Search the Library

Abstract: This poster reports on an initiative to implement HIV rapid testing in substance abuse treatment programs in the state of South Carolina. A multi-agency collaboration between the Single State Authority, the state Health Department, the regional Addiction Technology Transfer Center (ATTC), and one substance abuse treatment program (Lexington-Richland Alcohol and Drug Abuse Council (LRADAC)), facilitated state-wide implementation. LRADAC, a community-based treatment program, was one of twelve sites that participated in the CTN trial on HIV rapid testing (protocol CTN-0032). Upon completion of the trial, LRADAC implemented a rapid HIV testing and counseling program as a clinical service. South Carolina’s previous efforts to implement on-site rapid HIV testing in 10 pilot agencies had less than optimal success due to the absence of a successful model on which agencies could base their implementation plan. With support from the collaborating agencies, staff developed and presented a 2 1/2 day HIV testing and counseling curriculum at the annual SC School of Alcohol and Drug Studies in 2010. Following the successful completion of the course, participants were fully certified to conduct testing and counseling in their local programs. Course participants had the opportunity to learn the counseling and testing procedures that LRADAC staff found successful in implementing their program. Although challenging, implementing HIV testing program in substance abuse treatment programs is feasible for agencies. The multi-agency collaboration in South Carolina supported the development of an HIV testing and counseling course that was team taught and showcased a successful model on which implementation could be based. Consequently, this effort increased the likelihood that additional substance abuse agencies within the state would move forward with implementation. Related protocols: CTN-0032

Abstract:

There is an urgent need within the substance-use-disorders (SUD) treatment field to develop and implement consensus-based common core data elements (CDEs) with standardized vocabularies relevant to drug addiction treatment that could be incorporated and widely adopted into harmonized electronic medical record systems (EMRs). This will benefit patients by improving the quality of care and will assist in integration of specialty addiction treatment into disciplines of mainstream medicine. To achieve these aims, the NIDA Clinical Trials Network (CTN) has collected and collated dozens of treatment-form-related information and standardized instruments to develop a treatment-relevant set of CDEs. These CDEs were refined following a consensus-based meeting of federal, state, and community-based treatment stakeholders and providers. This poster describes the collaborative “Mind Map” used for developing and implementing core questions as CDEs for EMRs on SUD in primary care and SUD specialty treatment settings. Current progress in developing EMR core questions as CDEs for use in those settings is also provided, as well as implications of this project for the future of drug abuse treatment. NIDA is especially interested in input from College on Problems of Drug Dependence (CPDD) members on data collection hierarchy and core data elements and on the overall strategy in regards to other sources of input, other stakeholders who should be consulted, and other “next steps” as this project moves forward.

Abstract:

Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however, addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model, which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting (at Willamette Family Treatment Services, part of the CTN Oregon/Hawaii Node). Other treatment programs may use the experience and lessons learned from this CTN platform study about the ATTOC organization change model to better address tobacco use in the context of drug abuse treatment.

Abstract:

The health services field is increasingly concerned about burnout and turnover among service providers. Substance abuse professionals are particularly susceptible to burnout since factors such as large caseloads, limited resources, low pay, and bureaucratic work environments contribute to burnout. In addition, substance abuse professionals work with a challenging client population of addicts and referrals from the criminal justice system which can leave them feeling frustrated, depressed, and helpless in assisting clients. Examining work environment factors that are amenable to change may make a difference in curbing burnout (and ultimately deterring turnover) among substance abuse counselors. Clinical supervision is one such factor, as it is the primary mechanism for on-the-job training and counselor development. Further, negative experiences in clinical supervision can contribute to burnout and ultimately turnover. As such, the authors propose that positive experiences with one’s clinical supervisor may reduce counselor burnout whereas negative experiences may actually exacerbate burnout. And consistent with previous research, burnout should predict counselor turnover intentions.

This poster describes the outcomes of a CTN platform study that surveyed 462 counselors employed at fifteen CTPs (community treatment programs) in the Clinical Trials Network. Two dimensions of burnout were examined: depersonalization and emotional exhaustion. The variables of role overload, job satisfaction, and pay satisfaction were used as control variables in all of the multiple regression analyses. The results indicate that both positive and negative clinical supervisory experiences are associated with turnover intentions. Likewise, counselor burnout was associated with turnover intentions. Further, both depersonalization and emotional exhaustion were partial mediators of the relationship between positive and negative clinical supervisory experiences and turnover intentions. This study indicates that high quality clinical supervision may be important in reducing burnout and subsequent counselor intentions to turnover. The practical suggestions include in-house and education-based training on effective clinical supervision and performance management systems that hold clinical supervisors accountable for their behavior toward counselors.

Abstract:

The importance of implementing evidence-based practices has taken over health care, whether in the mental health, medical, or substance use treatment realms. While well-intentioned and important, the implementation of evidence-based practices is only one aspect of quality care. In fact, there are many other elements of treatment that are at least as important as offering evidence-based practices, and this is particularly true in levels of care other than traditional outpatient. Other elements of care essential to quality treatment include: 1) Monitoring and ensuring a positive therapeutic alliance between clients and providers – Much research has documented the relationship between positive treatment outcome and a positive therapeutic alliance; 2) Monitoring and ensuring high customer satisfaction: Regardless of the specific treatment offered, it is essential to monitor and address customer satisfaction, as without this, clients will not obtain benefit from treatment; 3) Monitoring administrative discharges – In residential treatment programs, clients are often discharged for non-compliance with treatment. This needs close monitoring, as from experience, administrative discharges have more to do with staff than with clients; 4) Ensuring readily-available treatment access – When individuals are ready to enter treatment, treatment needs to be available. Treatment not being available or long waiting periods to enter treatment will result in lost opportunities; 5) Monitoring no-show rates and overall treatment retention – People have to come to treatment and be retained for treatment to be effective. Thus, a focus on this is necessary; 6) Ensuring clients – multiple treatment needs are addressed – Either in-house or through linkages, clients – other problems need to be addressed; and 7) Ongoing quality improvement – To ensure quality treatment, a culture of continuous quality improvement must be developed.

This presentation will highlight other important aspects of care that must not be forgotten while programs are focused on implementing evidence-based practices.

Abstract:

This paper reports on a cost-effectiveness study of protocol CTN-0007, designed to determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is worth the additional cost to treatment agencies. Six methadone maintenance community-based treatment programs (CTPs) in the CTN participated, with a study sample of 388 participants, 190 in the UC condition and 198 in the CM condition (which combined usual care with contingency management).

The authors found that prize-based contingency management provided better patient outcomes than usual care, but required additional costs. Compared to usual care, the incremental cost of using prize-based contingency management to lengthen the longest duration of abstinence (LDA) by one week was $141. The incremental cost to obtain an additional stimulant-negative urine sample was $70. Whether this extra expenditure is worthwhile depends upon the value placed on these outcomes. Using only the benefit of averted crime, an acceptability curve developed by the authors demonstrates a cost-effectiveness benefit of 90%. However, this estimate is quite conservative because averted crime is only one of the many potential benefits of a reduction in substance abuse. By comparing this study to a companion study, the authors also found that adding prize-based contingency management to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics. Further empirical analyses are needed to help policy makers decide whether CM is worth the extra expense; this paper helps to build an empirical basis for these important decisions.

Related protocols: CTN-0007-A-2

Abstract:

Clinical research is increasingly being conducted in community-based addiction treatment settings. Although the primary focus of such research is on the development of effective clinical interventions, less attention has been paid to the potential impact of these projects on counseling staff who are involved in their implementation. Such involvement may be perceived as stressful or rewarding, and these perceptions may be associated with counselors’ intention to remain in their jobs (“turnover intention”). Using data from 207 counselors involved in research projects conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN), this study examines the associations between counselors’ reactions to research experiences and turnover intention. Counselors’ turnover intentions were found to be associated with their perceptions about the research activities their organizations were involved in. Turnover intention was significantly greater whenever counselors perceived that their job demands had increased due to the research. However, turnover intention was significantly lower if counselors perceived that the research was resulting in improvements for their clients and organization.

These findings suggest that the impact of clinical trials on treatment organizations and staff members warrants continued study.

Abstract:

Teleconferencing Supervision is a method for training community-based substance abuse clinicians in Motivational Interviewing (MI). In this CTN platform study, 13 clinicians recruited from 3 community treatment programs in the Long Island Node of the Clinical Trials Network attended a 2-day workshop and then received live supervision via telephone during 5 counseling sessions conducted at their community treatment facilities. Clinicians were assessed for skill level at post-workshop, at post-training, and 3 months later; learning was assessed using the MI Treatment Integrity instrument. All summary scores and therapist behavior frequency counts improved by post-training or by the 3 month follow-up, although some gains were not statistically significant.

This study suggests that Teleconferencing Supervision may help facilitate the proficient use of MI community clinicians following workshop instruction. By enabling both clinicians and supervisors to participate from their respective home bases, it is hoped that the TCS model will be able to project training to a broader range of community treatment programs.

Abstract:

Although substance abuse treatment programs are an important point of contact to provide health services to diagnose, treat and prevent transmission of hepatitis B (HBV) and hepatitis C (HCV) viral infection, little is known about the availability of these services in substance abuse programs. This presentation reports on a study that evaluated the prevalence and spectrum of HBV and HCV services offered by drug treatment programs in the U.S. A questionnaire-based survey of drug treatment programs within the National Drug Abuse Treatment Clinical Trials Network was conducted as part of protocol CTN-0012 (“Characteristics of Screening, Evaluation, and Treatment of HIV/AIDS, Hepatitis C Viral Infections, and Sexually Transmitted Infections in Substance Abuse Treatment Programs”). Completed questionnaires were received from 269 (84.3%) of the 319 program administrators. Although 78.7% of programs reported that they offered ongoing hepatitis training for clinical staff, only a minority of programs offered testing for HBsAg (37.7%), HBsAb (36.7%), HBcAb (27.7%), HBV DNA (7.8%), HCV antibodies (52.9%), HCV qualitative (10.1%) or quantitative (8.9%) PCR, and HCV genotyping (11.6%). Hepatitis A and B vaccinations were offered by 68.3% of programs, either on site (19.3%) or via referral (49.1%). Programs having clear guidelines for hepatitis testing were significantly more likely to offer each of the hepatitis tests as compared with those that did not have clear guidelines. Only 28.9% of programs offered HCV treatment either on-site or via referral.

Despite the importance of substance abuse in sustaining the hepatitis epidemics in the U.S., many substance abuse treatment programs do not offer comprehensive HBV, HCV and hepatitis vaccination services. Public health interventions to improve access to hepatitis testing, treatment and prevention for substance abusers are needed.

Abstract:

This poster discusses the results of a survey done as part of protocol CTN-0012 (“Characteristics of Screening, Evaluation, and Treatment of HIV/AIDS, Hepatitis C Viral Infections, and Sexually Transmitted Infections in Substance Abuse Treatment Programs”), emphasizing the perspective of state substance abuse and health departments in relationship to the treatment programs within their jurisdiction for three infection groups: HIV/AIDS, Hepatitis C virus, and sexually transmitted infections. State substance abuse and health departments were compared regarding priorities, written guidelines and availability of funding for 8 selected services for the 3 infections (24 comparisons). In addition, clarity of guidelines and availability of funding for the 8 services, as reported by administrators and clinicians at treatment programs offering these services were compared with guidelines and funding as reported by the states. Surveys were received from 48 states and DC (96%) representing 46 substance abuse and 42 health departments. The response rate from treatment program administrators and clinicians was 269 (84%) and 1723 (78%), respectively. There was general agreement between states and the two departments within the states regarding priorities and availability of funding (19 of 24 comparisons). While most states had guidelines for infection-related services, clarity of guidelines as expressed by treatment program administrators and clinicians was less than optimal. For funding, treatment program administrators indicated less availability than the states for all 24 comparisons, 19 of which were statistically significant. While states appear generally to have their priorities, guidelines and funding in place, the mosaic that constitutes the healthcare delivery system may be too complex for the treatment programs to access most efficiently.

Abstract:

Sex risk behaviors and substance use are intertwined. Many men continue to engage in high-risk sexual behaviors even when enrolled in substance use disorder (SUD) treatment. We hypothesized that changes in sex risk behaviors would coincide with changes in drug/alcohol use severity among men in SUD treatment. During an HIV risk-reduction trial, CTN-0018, men in methadone maintenance and outpatient drug-free treatment (N=359) completed assessments at baseline and six months after. Changes in sex risk and substance use severity were assessed using the Addiction Severity Index-Lite (ASI-Lite), controlling for treatment condition.

In multinomial logistic regressions, decreased alcohol severity was significantly associated with decreases in reported sex partners, and increased alcohol severity was significantly associated with increases in reported sex partners. Increasing drug use severity was significantly associated with maintaining and initiating sex with a high-risk partner, while decreasing alcohol use severity was significantly associated with discontinuing sex under the influence. However, changes in drug/alcohol use severity were not associated with changes in unprotected sex.

Conclusions: Substance use reductions may decrease HIV risk behaviors among male substance users. Our findings highlight the importance of integrating interventions in SUD treatment settings that address the intersection of sex risk behaviors and substance use.

Related protocols: CTN-0018

Abstract:

It is reasonable to consider family discord after treatment as a potential target for a next-step intervention, since family discord is often comorbid with substance use disorders. This study evaluated family discord after completing an initial course of treatment as a predictor of substance use and retention in the community treatment program during follow-up. Patients were from two multisite randomized clinical trials implemented through the NIDA Clinical Trials Network (CTN-0004 and CTN-0005). There were 315 participants from Study 1 (12-week posttreatment follow-up) and 295 participants from Study 2 (8-week posttreatment follow-up). Negative binomial and logistic regression were used to estimate days of substance use and odds of retention in the community treatment program at follow-up, respectively, from family discord status.

Results found that participants experiencing family discord reported significantly more days of substance use during the posttreatment follow-up period than those who did not experience family discord in both Study 1 (9.12 vs. 2.89 days, p=.0001) and Study 2 (5.58 vs. 2.83 days, p=.0062). Family discord was significantly associated with lower retention in the community treatment program at follow-up in Study 1 (47.6% vs. 60.6%; p=.03), but not in Study 2 (55.3% vs. 64.9%; p=.11).

Conclusions: Family discord after an initial course of treatment might be a clinically relevant predictor of substance use. There is mixed support for a conclusion that family discord is associated with lower retention in the community treatment program at follow-up. Family discord warrants assessment after an initial course of treatment and may be a useful target for adaptive treatment intervention.

Related protocols: CTN-0004, CTN-0005

Abstract:

It is often difficult for evidence-based practices (EBPs) to find their way into addiction treatment programs. One goal of the National Institute on Drug Abuse’s Clinical Trials Network (CTN) is to disseminate these EBPs into community treatment programs. The Southwest Node of the CTN hosted a series of 13 local workshops in EBPs led by experts in the topic areas. Participants (N=327) were asked to complete an online evaluation of the training with a follow-up rate of 75.8%. Respondents reported that the trainings had been applied to their workplace. Qualitative analysis revealed themes of gratitude and a need for additional training opportunities. Participant enthusiasm for training was indicated by the willingness to travel up to a thousand miles and independently pay for travel expenses.

Conclusions: Results suggest that following a workshop training in EBPs, participants reported long-term (14 month) high satisfaction with the training and believed the trainings had been incorporated into their daily practice. Frontline providers are aware of EBPs and eager for further trainings. However, future dissemination studies in front-line settings should involve formal assessments of training needs, objective measures of skill acquisition, and inclusion of training enrichments to supplement the workshop format.

Abstract:

HIV counseling with testing has been part of HIV prevention in the U.S. since the 1980s. Despite the long-standing history of HIV testing with prevention counseling, the CDC released HIV testing recommendations for health care settings contesting benefits of prevention counseling with testing in reducing sexual risk behaviors among HIV-negatives in 2006. Efficacy of brief HIV risk-reduction counseling (RRC) in decreasing sexual risk among subgroups of substance use treatment clients was examined using multi-site, randomized controlled trial data from NIDA Clinical Trials Network protocol CTN-0032.

Interaction tests between RRC and subgroups were performed; multivariable regression evaluated the relationship between RRC (with rapid testing) and sex risk. Subgroups were defined by demographics, risk type and level, attitudes/perceptions, and behavioral history. There was an effect (p < .0028) of counseling on number of sex partners among some subgroups.

Conclusions: Results of the analyses on total number of partners suggest that brief, client-centered HIV risk-reduction counseling may be efficacious in reducing total number of sex partners among low-risk participants (e.g., those with no baseline risky sex and those already consistently using condoms) in substance use treatment. However, because the majority of subgroups investigated did not report fewer sexual risk behaviors (acts or partners), the overall findings of this study lend support to the CDC’s 2006 recommendation to provide routine HIV testing without requiring HIV risk-reduction counseling at the time of testing. Findings should be viewed with caution given the number of post hoc subgroup analyses that were performed.

Abstract:

The NIDA Clinical Trials Network trial of rapid HIV testing/counseling in 1281 patients (protocol CTN-0032) was a unique opportunity to examine relationships among substance use, depressive symptoms, and sex risk behavior. In this ancillary examination of the study data, past 6-month substance use, substance use severity, depressive symptoms, and three types of sex risk behavior (unprotected sex occasions [USOs] with primary partners, with nonprimary partners, and while high/drunk) were assessed. Zero-inflated negative binomial analyses were provided: probability and rate of sex risk behavior (in risk behavior subsample). Levels of sexual risk behavior were high, while variable across the three types of sex risk behaviors. Among the patients, 50.4% has engaged in USOs with primary partners, 42% in sex while drunk or high, and 23.8% in USOs with nonprimary partners. Similar factors were significantly associated with all three types of sex risk behaviors. For all types, problem drinking, cocaine use, and substance use severity had an exacerbating effect. Older age was associated with lower risk behavior, other relationship categories (e.g., married, separated/divorced, cohabitating) were associated with greater risk behavior than was single status. Depressive symptoms were associated with decreased likelihood of USOs with a primary partner.

Conclusions: Sexual risk behavior is common among individuals in outpatient substance abuse treatment. Results highlight the roles of problem drinking (e.g., up to three-fold) and cocaine (e.g., up to twice) in increasing sex risk behavior. They also demonstrate the utility of distinguishing between partner types and presence/absence of alcohol/drugs during sex. Findings argue for the need to integrate sex risk reduction into drug treatment, in both the assessment and counseling process. Addressing sexual risk behavior may enhance relapse prevention in this vulnerable population.

Related protocols: CTN-0032