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.     

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.     

Criminal justice referral and incentives in outpatient substance abuse treatment

A substantial number of substance abusers entering outpatient psychosocial counseling treatment are referred from the criminal justice (CJ) system. This secondary analysis of previously published findings from a large (N = 415) multi-site trial of a prize-based abstinence incentive intervention ( Petry et al., 2005) examined the influence of CJ referral on usual care outcomes and response to the incentive procedure. CJ referrals (n = 138) were more likely than those not CJ referred (n = 277) to provide stimulant negative urine samples whether missing samples were counted as positive (50 versus 41%, p = .016) or as missing (96 versus 91%, p < .001). A significant interaction term was found only for percentage of treatment completers (p = .027). However, on that retention variable, and three additional drug use measures, significant incentive effects were confined to participants who entered treatment without referral from the criminal justice system. The study suggests that abstinence incentives should be offered as a first priority to stimulant users entering treatment without criminal justice referral. However, incentives can be considered for use with CJ-referred stimulant users based on the observation that best outcomes were obtained in CJ referrals who also received the abstinence incentive program.     

Changes in personal networks of women in residential and outpatient substance abuse treatment

Changes in personal network composition, support and structure over 12 months were examined in 377 women from residential (n = 119) and intensive outpatient substance abuse treatment (n = 258) through face-to-face interviews utilizing computer based data collection. Personal networks of women who entered residential treatment had more substance users, more people with whom they had used alcohol and/or drugs, and fewer people from treatment programs or self- help groups than personal networks of women who entered intensive outpatient treatment. By 12 months post treatment intake, network composition improved for women in residential treatment; however, concrete support was still lower and substance users are still more prevalent in their networks. Network composition of women in outpatient treatment remained largely the same over time. Both groups increased cohesiveness within the network over 12 months. Targeting interventions that support positive changes in personal networks may heighten positive long term outcomes for women entering treatment.     

Attendance incentives for outpatient treatment: effects in methadone- and nonmethadone-maintained pregnant drug dependent women

The effectiveness of behavioral incentives for improving treatment participation and retention in samples of methadone-maintained (n=66) and nonmethadone-maintained (n=76) pregnant drug dependent women was examined. Subjects were randomly assigned to receive $0 (standard care) and $1, $5, or $10/day for attending at least 4 h of interdisciplinary treatment programming during the first 7 consecutive days after transfer from residential to outpatient care, with payment dispensed in the form of gift certificates. Methadone-maintained women attended nearly twice as many full treatment days as those not receiving methadone (5.2 vs 2.8 days; P<0.001) and were retained in treatment significantly longer (86.4 vs 28.9% active in treatment at 30 days). There was no main effect of incentives and no effect on attendance in methadone patients. However, nonmethadone patients offered higher magnitude incentives ($5/$10) attended 3.3 days out of 7 on average, compared to 2.3 days for those offered $0 or $1 per day (t=1.73; P<0.05). The study confirmed that methadone maintenance is a powerful therapeutic adjunct which is associated with significantly better treatment retention and participation in ancillary programming than is abstinence-based treatment. It was also found that modest financial incentives can facilitate treatment participation for abstinence-based patients. However, more potent interventions would be needed to match the effectiveness of methadone in this regard.     

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.     

The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone—experience from a medium-sized Finnish city

Providing unobserved opioid substitution treatment (OST) safely is a major challenge. This study examined whether electronic medicine dispensers (EMDs) can reduce diversion of take-home buprenorphine–naloxone (BNX) in a medium-sized Finnish city. All BNX treated OST patients in Kuopio received their take-home BNX in EMDs for 4 months. EMDs' effect on diversion was investigated using questionnaires completed by patients (n = 37) and treatment staff (n = 19), by survey at the local needle exchange service and by systematic review of drug screen data from the Kuopio University Hospital. The majority of patients (n = 21, 68%) and treatment staff (n = 11, 58%) preferred to use EMDs for the safe storage of tablets. Five patients (16%) declared that EMDs had prevented them from diverting BNX. However, EMDs had no detectable effect on the availability or origin of illegal BNX or on the hospital-treated buprenorphine-related health problems. EMDs may improve the safety of storage of take-home BNX, but their ability to prevent diversion needs further research.     

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.     

Effectiveness of prize-based contingency management in a methadone maintenance program in China

Background

Methadone maintenance treatment (MMT) has been successfully scaled up nationally in China. However, the program faces problems of poor attendance and high rates of continued drug use. We assessed whether a contingency management (CM) intervention implemented by MMT clinic staff could improve treatment attendance and drug abstinence.

Methods

Eight MMT clinics in Guangdong province were randomly selected and divided into two groups. A total of 126 participants (55 in urban clinics and 71 in rural clinics) received CM during a 12-week trial, 120 participants (83 in urban clinics and 37 in rural clinics) received usual treatment (UT). Participants in the CM group had the opportunity to draw for prizes contingent on attending treatment daily and testing negative for morphine. Clinic- and individual-level outcomes were compared between the intervention and control groups.

Results

The retention rate and negative urine testing rate were 14.2% (P = 0.010) and 10.7% (P < 0.001) higher in the CM group compared to the UT group, respectively. Compared with participants who received UT, CM participants missed on average 7.3 fewer (P = 0.008) visits and were 1.91 (95% CI: 1.53–2.39) times more likely to submit a negative urine sample. All clinic- and individual- level effects of the intervention were observed at rural clinics, but the difference in retention rate between urban CM and UT clinics was not significant.

Conclusion

Although the frequency of monitoring and value of the incentives in this study was lower than in previous studies, the CM intervention significantly improved attendance and reduced drug use in China.     

Assessment of methadone clinic staff attitudes toward hepatitis C evaluation and treatment

We used a 25-item, self-administered questionnaire to assess staff's perceived barriers and willingness to engage in onsite treatment of hepatitis C virus (HCV) at the Beth Israel Medical Center methadone maintenance treatment program (MMTP) at its Harlem sites. Of 80 participants, 50% were counselors and 24% were directly involved in referral or HCV testing. Although 92% of the MMTP staff indicated that they discuss HCV evaluation and treatment with patients at least annually, 70% believed that less than 25% of patients accept referral for HCV treatment and attend their initial appointment. Most staff (66%) supported onsite HCV evaluation and treatment, although support was higher among those with a bachelor's degree or higher (p = 0.046). Lack of infrastructure was perceived as the greatest obstacle to onsite treatment. Educational interventions and skill building for staff to confidently engage and support MMTP patients in HCV treatment may be necessary prerequisites for onsite HCV management in MMTPs.     

Alcohol and drug treatment involvement, 12-step attendance and abstinence: 9-year cross-lagged analysis of adults in an integrated health plan

This study explored causal relationships between post-treatment 12-step attendance and abstinence at multiple data waves and examined indirect paths leading from treatment initiation to abstinence 9-years later. Adults (N = 1945) seeking help for alcohol or drug use disorders from integrated healthcare organization outpatient treatment programs were followed at 1-, 5-, 7- and 9-years. Path modeling with cross-lagged partial regression coefficients was used to test causal relationships. Cross-lagged paths indicated greater 12-step attendance during years 1 and 5 and were casually related to past-30-day abstinence at years 5 and 7 respectfully, suggesting 12-step attendance leads to abstinence (but not vice versa) well into the post-treatment period. Some gender differences were found in these relationships. Three significant time-lagged, indirect paths emerged linking treatment duration to year-9 abstinence. Conclusions are discussed in the context of other studies using longitudinal designs. For outpatient clients, results reinforce the value of lengthier treatment duration and 12-step attendance in year 1.     

Effects on substance use outcomes in adolescents receiving motivational interviewing for smoking cessation during psychiatric hospitalization

The purpose of this study was to compare substance involvement among psychiatrically hospitalized adolescent smokers who had received motivational interviewing (MI) versus brief advice (BA) for smoking cessation. One hundred and ninety-one (191) adolescent smokers (62.3% female; 15.4 years of age) were randomly assigned to MI (n = 116) or BA (n = 75). All patients were assessed at baseline, immediately after hospitalization, and at 1-, 3-, 6-, 9-, and 12-month follow-ups. Rates of substance use in the MI condition during follow-up increased from a low of 8.2% (SD = 18.5) to a high of 15.4% (SD = 30.0) substance use days, whereas in BA, substance use days increased from a low of 8.4% (SD = 20.8) to a high of 21.4% (SD = 35.2). The results of this study suggest that MI, relative to BA, for smoking cessation was associated with better substance use outcomes during the first 6 months following psychiatric hospitalization among adolescents. This finding is consistent with previous studies that have shown that smoking cessation does not have a detrimental effect on substance abuse treatment outcomes among youth.     

A randomized trial of Web-based videoconferencing for substance abuse counseling

Web-based videoconferencing can improve access to substance abuse treatment by allowing patients to receive counseling services in their homes. This randomized clinical trial evaluates the feasibility and acceptability of Web-based videoconferencing in community opioid treatment program (OTP) participants. Participants that reported computer and Internet access (n = 85) were randomly assigned to receive 12 weeks of weekly individual counseling in-person or via eGetgoing, a Web-based videoconferencing platform. Fifty-nine of these participants completed the study (eGetgoing = 24; in-person = 35), with most study withdrawal occurring among eGetgoing participants. Participants exposed to the study conditions had similar rates of counseling attendance and drug-positive urinalysis results, and reported similar and strong ratings of treatment satisfaction and therapeutic alliance. These results support the feasibility and acceptability of Web-based counseling as a good method to extend access to individual substance abuse counseling when compared to in-person counseling for patients that are able to maintain a computer and Internet connection for reliable communication.     

Feasibility of audit methods to study access to substance use treatment

Audit studies represent an emerging method for examining disparities in access to care, like substance use treatment, whereby fake patients (i.e., actors) attempt to procure a service with one or more characteristics isolated across condition. This allows for manipulation of variables, like insurance status, that are normally fixed or impossible to standardize with precision when studying actual patients. This pilot study explored whether these methods were feasible for the examination of community-based substance use treatment access. Masked telephone calls (n = 48) were made to providers (k = 8) in a single city seeking an appointment. A male and female “patient” made calls in three insurance status conditions: no insurance, state-funded insurance, and private insurance. All other subject characteristics were held constant. Results showed an audit design to be a feasible method for examining disparities in access and demonstrated substantial barriers to voluntary treatment. Implications and future directions are discussed.     

Medicaid care management: Description of high-cost addictions treatment clients

High utilizers of alcohol and other drug treatment (AODTx) services are a priority for healthcare cost control. We examine characteristics of Medicaid-funded AODTx clients, comparing three groups: individuals < 90th percentile of AODTx expenditures (n = 41,054); high-cost clients in the top decile of AODTx expenditures (HC; n = 5,718); and 1760 enrollees in a chronic care management (CM) program for HC clients implemented in 22 counties in New York State. Medicaid and state AODTx registry databases were combined to draw demographic, clinical, social needs and treatment history data. HC clients accounted for 49% of AODTx costs funded by Medicaid. As expected, HC clients had significant social welfare needs, comorbid medical and psychiatric conditions, and use of inpatient services. The CM program was successful in enrolling some high-needs, high-cost clients but faced barriers to reaching the most costly and disengaged individuals.     

Cigarette smoking in opioid-dependent pregnant women: Neonatal and maternal outcomes

Background

The relationship between cigarette smoking and neonatal and maternal clinical outcomes among opioid-agonist-treated pregnant patients is sparse.

Objectives

(1) Is smoking measured at study entry related to neonatal and maternal outcomes in pregnant women receiving opioid-agonist medication? (2) Is it more informative to use a multi-item measure of smoking dependence or a single-item measure of daily smoking? (3) Is the relationship between smoking at study entry and outcomes different between methadone and buprenorphine?

Methods

Secondary analyses examined the ability of the tobacco dependence screener (TDS) and self-reported past 30-day daily average number of cigarettes smoked, both measured at study entry, to predict 12 neonatal and 9 maternal outcomes in 131 opioid-agonist-maintained pregnant participants.

Results

Past 30-day daily average number of cigarettes smoked was significantly positively associated with total amount of morphine (mg) needed to treat neonatal abstinence syndrome (NAS), Adjusted Odds Ratio (AOR) = 1.06 (95% CI: 1.02, 1.09), number of days medicated for NAS, AOR = 1.04 (95% CI: 1.01, 1.06), neonatal length of hospital stay in days, AOR = 1.03 (95% CI: 1.01, 1.05), and negatively associated with 1-AOR = .995 (95% CI: .991,.999) and 5-min Apgar scores, AOR = .996 (95% CI: .994,.998). Simple effect tests of the two significant TDS × medication condition effects found TDS was unrelated to non-normal presentation and amount of voucher money earned in the methadone [AORs = .90 (95% CI: .74, 1.08, p > .24) and 1.0 (95% CI: .97, 1.03, p > .9)] but significant in the buprenorphine condition [AORs = 1.57 (95% CI: 1.01, 2.45, p < .05) and 1.08 (95% CI: 1.04, 1.12, p < .01)].

Conclusions

Regardless of prenatal methadone or buprenorphine exposure, heavier cigarette smoking was associated with more compromised birth outcomes.     

Exploring productivity outcomes from a brief intervention for at-risk drinking in an employee assistance program

Brief intervention (BI) research has traditionally examined alcohol and drug use outcomes; however it is unknown whether BIs can also impact on-the-job productivity. This exploratory study examines changes in workplace productivity and related costs for clients receiving a BI for at-risk drinking in the employee assistance program (EAP). Participants were 44 clients attending the EAP for behavioral health concerns, screened for at-risk drinking, assigned to BI + Usual Care (n = 25) or UC alone (n = 19), and who completed 3-month follow-up. Absenteeism, presenteeism, and productivity costs were derived as outcomes. At follow-up, participants in the BI + UC group had improved productivity when at work (presenteeism) compared to the UC group. The estimated cost savings from improved productivity for the BI + UC group was $1200 per client over the UC group. Groups did not differ by absenteeism (missed days of work). Preliminary evidence suggests the broad impact BIs may have. Implications for future BI research are discussed.     

Efficacy of an emergency department-based multicomponent intervention for smokers with substance use disorders

The efficacy of brief emergency department (ED)-based interventions for smokers with concurrent alcohol or substance use is unknown. We performed a subgroup analysis of a trial enrolling adult smokers in an urban ED, focusing on subjects who screened positive for alcohol abuse or illicit drug use. Subjects receiving usual care (UC) were given a smoking cessation brochure; those receiving enhanced care (EC) got the brochure, a brief negotiated interview, 6 weeks of nicotine patches, and a telephone call. Follow-up occurred at 3 months. Of 340 subjects in the parent study, 88 (25.9%) reported a substance use disorder. At 3 months, substance users receiving EC were more likely to be tobacco-abstinent than those receiving UC (14.6% versus 0%, p = .015), and to self-identify as nonsmokers (12.5% v. 0%, p = .03). This finding suggests that concurrent alcohol or substance use should not prevent initiation of tobacco dependence treatment in the ED.     

Initiation of buprenorphine during incarceration and retention in treatment upon release

We report here on a feasibility study of initiating buprenorphine/naloxone prior to release from incarceration and linking participants to community treatment providers upon release. The study consisted of a small number of Rhode Island (RI) prisoners (N = 44) diagnosed with opioid dependence. The study design is a single arm, open-label pilot study with a 6-month follow up interview conducted in the community. However, a natural experiment arose during the study comparing pre-release initiation of buprenorphone/naloxone to initiation post-release. Time to post-release prescriber appointment (mean days) for initiation of treatment outside Rhode Island Department of Corrections (RIDOC) versus inside RIDOC was 8.8 and 3.9, respectively (p = .1). Median post release treatment duration (weeks) for outside RIDOC versus inside RIDOC was 9 and 24, respectively (p = .007). We conclude that initiating buprenorphine/naloxone prior to release from incarceration may increase engagement and retention in community-based treatment.