when they drank, had a greater number of alcohol problems, and evidenced higher blood levels as measured by gamma-glutamyltranspeptidase and carbohydrate-deficient transferrin. Individuals with poorer composite outcome statuses had poorer social and behavioral role functioning and mental and physical health-related quality of life. Findings on short- and long-term composite outcome statuses revealed that only a minority of clients (30%) sustained a remitted status (i.e., abstinent or moderate drinking without problems) over the 1-year follow-up, and fully 70% of the clients had reached a nonremitted status (i.e., heavy drinking and/or problems) on the composite measure at one or more time points during the 12-month follow-up.

CONCLUSIONS

The composite outcome index could be used usefully along with singular measures of consumption to obtain a more complete picture of what has occurred among clients posttreatment. Future work will involve the testing of the composite outcome index with other client populations and/or different treatments to further our understanding of the varying response patterns found among alcohol-dependent clients.

Alcoholism treatment and medical care costs from Project MATCH

AIMS

This paper examines the costs of medical care prior to and following initiation of alcoholism treatment as part of a study of patient matching to treatment modality.

DESIGN

Longitudinal study with pre- and post-treatment initiation.

MEASUREMENTS

The total medical care costs for inpatient and outpatient treatment for patients participating over a span of 3 years post-treatment.

SETTING

Three treatment sites at two of the nine Project MATCH locations (Milwaukee, WI and Providence, RI).

PARTICIPANTS

Two hundred and seventy-nine patients.

INTERVENTION

Patients were randomly assigned to one of three treatment modalities: a 12-session cognitive behavioral therapy (CBT), a four-session motivational enhancement therapy (MET) or a 12-session Twelve-Step facilitation (TSF) treatment over 12 weeks.

FINDINGS

Total medical care costs declined from pre- to post-treatment overall and for each modality. Matching effects independent of clinical prognosis showed that MET has potential for medical-care cost-savings. However, patients with poor prognostic characteristics (alcohol dependence, psychiatric severity and/or social network support for drinking) have better cost-savings potential with CBT and/or TSF.

CONCLUSIONS

Matching variables have significant importance in increasing the potential for medical-care cost-reductions following alcoholism treatment.

Development of a composite measure for assessing alcohol treatment outcome: operationalization and validation

This article operationally describes and empirically validates a composite outcome measure developed for use in a multisite alcohol treatment matching study. Using empirically based clinical guidelines to establish alcohol consumption and alcohol-related problems criteria, 1,726 subjects were classified as abstinent, moderate drinking without problems, heavy drinking or problems, or heavy drinking and problems at intake and 3, 6, 9, 12, and 15 months postintake. Subjects with poorer composite outcome also had poorer outcomes related to quantity and frequency of alcohol consumption, alcohol-related problems, serum gamma-glutamyltranspeptidase and other nonalcohol-related measures assessing psychiatric dysfunction, psychosocial functioning, and purpose or meaning in life. Differences in the present composite measure relative to other categorical measures used in research to date and the potential for incorporating nonalcohol-specific variables into composite measures are discussed.

Actual and estimated replication costs for alcohol treatment modalities: case study from Project MATCH

OBJECTIVE

As a first step in a thorough cost-effectiveness analysis of a randomized alcohol-treatment-matching trial (Project MATCH), the present study examines the relative costs of three manual-guided, individually delivered treatments and the costs of replicating them in nonresearch settings.

METHOD

Costs of delivering a 12-session Cognitive Behavioral Therapy (CBT), a 4-session Motivational Enhancement Therapy (MET) and a 12- session Twelve-Step Facilitation (TSF) treatment over 12 weeks were assessed for three treatment sites at two of the nine Project MATCH locations (Milwaukee, WI, and Providence, RI). Research cost calculations included clinical, administrative and training/supervision variables in determining total treatment costs, average cost per contact hour and average cost per research participant. Investigators from all nine MATCH locations estimated direct clinical costs, administrative overhead costs and training/supervision costs for replicating these treatments.

RESULTS

For Project MATCH, MET cost twice as much or more per patient contact hour (mean = $498) than CBT (mean = $198) and TSF (mean = $253) but was less costly per research participant (mean = $1,700) than both CBT (mean = $1,901) and TSF (mean = $1,969). For clinical replication, high end per patient costs ranged from $512 for MET to $750 for TSF to $788 for CBT: a cost savings for MET of $238 (32%) over TSF and $276 (35%) over CBT.

CONCLUSIONS

As part of a randomized clinical trial, MATCH treatments are costly to produce. However, when estimates are used to project these costs to nonresearch clinical settings, the costs are greatly reduced. Whereas MET appears to be much less costly to deliver in nonresearch settings than the other two treatments, the estimated cost differentials are less than the 1:3 treatment session ratio for MET versus TSF or CBT.

Compliance with treatment and follow-up protocols in project MATCH: predictors and relationship to outcome

Treatment and follow-up session attendance data from Project MATCH, a multisite clinical trial investigating patient-treatment matching, were analyzed to study compliance. High rates of compliance to both therapy and research protocols were achieved, enhancing treatment integrity and data quality. Strong baseline predictors of compliance did not emerge, and the small relationships found were consistent with reports from previous studies. Attendance at therapy sessions was moderately correlated with research follow-up participation. Treatment compliance predicted drinking outcome, underscoring the importance of retaining patients in treatment. Future studies should examine the associations between compliance and structural features of the treatment environment, treatment delivery, and context-features that are often under the control of the clinician/investigator.

Network support for drinking, Alcoholics Anonymous and long-term matching effects

AIMS

(1) To examine the matching hypothesis that Twelve Step Facilitation Therapy (TSF) is more effective than Motivational Enhancement Therapy (MET) for alcohol-dependent clients with networks highly supportive of drinking 3 years following treatment; (2) to test a causal chain providing the rationale for this effect.

DESIGN

Outpatients were re-interviewed 3 years following treatment. ANCOVAs tested the matching hypothesis.

SETTING

Outpatients from five clinical research units distributed across the United States.

PARTICIPANTS

Eight hundred and six alcohol-dependent clients.

INTERVENTION

Clients were randomly assigned to one of three 12-week, manually-guided, individual treatments: TSF, MET or Cognitive Behavioral Coping Skills Therapy (CBT).

MEASUREMENTS

Network support for drinking prior to treatment, Alcoholics Anonymous (AA) involvement during and following treatment, percentage of days abstinent and drinks per drinking day during months 37-39.

FINDINGS

(1) The a priori matching hypothesis that TSF is more effective than MET for clients with networks supportive of drinking was supported at the 3 year follow-up; (2) AA involvement was a partial mediator of this effect; clients with networks supportive of drinking assigned to TSF were more likely to be involved in AA; AA involvement was associated with better 3-year drinking outcomes for such clients.

CONCLUSIONS

(1) In the long-term TSF may be the treatment of choice for alcohol-dependent clients with networks supportive of drinking; (2) involvement in AA should be given special consideration for clients with networks supportive of drinking, irrespective of the therapy they will receive.

Internal validity of Project MATCH treatments: discriminability and integrity

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.

Internal validity of Project MATCH treatments: discriminability and integrity

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.

Composite outcome measures in alcoholism treatment research: problems and potentialities

Alcoholism treatment researchers have increasingly incorporated multiple measures representing multiple dimensions in assessing treatment outcomes. However, no satisfactory model exists for examining the dynamic interrelationships of multiple measures in determining clinically meaningful and interpretable outcomes. One approach to analyzing multiple outcomes is to combine them into a composite measure. In their most elementary form, composite measures combine alcohol consumption and consumption-related problems dimensions into treatment outcome classifications. This paper discusses conceptual and methodological issues in studies reporting composite outcomes and provides a model and recommendations for using composite measures in alcohol treatment research.

Implementing treatment and protecting the validity of the independent variable in treatment matching studies

Treatment matching research is predicated on heterogeneity among subjects and their differential response to treatments. The sine qua non of a treatment matching study is the integrity of the treatment variable, since detection of client-treatment interactions requires delivery of treatments that are highly specific, consistent and distinct. Matching research thus presents particular challenges in treatment implementation, as greater heterogeneity in subjects may generate a broader array of problems than study treatments are designed to address, leading to several potential threats to treatment integrity. Moreover, as practiced outside of research settings, treatments for alcoholism are marked by ideological heterogeneity and a lack of purity across approaches. In this article we describe the strategies used in Project MATCH to protect treatment integrity while treating a large and heterogeneous sample of alcoholics in a number of geographically distant sites. These include: strategies for treating a variety of alcoholics within a single treatment approach; development of clinical care guidelines and clinical deterioration criteria; specification of treatments in manuals with minimization of overlapping active ingredients; selection criteria for therapists intended to enhance both generalizability of findings as well as treatment integrity; and extensive therapist training and monitoring.

Issues in the selection and development of therapies in alcoholism treatment matching research

There are a large number of possible approaches to the treatment of alcohol abuse and dependence. From a practical and methodological standpoint, however, only a limited number of interventions can realistically be included in research studies of treatment matching. A key question in planning studies of matching is what treatments to include. The recent book by Beutler and Clarkin on systematic treatment selection in general psychotherapy provides a framework within which to discuss alcoholism treatment matching and the criteria applied to decisions concerning (1) modes of treatment, (2) treatment format, (3) specific therapeutic strategies and the (4) treatment setting. The methodological and practical issues raised and the decisions reached in Project MATCH are presented in each of these areas. The therapies chosen for Project MATCH, based on these criteria, are described.

Issues in the development of subject recruitment strategies and eligibility criteria in multisite trials of matching

Decision-making in selecting and recruiting subjects for treatment matching research is a complex process involving conceptual, methodological and practical considerations. In selecting clients, concerns arise about whether the criteria will produce a subject population that is (1) relevant to the dimensions associated with the treatment matching, (2) representative of persons typically seen in alcohol treatment settings and, for practical purposes, (3) able or willing to comply with the requirements of the study protocol. Also, in order to fulfill sampling requirements, it may be necessary to employ a variety of creative outreach methods. However, these recruitment mechanisms can pose additional logistical and methodological problems for the research. This article focuses on various issues arising in the selection and recruitment of subjects in matching research. Project MATCH serves to highlight issues related to client eligibility and recruitment and to discuss effective strategies for resolving these matters.

Issues in the definition and measurement of drinking outcomes in alcoholism treatment research

This article reviews methodological and conceptual issues regarding the choice of drinking outcome measures in alcoholism treatment research. The following issues are discussed: Should drinking outcomes be conceptualized in terms of an underlying unitary disorder, or should provision be made for independent outcomes that cover a wide variety of dimensions? Which drinking outcomes are typically measured in treatment evaluation studies and how are they operationalized? What are the empirical associations among drinking outcome measures? If multiple outcomes are measured, which should be given primary importance? Over what period of time should treatment outcome be evaluated? What procedures can be used to detect, correct or prevent the response bias associated with verbal report methods? Because outcome measures need to fit the hypotheses and practical needs of a particular study, it is unlikely that complete standardization can be achieved across all studies. Nevertheless, given the importance of drinking outcomes and the need for economy, two primary dependent measures are recommended: (1) proportion of available drinking days abstinent; and (2) intensity of drinking, as defined by the total amount consumed (in ounces absolute alcohol) during the follow-up period divided by the number of actual drinking days. This article also proposes a strategy that may help to guide the selection of outcome measures in future research.

The comparability of solicited versus clinic subjects in alcohol treatment research

The increasing use of media advertisements to recruit subjects in alcohol treatment research has raised concerns about the comparability of such solicited subjects and subjects drawn from more traditional clinic populations. This paper, based on a study that involved both solicited and clinic subjects, identifies differences between the two types of subjects in terms of sociodemographic variables; pre-treatment drinking and marital adjustment; several dimensions of 'self-definition'; and three outcome measures. These findings suggest that there may be significant differences between solicited and clinic subjects and that these differences should be taken into account in the design of studies utilizing solicited subjects in order to determine the generalizability of the results.

Problem drinking and marital adjustment

To examine the interdependency between alcohol misuse and marital adjustment, emphasis was placed on investigating how different patterns of alcohol use vary with different levels of marital satisfaction, and how such relationships might be mediated by the sociobehavioral consequences of problem drinking within the family. It was found that the likelihood of marital disruption was greater in heavy drinking households than in nonheavy drinking households. However, differences between heavy drinking and nonheavy drinking settings with respect to the marital relationship became largely nonsignificant when the number of sociobehavioral consequences of alcohol use for the marriage was controlled. The relationship between patterns of alcohol misuse and marital adjustment seems to be complex and variable and is in need of further investigation. Findings in the present study are compared with other research on the alcoholic marriage. Recommendations are offered for future studies on this topic.

Reducing attrition from conjoint therapy with alcoholic couples

Premature termination of treatment by the client has been a pervasive problem in the alcohol treatment field. This drop-out problem is compounded in conjoint therapy for alcoholic couples since most clients typically do not view the drinking problem from a systemic, interactional perspective. Within a short-term communication-interaction based conjoint therapy program offered to couples with an alcohol problem on an outpatient basis, specific mechanisms were developed to deal with client-initiated attrition from treatment. These procedures involve the systematic involvement of the spouse in all aspects of intake, assessment and treatment; the use of role induction in a pretherapy interview; and formal contracting during the beginning phase of therapy. Preliminary results suggest that these efforts may be effective in retaining more socially stable alcoholic clients. For the more transient, less socially stable group of individuals with alcohol-related difficulties, the above mechanisms may not be sufficient to forestall unplanned terminations. It is suggested that the latter group may require help to reduce stresses related to concrete concerns prior to receiving conjoint therapy for their alcohol problem.

The efficacy of role induction in preventing early dropout from outpatient treatment of drug dependency

A study was conducted to examine the impact of various role induction modalities in dealing with the problem of early dropout among substance abusing patients. Emphasis was placed on tracing the interdependency between patient misperceptions of treatment, termed level of discrepancy in treatment expectations (Level of DTE) and continuance. Results indicated that patients who were more favorably disposed to the program (low Level of DTE) were more likely to remain in care than those who were not (high Level of DTE) only if role induction was provided; in the absence of the pretreatment intervention, differences between high and low discrepant patients were virtually nonexistent. These data suggest that the real utility of role induction lies in its ability to confirm the expectations of low discrepant patients (in contrast to improving patient knowledge of therapy) while at the same time providing them with a mechanism to learn coping skills necessary for adjusting to a new program. For those classified as high discrepant patients, role induction alone was not sufficient to prevent early termination; the majority did not stay past four sessions. Implications for this group are that greater efforts should be made in responding to their concrete problems, actively engaging "significant other(s)" or providing them with an external support system in the form of a "buddy" at the point of entry, in order to forestall premature termination.

Human antithrombin III. Carbohydrate components and associated glycolipid

Human antithrombin III was found to contain covalently linked N-acetylglucosamine, mannose, galactose, and sialic acid in a molar ratio of approximately 1:1:0.6:1. Sialic acid was released upon treatment with neuraminidase. The modified glycoprotein retained the capability to inhibit thrombin and to bind with heparin. Antithrombin III isolated by different procedures was also found to contain glucose in an approximately equimolar ratio with N-acetylglucosamine. Th" glucose-containing component was extractable with lipid solvents and shown to be beta-glucosylceramide. This glycolipid is tightly complexed with antithrombin III and could not be separated by fractional precipitations or ion exchange gels. Although it remains to be established whether the inhibitory actions of antithrombin III are affected by glucosylceramide, the relative amounts which are bound suggest that antithrombin III may be a significant carrier of the glycolipid.