A Randomized,Controlled Trial of the Efficacy of an Interoceptive Exposure-Based CBT for Treatment-Refractory Outpatients with Opioid Dependence

Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.     

Characteristics,beliefs, and practices of community clinicians trained to provide manual-guided therapy for substance abusers

The successful dissemination of empirically supported addiction therapies to community providers requires an appreciation of the characteristics of those practitioners who might be willing participants in this process of technology transfer. Clinicians (N = 66) from 11 community treatment programs associated with six research-clinic partnerships of the National Drug Abuse Clinical Trials Network volunteered to be trained in Motivational Interviewing or Motivational Enhancement Therapy (MET/MI) and were assessed prior to training. The sample of clinicians was heterogeneous in education and credentials, had a high level of counseling experience, reported using a wide range of counseling techniques and orientations, but had limited prior exposure to MET/MI or to the use of treatment manuals of empirically supported therapies. In general, many of the clinicians reported beliefs and techniques that were consistent with their stated theoretical orientation and recovery status. Relatively few participants reported relying on one dominant orientation or set of techniques.     

A survey of the use and educational value of the hospital formularly manual

The medical and nursing staffs of two affiliated hospitals were surveyed on their frequency and purpose of use of their hospital's formulary manual. A numerical rating of the perceived educational value of the manuals was also requested. Twenty-two per cent (141/650) of those surveyed completed their questionnaires. Ninety-six per cent of the respondents indicated use of the formulary manuals at least once a month; 62% used the manuals at least once a week. The frequency and character of use of various sections of the formulary manuals are presented. The perceived educational value of the manuals was rated 3 or greater on a scale of 1 (no value) to 5 (greatest value) by 80% of the respondents. The hospitals' formulary manuals are frequently referred to for various types of drug information. The professional staffs perceive the formulary manuals to be educationally valuable sources of drug information. Reasons for the low rate of response to the survey are presented. A plan of how to increase the response rate in a planned future survey is also presented.     

An alternative program for methadone maintenance dropouts: description and preliminary data

Time in drug treatment has been shown to be one of the best predictors of post-treatment success. Since as many as half of the enrollees leave methadone treatment during the first year, the project described in this article was designed to test the effectiveness of an alternative program for individuals who have recently dropped out of methadone maintenance treatment. The goals of this "Alternative Program" are to help participants re-connect with formal drug treatment and other community or medical programs, reduce their HIV risk behavior, decrease or eliminate drug use, join self-help groups, and obtain entitlements. Program components include: contacts by local outreach workers, cognitive-behavioral relapse-prevention group counseling, and individual counseling for needs assessment and referral. This paper describes the basis for development of the intervention, summarizes the methodology being used, and provides preliminary data on participation in the Alternative Program.     

Substance abuse treatment entry,retention and effectiveness: out-of-treatment opiate injection drug users

This study was designed to assess the effect of client characteristics and community interventions on treatment entry and retention, and to evaluate the relative effectiveness of treatment, compared to other interventions, in reducing drug use and crime among out-of-treatment opiate injectors. Subjects (N = 2973) from 15 cities were randomly assigned to: standard intervention (SI)-HIV testing and counseling; or enhanced intervention (EI)-SI plus additional educational sessions stressing responsible drug use. EI in some cities included staff assistance with treatment admission (i.e. ‘active’ referral). All locations provided intervention by community outreach workers. Factors positively associated with treatment entry included: prior treatment, intervention by community workers, assignment to the EI, not injecting cocaine, injecting opiates, and fewer program interventions received. Sites where the EI included active referral achieved significantly higher treatment entry rates than sites where the EI did not. Findings supported the efficacy of treatment over other interventions in reducing drug use and arrests, the addition of staff assistance to facilitate clients' entry into treatment, and the involvement of community outreach workers in achieving treatment entry.     

The Women's Recovery Group Study: a Stage I trial of women-focused group therapy for substance use disorders versus mixed-gender group drug counseling

The aim of this Stage I Behavioral Development Trial was to develop a manual-based 12-session Women's Recovery Group (WRG) and to pilot test this new treatment in a randomized controlled trial against a mixed-gender Group Drug Counseling (GDC), an effective manual-based treatment for substance use disorders. After initial manual development, two pre-pilot groups of WRG were conducted to determine feasibility and initial acceptability of the treatment among subjects and therapists. In the pilot stage, women were randomized to either WRG or GDC. No significant differences in substance use outcomes were found between WRG and GDC during the 12-week group treatment. However, during the 6-month post-treatment follow-up, WRG members demonstrated a pattern of continued reductions in substance use while GDC women did not. In addition, pilot WRG women with alcohol dependence had significantly greater reductions in average drinks/drinking day than GDC women 6 months post-treatment (p<.03, effect size=0.81). While satisfaction with both groups was high, women were significantly more satisfied with WRG than GDC (p<.009, effect size=1.11). In this study, the newly developed 12-session women-focused WRG was feasible with high satisfaction among participants. It was equally effective as mixed-gender GDC in reducing substance use during the 12-week in-treatment phase, but demonstrated significantly greater improvement in reductions in drug and alcohol use over the post-treatment follow-up phase compared with GDC. A women-focused single-gender group treatment may enhance longer-term clinical outcomes among women with substance use disorders.     

Evidence for Site-Specific,Systematic Adaptation of Substance Prevention Curriculum With High-Risk Youths in Community and Alternative School Settings

The problem of substance use among older youths is often disregarded in prevention research. The prevailing perception has been that prevention programming is developmentally inappropriate for those who are actively experimenting with substances. This project examines the differential effectiveness of youth-driven adaptations of the evidence-based prevention program, keepin' it REAL (kiR). During Phase I, high-risk youths in a variety of community settings (social, therapeutic, and academic) tailored kiR workbooks/videos to increase the relevance for their peers, older adolescents who are likely to have already initiated drug use. Phase II, discussed here in detail, evaluates the effectiveness of the adapted versions of kiR compared with the original and comparison condition using a quasi-experimental pretest-posttest design with a 6-week follow-up and focus groups. Data suggest that participants receiving the adapted version of the curriculum experienced greater improvement in acceptance and use of substances than youths in the other two groups.     

Evaluation of medication counseling practice at community pharmacies in Qassim region,Saudi Arabia

Introduction

Pharmacists have a unique opportunity to promote good health through assuring the quality use of medicines. One of the most important tools to achieve this is medication counseling. Counseling plays an important role in enhancing medication adherence and optimizing medication therapy. Therefore, for improving the quality of services delivered by community pharmacists, it is essential to assess the current situation of counseling services delivered to patients.

Interaction of Counseling Rapport and Topics Discussed in Sessions with Methadone Treatment Clients

Therapeutic rapport between counselors and clients in drug user treatment has been shown to be an important predictor of follow-up outcomes. This naturalistic study investigated the relationship of counseling rapport to drug-related topics discussed in counseling sessions in a sample of 330 clients and nine counselors. These voluntary clients had been admitted to a private, for-profit outpatient methadone treatment in Texas between September 1995 and August 1997 and received no-fee services for a year for participation in this study. The data were gathered using forms in the TCU community treatment assessments (www.ibr.tcu.edu) that measured intake information, counseling session topics, and counselor evaluation of the client. A majority were males, Hispanic, had a pending legal status and the average age was 39. Co-occurring drug dependence for these heroin users included cocaine (38%) and alcohol (31%). The results supported the hypothesis that higher rapport would be associated with addressing clients in a more “supportive approach” that emphasized relapse prevention and strengths-building while lower rapport would be associated with a punitive counseling style that stressed program rules and compliance. The influences of client background, counselor differences, and during-treatment positive urines were also examined. Although counselors differed in their general manner of dealing with clients, each also showed flexibility determined in part by client behavior (such as continued cocaine use). The findings indicate that focusing on constructive solutions is the preferred counseling approach.     

A randomized clinical trial of methadone maintenance for prisoners: Results at 12 months postrelease

This study examined the impact of prison-initiated methadone maintenance at 12 months postrelease. Males with preincarceration heroin dependence (N = 204) were randomly assigned to (a) Counseling Only: counseling in prison, with passive referral to treatment upon release; (b) Counseling + Transfer: counseling in prison with transfer to methadone maintenance treatment upon release; and (c) Counseling + Methadone: counseling and methadone maintenance in prison, continued in the community upon release. The mean number of days in community-based drug abuse treatment were, respectively, Counseling Only, 23.1; Counseling + Transfer, 91.3; and Counseling + Methadone, 166.0 (p < .01); all pairwise comparisons were statistically significant (all ps < .01). Counseling + Methadone participants were also significantly less likely than participants in each of the other two groups to be opioid-positive or cocaine-positive according to urine drug testing. These results support the effectiveness of prison-initiated methadone for males in the United States. Further study is required to confirm the findings for women.     

某院结核病患者门诊药学服务的开展及其成效分析

目的:分析结核病患者门诊药学服务(简称"药学门诊")的开展对合理用药的影响,探究结核病患者临床治疗个体化药学服务新模式。方法:通过开展结核病门诊半日制药学服务,提供患者药物咨询、健康及用药教育、药学监护等内容后;抽取2018年1月-2019年4月间门诊就诊的结核病患者940例次数据,分析其门诊药学服务的开展对合理用药的影响及其工作成效。结果:940例次患者中,其中药物咨询473例、用药教育253例和药学监护214例,有效解答了患者用药的相关问题,提高了患者用药的依从性,及时干预了用药期间产生的药物不良反应,改善了预后,提高了患者对治疗的满意度。结论:结核病门诊药学服务新模式的开展,有效提高了结核病患者用药的合理性、有效性及依从性,发挥了临床药师的专业特长。     

A novel cognitive-behavioral approach for treatment-resistant drug dependence

Despite the application of treatments that combine methadone administration, weekly counseling, and contingency reinforcement strategies, many opiate-dependent patients continue illicit drug use. In this controlled study we piloted a novel cognitive-behavioral treatment (CBT) designed to reduce illicit drug use among patients receiving methadone treatment. The treatment targeted the reduction of sensitivity to interoceptive cues associated with drug craving, and trained alternative responses to these cues. Patients (N = 23) were randomly assigned to either this novel CBT program or a program of increased counseling, such that the two programs of treatment were equated for therapist contact, assessment time, and contingency-reinforcement strategies. We found that, compared to a doubling of contact with their outpatient counselor, the new program was associated with significantly greater reductions in illicit drug use for women, but not for men. Reasons for differential performance by women and men and future directions for this new treatment are discussed.     

A stepped care approach for reducing cannabis use in opioid-dependent outpatients

This study evaluated rates of cannabis use and the effectiveness of an adaptive stepped care intervention for reducing cannabis use in methadone maintenance patients. Patients testing cannabis positive during a 6-month baseline were advanced to more weekly counseling (up to 9 hours per week) until producing four consecutive weeks of cannabis- and other drug-negative urine samples. Patients were followed up for 1 year. Continued access to uninterrupted methadone delivery was ultimately contingent upon attending scheduled counseling and achieving abstinence from all drug use. The results showed that 18% of the clinic census (n = 57) tested positive for cannabis. The effectiveness of the intervention was assessed for 15 patients testing positive for cannabis exclusively. Ten of these patients (67%) discontinued cannabis use prior to the intervention and remained at reduced care. Four of the five patients who were advanced to higher steps of care ultimately discontinued cannabis use; one left treatment against medical advice. The results suggest that motivated stepped care is an effective intervention for reducing cannabis use.     

社区海洛因依赖者美沙酮维持治疗的效果评估

目的:探讨美沙酮维持治疗在中国实施的可行性和有效性。方法:对海洛因依赖者开展美沙酮维持治疗试验性项目并定期开展小组心理干预、个别心理咨询和相关的支持活动。项目实施1a后,采用自制问卷对美沙酮维持治疗前后的效果进行评估,并将结果与37名社区海洛因依赖者进行比较。结果:美沙酮维持治疗后,维持者自我报告使用海洛因的比例由治疗前的100·0%下降为64·4%,其中,每天使用3次以上海洛因者由维持治疗前的50·0%降为0;对照组为43·2%。维持者的总违法犯罪率与维持治疗前和对照组比较,分别下降了4·6%和15·3%。维持者以注射方式吸毒的比例显著低于项目开展前和对照组(P<0·01),而从不使用安全套的比例明显少于项目前和对照组(P<0·01)。结论:在我国的海洛因依赖者中开展美沙酮维持治疗对于减少非法毒品的使用,降低违法犯罪率和减少感染艾滋病的高危行为是有效的。     

Attendance, drug use patterns, and referrals made from North America's first supervised injection facility

BACKGROUND: North America's first government sanctioned supervised injection facility (SIF) was opened in Vancouver in response to the serious health and social consequences of injection drug use and the perseverance of committed advocates and drug user groups who demanded change. This analysis was conducted to describe the attendance, demographic characteristics, drug use patterns, and referrals made during the first 18 months of operation. METHODS: As part of the evaluation strategy for the SIF, information is collected through a comprehensive on-site database designed to track attendance and the daily activities within the facility. All users of the SIF must sign a waiver form and are then entered into a database using a unique identifier of their choice. This identifier is used at each subsequent visit to provide a prospective record of attendance, drug use, and interventions. RESULTS: From 10 March 2004 to 30 April 2005 inclusive, there were 4764 unique individuals who registered at the SIF. The facility successfully attracted a range of community injection drug users including women (23%) and members of the Aboriginal community (18%). Although heroin was used in 46% of all injections, cocaine was injected 37% of the time. There were 273 witnessed overdoses with no fatalities. During just 12 months of observation, 2171 individual referrals were made with the majority (37%) being referred for addiction counseling. INTERPRETATION: Vancouver's SIF has successfully been integrated into the community, has attracted a wide cross section of community injection drug users, has intervened in overdoses, and initiated over 2000 referrals to counseling and other support services. These findings should be useful for other settings considering SIF trials.     

A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release

BACKGROUND: Despite its effectiveness, methadone maintenance is rarely provided in American correctional facilities. This study is the first randomized clinical trial in the US to examine the effectiveness of methadone maintenance treatment provided to prisoners with pre-incarceration heroin addiction. METHODS: A three-group randomized controlled trial was conducted between September 2003 and June 2005. Two hundred eleven Baltimore pre-release inmates who were heroin dependent during the year prior to incarceration were enrolled in this study. Participants were randomly assigned to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n=70); counseling+transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n=70); and counseling+methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n=71). RESULTS: Two hundred participants were located for follow-up interviews and included in the current analysis. The percentages of participants in each condition that entered community-based treatment were, respectively, counseling only 7.8%, counseling+transfer 50.0%, and counseling+methadone 68.6%, p<.05. All pairwise comparisons were statistically significant (all ps<.05). The percentage of participants in each condition that tested positive for opioids at 1-month post-release were, respectively, counseling only 62.9%, counseling+transfer 41.0%, and counseling+methadone 27.6%, p<.05, with the counseling only group significantly more likely to test positive than the counseling+methadone group. CONCLUSIONS: Methadone maintenance initiated prior to or immediately after release from prison appears to have beneficial short-term impact on community treatment entry and heroin use. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.     

Node-link mapping and psychological problems. Perceptions of a residential drug abuse treatment program for probationers

The current study examined program perceptions of 367 probationers admitted to a 4-month residential drug abuse treatment facility that focuses on group counseling. Prior research has shown that many individuals within the criminal justice system have both psychological and drug abuse problems, and that they often have limited success in drug abuse treatment programs. The current study examined whether the benefits of node-link mapping, a visual representation counseling technique that is especially beneficial in group counseling environments, would extend to individuals with psychological problems. Probationers were randomly assigned to mapping-enhanced or standard counseling. Those residents who had higher levels of psychological problems (based on a global indicator of psychological problems), and who received mapping-enhanced counseling, had more favorable perceptions of their counselors and fellow community members over time than their counterparts who received standard counseling.     

我院2013年上半年药物咨询情况分析

目的：开展门诊药物咨询服务,促进患者安全、合理用药。方法：对我院2013年1—6月期间临床药师登记完整的432例门诊药物咨询信息进行统计分析。结果：门诊药物咨询人群中以儿童家长居多,其次是孕妇;咨询内容以用法用量居多,其次是注意事项与孕妇用药安全,另外一些特殊剂型使用药物的咨询逐渐增多。结论：通过开展药物咨询服务,逐步提高门诊患者用药的安全性、有效性及依从性,同时不断提高临床药师的业务水平。     

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.     

Drug abuse treatment process components that improve retention

Background: Longer retention has been the most consistent predictor of favorable drug abuse treatment outcomes, but key therapeutic and patient engagement indicators of treatment process need to be more clearly established. Methods: An integrative model representing treatment dynamics was tested for explaining long-term program retention. It was based on a multisite sample of 527 daily opioid users who remained in methadone maintenance a minimum of 3 months. All had been assigned randomly to a counseling condition at admission (i.e., cognitively enhanced or standard), and information obtained from patient files, as well as periodic assessments completed by patients and their counselors in the first 90 days after admission were the sources of predictors. Results: Counseling enhancements (using node-link mapping, a visual representation tool for improving communication and problem solving) contributed to stronger therapeutic relationships between counselor and patient, which in turn had a positive reciprocal relationship with patient engagement (session attendance). Pretreatment motivation measured at intake was also related to higher engagement. More positive therapeutic relationships (in months 1 and 2) led to lower levels of during-treatment drug use (defined from urinalysis results in months 2 and 3), and better session attendance and therapeutic relationships both predicted longer retention. In addition, lower drug use during treatment was related to longer retention. Conclusions: Major conceptual domains of drug abuse treatment process were identified in community-based programs and their interrelationships with retention specified. As intermediate (during treatment) criteria, they can help guide functional improvements in program effectiveness as illustrated with our counseling enhancements.