Drug users’ adherence to a 6-month vaccination protocol: Effects of motivational incentives

Vaccines represent a new and promising avenue of treatment for drug abuse but pose new medication adherence challenges due to prolonged and widely spaced administration schedules. This study examined effects of prize-based incentives on retention and medication adherence among 26 cocaine users involved in a 6-month hepatitis B vaccination series. Participants could meet with research staff weekly for 24 weeks and receive 7 injections containing either the Hepatitis B vaccine or a placebo. All participants received $10 at each weekly visit (maximum of $240). Those randomly assigned to the incentive program received additional monetary payments on an escalating schedule for attendance at weekly monitoring and vaccination visits with maximum possible earnings of $751. Group attendance diverged after study week 8 with attendance better sustained in the incentive than control group (group by time interaction, p = .035). Overall percent of weekly sessions attended was 82% for incentive versus 64% for control (p = .139). Receiving all scheduled injections were 77% of incentive versus 46% of control participants (p = .107). A significantly larger percentage (74% versus 51%; p = .016) of injections were received by incentive versus control participants on the originally scheduled day. Results suggest that monetary incentives can successfully motivate drug users to attend sessions regularly and to receive injected medications in a more reliable and timely manner than may be seen under usual care procedures. Thus, incentives may be useful for addressing adherence and allowing participants to reap the full benefits of newly developed medications.     

Results of a pilot randomized controlled trial of buprenorphine for opioid dependent women in the criminal justice system

Aims

Recent studies have demonstrated the efficacy of both methadone and buprenorphine when used with opioid dependent men transitioning from prison to the community, but no studies have been conducted with women in the criminal justice (CJ) system. The aim of this study was to determine the efficacy of buprenorphine for relapse prevention among opioid dependent women in the CJ system transitioning back to the community.

Methods

36 women under CJ supervision were recruited from an inpatient drug treatment facility that treats CJ individuals returning back to the community. Nine were enrolled in an open label buprenorphine arm then 27 were randomized to buprenorphine (n = 15) or placebo (n = 12; double-blind). All women completed baseline measures and started study medication prior to release. Participants were followed weekly, provided urine drug screens (UDS), received study medication for 12 weeks, and returned for a 3-month follow-up. Intent-to-treat analyses were performed for all time points through 3 month follow-up.

Results

The majority of participants were Caucasian (88.9%), young (M ± SD = 31.8 ± 8.4 years), divorced/separated (59.2%) women with at least a high school/GED education (M ± SD = 12 ± 1.7 years). GEE analyses showed that buprenorphine was efficacious in maintaining abstinence across time compared to placebo. At end of treatment, 92% of placebo and 33% of active medication participants were positive for opiates on urine drug screen (Chi-Square = 10.9, df = 1; p < 0.001). However, by the three month follow-up point, no differences were found between the two groups, with 83% of participants at follow-up positive for opiates.

Conclusions

Women in the CJ system who received buprenorphine prior to release from a treatment facility had fewer opiate positive UDS through the 12 weeks of treatment compared to women receiving placebo. Initiating buprenorphine in a controlled environment prior to release appears to be a viable strategy to reduce opiate use when transitioning back to the community.     

Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care

This study examined the relationship between substance treatment referrals and depression improvement among 2,373 participants with concurrent substance use and depressive disorders enrolled in an integrated behavioral health program. Three groups of substance treatment referral status were identified: accessed treatment (n = 780), declined treatment (n = 315), and no referral for treatment (n = 1278). The primary outcome is improvement in depressive symptoms (PHQ-9 < 10 or ≥ 50% reduction). Using propensity score adjustments, patients accessing substance treatment were significantly more likely to achieve depression improvement than those who declined receiving treatment services (hazard ratio (HR) = 1.82, 95% confidence interval (CI): 1.50–2.20, p < 0.001) and those without a referral for treatment (HR = 1.13, 95% CI: 1.03–1.25, p = 0.014). Each 1 week delay in initiating a referral was associated with a decreased likelihood of depression improvement (HR = 0.97, 95% CI: 0.96–0.98, p < 0.001). Study findings highlight the need of enhancing early treatment contact for co-occurring substance use disorders in primary care.     

Longitudinal study of cognition among adolescent marijuana users over three weeks of abstinence

Background

Cognitive deficits that persist up to a month have been detected among adult marijuana users, but decrements and their pattern of recovery are less known in adolescent users. Previously, we reported cognitive deficits among adolescent marijuana users after one month of abstinence (Medina, Hanson, Schweinsburg, Cohen-Zion, Nagel, & Tapert, 2007). In this longitudinal study, we characterized neurocognitive changes among marijuana-using adolescents across the first three weeks of abstinence.

Method

Participants were adolescent marijuana users with limited alcohol and other drug use (n = 19) and demographically similar non-using controls (n = 21) ages 15–19. Participants completed a brief neuropsychological battery on three occasions, after 3 days, 2 weeks, and 3 weeks of stopping substance use. Abstinence was ascertained by decreasing tetrahydrocannabinol metabolite values on serial urine drug screens. Verbal learning, verbal working memory, attention and vigilance, and time estimation were evaluated.

Results

Marijuana users demonstrated poorer verbal learning (p < .01), verbal working memory (p < .05), and attention accuracy (p < .01) compared to controls. Improvements in users were seen on word list learning after 2 weeks of abstinence and on verbal working memory after 3 weeks. While attention processing speed was similar between groups, attention accuracy remained deficient in users throughout the 3-week abstinence period.

Conclusions

This preliminary study detected poorer verbal learning and verbal working memory among adolescent marijuana users that improved during three weeks of abstinence, while attention deficits persisted. These results implicate possible hippocampal, subcortical, and prefrontal cortex abnormalities.     

Small financial incentives increase smoking cessation in homeless smokers: A pilot study

Although over 70% of homeless individuals smoke, few studies have examined the effectiveness of smoking cessation interventions in this vulnerable population. The purpose of this pilot study was to compare the effectiveness of shelter-based smoking cessation clinic usual care (UC) to an adjunctive contingency management (CM) treatment that offered UC plus small financial incentives for smoking abstinence. Sixty-eight homeless individuals in Dallas, Texas (recruited in 2012) were assigned to UC (n = 58) or UC plus financial incentives (CM; n = 10) groups and were followed for 5 consecutive weeks (1 week pre-quit through 4 weeks post-quit). A generalized linear mixed model regression analysis was conducted to compare biochemically-verified abstinence rates between groups. An additional model examined the interaction between time and treatment group. The participants were primarily male (61.8%) and African American (58.8%), and were 49 years of age on average. There was a significant effect of treatment group on abstinence overall, and effects varied over time. Follow-up logistic regression analyses indicated that CM participants were significantly more likely than UC participants to be abstinent on the quit date (50% vs. 19% abstinent) and at 4 weeks post-quit (30% vs. 1.7% abstinent). Offering small financial incentives for smoking abstinence may be an effective way to facilitate smoking cessation in homeless individuals.     

Randomized clinical trial examining duration of voucher-based reinforcement therapy for cocaine abstinence

Background

This is the first study to systematically manipulate duration of voucher-based reinforcement therapy (VBRT) to see if extending the duration increases abstinence during and following VBRT.

Methods

We randomized cocaine-dependent methadone-maintained adults to Standard (12 weeks; n = 62) or Extended (36 weeks; n = 68) VBRT and provided escalating voucher amounts contingent upon urinalysis verification of cocaine abstinence. Urinalysis was scheduled at least every 2 weeks during the 48-week study and more frequently during VBRT (3/week) and 12 weeks of Aftercare (2/week).

Results

Extended VBRT produced longer durations of continuous cocaine abstinence during weeks 1–24 (5.7 vs 2.7 weeks; p = 0.003) and proportionally more abstinence during weeks 24–36 (X² = 4.57, p = .03, OR = 2.18) compared to Standard VBRT. Duration of VBRT did not directly predict after-VBRT abstinence; but longer continuous abstinence during VBRT predicted abstinence during Aftercare (p = 0.001) and during the last 12 weeks of the study (p < 0.001). Extended VBRT averaged higher monthly voucher costs compared to Standard VBRT ($96 vs $43, p < .001); however, the average cost per week of abstinence attained was higher in the Standard group ($8.06 vs $5.88, p < .001). Participants in the Extended group with voucher costs exceeding $25 monthly averaged 20 weeks of continuous abstinence.

Conclusions

Greater abstinence occurred during Extended VBRT, but providing a longer duration was not by itself sufficient to maintain abstinence after VBRT. However, if abstinence can be captured and sustained during VBRT, then providing longer durations may help increase the continuous abstinence that predicts better long-term outcomes.     

Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment

This study is the first experimental trial to evaluate the effectiveness of a Web-based behavioral intervention when deployed in a model where it partially substituted for standard counseling in a community-based specialty addiction treatment program. New opioid-dependent intakes in methadone maintenance treatment (n = 160) were randomly assigned for 12 months to either: (1) standard treatment or (2) reduced standard treatment plus a Web-based psychosocial intervention, the Therapeutic Education System (TES). Results demonstrated that replacing a portion of standard treatment with TES resulted in significantly greater rates of objectively measured opioid abstinence (48% vs. 37% abstinence across all study weeks; F(1, 158) = 5.90, p < .05 and 59% vs. 43% abstinence on weeks participants provided urine samples for testing; F(1, 158) = 8.81, p < .01). This result was robust and was evident despite how opioid abstinence was operationally defined and evaluated. The potential implications for service delivery models within substance abuse treatment programs and other healthcare entities are discussed.     

Possible barriers to enrollment in substance abuse treatment among a diverse sample of Asian Americans and Pacific Islanders: Opinions of treatment clients

This mixed methods study examined motivations and barriers to substance abuse treatment entry and treatment continuation among Asian American and Pacific Islander (AAPI) substance users. AAPI substance users (N = 61) were recruited from substance abuse treatment programs in California and Hawaii. Semi-structured interviews and interviewer-administered surveys assessed barriers and facilitators to entering substance abuse treatment. Barriers included peer pressure, family influences, and face loss concerns. Facilitators included peer support, involvement in the criminal justice system, a perceived need for treatment, and culturally competent substance abuse treatment services. Family and peer influences may act as both facilitators and impediments. AAPI substance using populations face many of the same individual-level and structural and systems barriers to entry to treatment as other substance using populations. However, similar to other racial/ethnic minority groups, it is important to address cultural differences and develop culturally competent substance abuse treatments for the AAPI population.     

Rewarding early abstinence in Veterans Health Administration addiction clinics

This study investigates the addition of a contingency management (CM) intervention to Veterans Health Administration substance use disorders treatment on during- and post-treatment outcomes for Veterans diagnosed with alcohol dependence only (n = 191) or stimulant dependence (n = 139). Participants were randomly assigned to 8 weeks of usual care or usual care plus CM. Follow-up assessments occurred at 2, 6 and 12 months. In the alcohol dependent subgroup, CM participants submitted significantly more negative samples (13 versus 11 samples, Cohen's d = 0.54), were retained significantly longer (7 versus 6 weeks, d = 0.47), achieved significantly longer median durations of abstinence (16 versus 9 consecutive visits; median difference = 7, 95% CI = 4–8), and submitted significantly more negative samples at follow-ups (unstandardized effect size = 0.669, se = 0.2483) compared to usual care participants. Intervention effects were non-significant for the stimulant dependent subgroup. The study provides support for the effectiveness of CM interventions for alcohol dependent patients.     

Client incentives versus contracting and staff incentives: How care continuity interventions in substance abuse treatment can improve residential to outpatient transition

Interventions for improving transition from short-term residential to outpatient treatment were examined. Usual care (UC; n = 114) was referral to a preferred outpatient program with advance appointment optional. Client incentive (CI; n = 97) offered up to $100 in gift cards for intake and attendance during the first 30 days of treatment. Contracting with staff incentives (CSI; n = 49) consisted of meeting with an outpatient counselor prior to residential discharge, signing an attendance contract, receiving an appointment and payment to staff if clients attended. CSI significantly improved rates of successful transition (84%) and admission (74%) compared to UC (64% contact; 49% admitted). CI did not result in significantly improved outcomes (74%; 60%). CSI was likely mediated by the reliability (92 versus 52% in UC) and immediacy (1.0 versus 3.9 days) of appointment scheduling. This study supports use of CSI for improving rates of transition between residential and outpatient continuing care treatment.     

Motivational incentives research in the National Drug Abuse Treatment Clinical Trials Network

The purpose of this article is to review both main findings and secondary analyses from studies of abstinence incentives conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN). Previous research has supported the efficacy of tangible incentives provided contingent on evidence of recent drug abstinence. CTN conducted the first multisite effectiveness trial of this novel intervention. Study participants were stimulant abusers (N = 803) participating in treatment at 14 clinical sites and randomly assigned to treatment as usual with or without a prize draw incentive program. Study participants could earn up to $400 over 3 months for submission of drug-free urine and breath (BAL) specimens. Three-month retention was significantly improved by incentives offered to psychosocial counseling clients (50% incentive vs. 35% control retained), whereas ongoing stimulant drug use was significantly reduced in methadone maintenance clients (54.4% incentive vs. 38.7% control samples testing stimulant-negative). In both settings, duration of continuous abstinence achieved was improved in the incentive condition. These studies support effectiveness of one abstinence incentive intervention and highlight the different outcomes that can be expected with application in methadone maintenance versus psychosocial counseling treatment settings. Secondary analyses have shown the importance of early treatment positive versus negative urine screens in moderating the outcome of abstinence incentives and have explored both safety and cost-effectiveness of the intervention. Implications for the use of motivational incentive methods in clinical practice are discussed.     

Examining maternal weight gain during contingency-management treatment for smoking cessation among pregnant women

Excessive maternal weight gain during pregnancy can result in serious adverse maternal and neonatal health consequences making it an important outcome to monitor in developing smoking-cessation interventions for pregnant women. Maternal weight gain was investigated in the present study with 154 pregnant participants in controlled trials investigating the efficacy of contingency management (CM) for smoking cessation. Women were assigned to either an abstinence-contingent condition wherein they earned vouchers exchangeable for retail items by abstaining from smoking or to a control condition where they received comparable vouchers independent of smoking status. Mean percent of negative smoking-status tests throughout antepartum was greater in the incentive than control condition (45.2 ± 4.6 vs. 15.5 ± 2.4, p < .001) as was late-pregnancy point-prevalence abstinence (36% vs. 8%, p < .001) but maternal weight gain did not differ significantly between treatment conditions (15.0 ± 0.8 kg vs. 15.0 ± 0.9 kg, p = .97). In a comparison of women classified by smoking status rather than treatment condition, a greater percent of negative smoking-status tests predicted significantly more weight gain (0.34 kg per 10% increase in negative tests), an effect that appeared to be attributable to women with greater abstinence having larger infants. This study shows no evidence of excessive maternal weight gain among pregnant women receiving a CM intervention for smoking cessation.     

Sex differences in sleep and sleep-dependent learning in abstinent cocaine users

Sleep and sleep-dependent learning are impaired in male cocaine users during abstinence, but for female users little is known. Cocaine dependent men (n = 12) and women (n = 14), and control participants (n = 19) participated in this study of sleep and sleep-dependent learning. Cocaine users were assessed at 3, 10 and 20 days of abstinence and controls were studied over one night. Total sleep time, sleep efficiency and overnight motor learning were the main outcome measures. Cocaine dependent men compared to women exhibited deteriorations in sleep time, sleep efficiency, and overnight learning as abstinence progressed from 3 to 20 days. At abstinence day 3, cocaine dependent men and women were no different than control participants in the main outcomes. However, there were significant differences between cocaine men at abstinence day 20 and controls in sleep time and sleep-dependent learning, but no differences between controls and cocaine dependent women. There is growing evidence that sleep disturbances are associated with cocaine abuse and abstinence and have functional consequences that may be relevant to the development of effective treatments. The absence of sleep disturbances in women suggests a need to understand the mechanisms underlying these differences, as such knowledge could lead to novel therapies in cocaine dependence.     

Associations between polysubstance use and psychiatric problems in a criminal justice population in Sweden

Background

Polysubstance use is common in substance users, and may complicate their clinical course. This study, in a criminal justice setting in Sweden, examines the association between the number of concurrently used substance types and psychiatric symptoms during 30 days before incarceration, while controlling for background variables such as family history (drug and alcohol problems, psychiatric problems, criminality), demographic data and history of emotional, physical or sexual abuse.

Methods

The data material comprised 5659 criminal justice clients reporting a substance use problem, examined with the Addiction Severity Index. Variables were compared in a multinomial regression analysis, comparing clients reporting one (n = 1877), two (n = 1408), three (n = 956), four (n = 443) and five or more (n = 167) substance types.

Results

The 30-day prevalence of most psychiatric symptoms included in the study (depression, anxiety, cognitive problems, hallucinations, difficulty controlling violent behaviour, suicidal ideation, suicide attempts) was higher in individuals with a higher number of concurrent substance types used. In multinomial regression analysis, while controlling for background variables, these associations remained for concurrent suicidal ideation, cognitive problems, hallucinations and violent behaviour, with the latter two being associated with the higher numbers of substance types. Binge alcohol drinking, tranquilizers, opioids and the number of substance types reported were associated with several of the psychiatric symptoms.

Conclusions

In the present criminal justice setting in Sweden, the use of multiple substance types and concurrent psychiatric symptoms appear to be associated, and a sub-group reporting particularly high numbers of concurrent substance types are particularly likely to report potentially severe psychiatric problems.     

Feasibility and impact of brief interventions for frequent cannabis users in Canada

Cannabis use is prevalent among young people, and frequent users are at an elevated risk for health problems. Availability and effectiveness of conventional treatment are limited, and brief interventions (BIs) may present viable alternatives. One hundred thirty-four young high-frequency cannabis users from among university students were randomized to either an oral (C-O; n = 25) or a written experimental cannabis BI (C-W; n = 47) intervention group, or to either an oral (H-O; n = 25) or written health BI (H-W; n = 37) control group. Three-month follow-up assessments based on repeated measures analysis of variance techniques found a decrease in the mean number of cannabis use days in the total sample (p = 0.024), reduced deep inhalation/breathholding use in the C-O group (p = 0.003), reduced driving after cannabis use in the C-W group (p = 0.02), and a significant reduction in deep inhalation/breathholding in the C-O group (p = 0.011) compared with controls. Feasibility and short-term impact of the BIs were demonstrated, yet more research is needed.     

Comparative effectiveness of the nicotine lozenge and tobacco-free snuff for smokeless tobacco reduction

Long-term smokeless tobacco (ST) use is associated with cardiovascular disease and cancer, but not all ST users want to quit. Previous studies have evaluated the effectiveness of nicotine lozenges and tobacco-free snuff for reducing ST use among ST users not ready to quit, but no comparative effectiveness trials of these two products have been conducted. We conducted a multicenter, randomized clinical pilot study evaluating the comparative effectiveness of the 4-mg nicotine lozenge and tobacco-free snuff for reducing ST use and increasing tobacco abstinence among ST users with no intention of quitting in the next 30 days. Participants received 8 weeks of treatment and behavioral counseling on tobacco reduction strategies with follow-up to 26 weeks. We randomized 81 participants (40 nicotine lozenges, 41 tobacco-free snuff). No significant differences in reduction were observed between the two groups at weeks 8, 12, and 26. No significant differences were observed between groups in nicotine withdrawal or tobacco craving. However, both groups significantly reduced (p < .001) ST use in cans/week and dips/day from baseline which was sustained through the end-of-study. The observed biochemically-confirmed abstinence rates at week 26 were similar between groups (12% vs. 12%, one-tailed p = .615). The 4-mg nicotine lozenge and the tobacco-free snuff both appear to be effective and comparable for reducing ST use among ST users not ready to quit in the next 30 days.     

Racial and Ethnic Differences in Reported Criminal Justice Referral at Treatment Admission

Abstract

In the U.S. and elsewhere, the criminal justice system is a frequent referral source for substance abuse treatment admission. To expand and improve pathways to treatment, outreach efforts need additional information about different demographic groups. Locally, clinicians observed racial and ethnic differences between minority groups in self-identifying criminal justice as the referral sources for admission. To test this clinical observation, reported criminal justice referral was examined by race/ethnicity and gender in multiple years of both national and local treatment admissions. Confirming the clinical observations, racial/ethnic referral source by gender systematically differed across years nationally (p < .001) and in an examination of verbatim recorded presenting problems locally (p < .001). African Americans and Puerto Ricans were less likely to have criminal justice referral sources than the White reference group, whereas American Indians, Arab Americans, Asian Americans, and other Hispanic ethnicities were more likely to have criminal justice referral sources. Racial/ethnic groups systematically differed in reported criminal justice involvement, suggesting hypotheses potentially impacting clinical treatment and outreach. Published primary referral sources may underestimate criminal justice involvement in treatment admissions.     

Mindfulness-based relapse prevention with racial and ethnic minority women

Racial and ethnic disparities in the treatment of addiction have been acknowledged for several years, yet little is known about which empirically supported treatments for substance use disorders are more or less effective in treating racial and ethnic minority clients. The current study was a secondary analysis of a randomized clinical trial of two evidence-based treatments, mindfulness-based relapse prevention (MBRP) and relapse prevention (RP), as part of a residential addiction treatment program for women referred by the criminal justice system (n = 70). At 15-week follow-up, regression analyses found that racial and ethnic minority women in MBRP, compared to non-Hispanic and racial and ethnic minority women in RP, reported significantly fewer drug use days (d = .31) and lower addiction severity (d = .65), based on the Addiction Severity Index. Although the small sample size is a limitation, the results suggest that MBRP may be more efficacious than traditional treatments for racial and ethnic minority women.     

Brief versus extended counseling along with buprenorphine/naloxone for HIV-infected opioid dependent patients

Untreated opioid dependence adversely affects HIV outcomes. Integrating buprenorphine/naloxone into HIV treatment settings is feasible; however, the optimal level of counseling has not been established. We conducted a 12-week randomized clinical trial of physician management (PM) versus PM plus enhanced medical management (EMM) in 47 subjects. At 12 weeks, there were no differences between the two groups in percentage of opioid negative urines (63.6% PM vs. 69.0% PM + EMM, p = .5), maximum duration of continuous abstinence (4.9 weeks PM vs. 5.2 weeks PM + EMM, p = .8) or retention (80% PM vs. 59% PM + EMM, p = .1). The percentage of subjects with detectable HIV viral loads decreased from 58% at baseline to 40% at 12 weeks across both groups (p = .02 for time) with no between group differences (p = .84 and p = .27 for the interaction). Providing more extensive counseling beyond PM is feasible in an HIV clinic, but we are unable to detect an improvement in outcomes associated with these services.     

Psychiatric distress,risk behavior,and treatment enrollment among syringe exchange participants

The present study evaluated psychiatric distress as a predictor of treatment enrollment in out-of-treatment injection opioid users newly registered at the Baltimore Needle Exchange Program (BNEP). Study participants (n = 281) completed the Addiction Severity Index (ASI), the Risk Assessment Battery (RAB), and the Symptom Checklist-90 (SCL-90-R), and were randomly assigned to one of three different conditions for 4 months that evaluated referral strategies designed to promote treatment interest and enrollment. The Global Severity Index (GSI) of the SCL-90 was used as a measure of psychiatric distress. A logistic regression showed that higher GSI scores predicted more treatment enrollment (Adjusted OR = 2.15, CI = 1.10–4.23, p < 0.05), after controlling for study condition, demographic variables, syringe exchange site, and severity of drug use. The results suggest that the data from the assessment of psychiatric distress in syringe exchange settings can be used to support motivational strategies for encouraging syringe exchangers to seek substance abuse treatment.