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Abstract: Background: American Indian and Alaska Native (AI/AN) communities experienced a disproportionate increase in opioid-related fatal and non-fatal poisonings during the COVID-19 pandemic. Access to treatment, such as medications for opioid use disorder (MOUD), became even more critical, although research among this population is limited. We completed qualitative interviews with substance use disorder (SUD) treatment providers (i.e., MOUD prescribers, non-prescribing clinicians, non-clinical support staff) to assess the impact of COVID-19 on MOUD care among AI/AN adults. Methods: This research was completed in connection with two CTN studies: CTN-0096 and CTN-0118. Sixty-minute semi-structured interviews were completed with providers working in SUD treatment (N = 25). Eligible providers represented 6 programs serving rural Tribal and urban areas primarily in the Pacific Northwest United States. Transcripts were independently reviewed and analyzed for themes based upon the research aims. Results: Nineteen female and six male providers completed interviews. Four themes were identified: (1) Beneficial policy changes for MOUD delivery; (2) Telehealth as the biggest policy shift; (3) Addressing complexity, and (4) Cultural services. Findings indicated providers viewed the introduction of telehealth, implementation of mobile services, and expanded take home dosing as positive and leading to increased treatment access. However, barriers related to the internet, transportation, and reimbursement of telehealth remain. Conclusions: Providers highlighted the utility in the expansion and sustainment of telehealth. Flexible policies for MOUD were particularly beneficial during the height of COVID-19 to maintain and increase access to treatment. Providing a menu of treatment options, emphasizing cultural engagement and social support were deemed necessary to enhance AI/AN community driven solutions in curbing the opioid poisoning public health crisis. Related protocols: CTN-0096, CTN-0118

Abstract:

Background: Incorporating American Indian and Alaska Native (AI/AN) traditional practices and knowledge into healthcare can support AI/AN health. Drug overdose deaths disproportionately impact AI/AN communities due to colonization, genocide, historical trauma, discriminatory policies, and under-resourced healthcare. Medications for opioid use disorder (MOUD; e.g., buprenorphine, methadone, naltrexone) are considered the most effective treatment for reducing mortality. Integrating AI/AN cultural practices with MOUD may increase acceptability and uptake of MOUD within AI/AN communities.

Methods: National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) Protocol #0096 (Tribal MOUD) is a two-phase community-based participatory research (CBPR) trial to develop and evaluate an implementation intervention to culturally center MOUD delivery in AI/AN communities (N = 4 sites). A Collaborative Board (CB) guided intervention development (Phase I completed). A stepped wedge design (two sites/step) allows intervention implementation at all sites and improvements across sites (Phase II ongoing). The primary implementation outcome is the number of consumers with OUD who initiate MOUD in the six months pre-intervention vs. implementation periods; secondary outcomes are MOUD screening and retention (de-identified electronic medical record data). Additional data include organizational predictors (staff surveys) and moderators (consumer assessments) of implementation outcomes; and MOUD intervention acceptability (staff/consumer qualitative interviews).

Conclusions: This is the first study to develop and evaluate an implementation intervention to culturally center MOUD delivery in AI/AN communities. Implementation science and CBPR are complimentary for co-developing strategies with AI/AN communities to integrate Indigenous and Western best practices, which may ultimately reduce opioid-related mortality among AI/AN peoples and enhance Indigenous community wellness.

Related protocols: CTN-0096

Abstract:

American Indian and Alaska Native (AI/AN) populations are disproportionately affected by substance use disorders (SUDs) and related health disparities in contrast to other ethnoracial groups in the United States. Over the past 20 years, substantial resources have been allocated to NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) to disseminate and implement effective SUD treatments in communities. However, we know little about how these resources have benefitted AI/AN peoples with SUD who arguably experience the greatest burden of SUDs. This review aims to determine lessons learned about AI/AN substance use and treatment outcomes in the CTN and the role of racism and Tribal identity.

The authors conducted a scoping review informed by the Joanna Briggs framework and PRISMA Extension for Scoping Reviews checklist and explanation. The study team conducted the search strategy within the CTN Dissemination Library and nine additional databases for articles published between 2000 and 2021. The review included studies if they reported results for AI/AN participants. Two reviewers determined study eligibility.

A systematic search yielded 13 empirical articles and six conceptual articles. Themes from the 13 empirical articles included: (1) Tribal Identity: Race, Culture, and Discrimination; (2) Treatment Engagement: Access and Retention; (3) Comorbid Conditions; (4) HIV/Risky Sexual Behaviors; and (5) Dissemination. The most salient theme was Tribal Identity: Race, Culture, and Discrimination, which was present in all articles that included a primary AI/AN sample (k = 8). Themes assessed but not identified for AI/AN peoples were Harm Reduction, Measurement Equivalence, Pharmacotherapy, and Substance Use Outcomes. The conceptual contributions used AI/AN CTN studies as exemplars of community-based and Tribal participatory research (CBPR/TPR).

Conclusions: CTN studies conducted with AI/AN communities demonstrate culturally congruent methods, including CBPR/TPR strategies; consideration/assessment of cultural identity, racism, and discrimination; and CBPR/TPR informed dissemination plans. Although important efforts are underway to increase AI/AN participation in the CTN, future research would benefit from strategies to increase participation of this population. Such strategies include reporting AI/AN subgroup data; addressing issues of cultural identity and experiences of racism; and adopting an overall effort for research aimed at understanding barriers to treatment access, engagement, utilization, retention, and outcomes for both treatment and research disparities for AI/AN populations.

Abstract:

Black participants experience a disproportionate burden of substance-related disabilities and premature death relative to other racial/ethnic groups, highlighting the need for additional research. The National Drug Abuse Treatment Clinical Trials Network (CTN), a research platform for multisite behavioral, pharmacological, and integrated trials designed to evaluate the effectiveness of a substance use treatments in community settings with diversified patient populations, provides a wealth of research knowledge on substance use. Although CTN trials have enrolled over 5,000 Black individuals since its inception in 2000, there has been no synthesis of the findings, discussion of the implications, or suggestions for future research for Black individuals. Members of the Minority Interest Group of the CTN conducted a scoping review of published research on Black participants in CTN trials. The primary source for identifying articles was the CTN Dissemination Library, with studies also identified through PubMed, PsycINFO, and Google Scholar. Studies were included if the sample was more than 75% Black and/or specific findings pertaining to Black participants were reported. The review yielded 50 articles, with studies that mostly focused on baseline characteristics, followed by substance use treatment outcomes, HIV/risky sex behaviors, retention, comorbid conditions and measurement issues.

This review highlighted the importance of several issues that are critical to understanding and treating substance misuse among Black people, such as the characteristics of Black people entering treatment, measurement equivalence, and engaging/retaining adolescents and young adults in treatment. There is still a continued need to identify the most effective treatments for Black individuals who use substances. The CTN offers several untapped opportunities to further advance research on Black individuals who use substances (e.g., secondary analyses on publicly available data).

Abstract:

This is the Results Article for CTN-0044-A-2.

Longstanding disparities in substance use disorders and treatment access exist among American Indians/Alaska Natives (AI/AN). Computerized, web-delivered interventions have the potential to increase access to quality treatment and improve patient outcomes. National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0044 established the efficacy in lowering drop-out rates and increasing abstinence of an interactive, web-based version of the Community Reinforcement Approach (CRA) intervention plus incentives, the Therapeutic Education System (TES). However, TES has not been tested among AI/AN populations. This mixed method acceptability study was conducted at two urban outpatient substance abuse treatment programs affiliated with the Clinical Trials Network; one in the Northern Plains region, the other on the Pacific Northwest. The sample consisted of 40 urban AI/AN, and results found TES acceptable across seven indices (range 7.8-9.4 on 0-10 scales with 10 indicating highest acceptability). Clients gave the highest ratings of acceptability to TES modules that included HIV/STI information, as well as managing triggers that can lead to risky sexual or drug using behavior. Modules receiving lower ratings tended to be those completed earlier; lower rating may reflect features of TES functionality, such as getting comfortable with the interface and answering questions to demonstrate learning to be able to move from one module to the next. Initial, lower acceptable rates, and the relatively low use of the internet of the population at baseline, may indicate that web-based interventions need more comprehensive introduction in this population.

Conclusions: Overall, findings suggest that core TES content is acceptable among a diverse population of AI/AN clients in outpatient substance use treatment. Qualitative interviews suggest adaptation of the TES content specific to AI/AN culture could improve adoption. Additional efforts to adapt TES and conduct a larger effectiveness study are warranted.

Related protocols: CTN-0044-A-2

Abstract:

Community-university teams investigated substance use, abuse, and dependence (SUAD) and related concerns, needs, strengths, and resources in four Washington State Tribal communities as part of National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0033-Ot-3.

One hundred and fifty-three key community members shared their perspectives through 45 semi-structured interviews and 19 semi-structured focus groups. Qualitative data analysis revealed robust themes: prescription medications and alcohol were perceived as most prevalent and concerning; family and peer influences and emotional distress were prominent perceived risk factors; and SUAD intervention resources varied across communities. Findings may guide future research and the development of much needed strength-based, culturally appropriate, and effective SUAD interventions for American Indians, Alaska Natives, and their communities.

Related protocols: CTN-0033-Ot-3

Abstract:

Latino Americans report underutilization of treatment and poor treatment response for substance use and abuse compared to other racial/ethnic groups; thus, it is important to assess factors that contribute to these disparities. The current study, an ancillary investigation of data from a National Drug Abuse Treatment Clinical Trials Network (CTN) study about Motivational Enhancement Treatment for Spanish-speaking individuals (CTN-0021), aimed to assess the influence of family conflict on substance abuse treatment response in a sample of Latino Americans using two different yet complementary analyses. First, ordinary least squares regression was used to assess the association between overall family conflict and pre- and post-treatment substance use. Second, repeated measures latent class analysis was used to identify groups based on family member conflict and timing of conflict during treatment. Findings indicated that family conflict contributed unique variance to concurrent substance use; however, pre-treatment family conflict was not related to post-treatment outcomes. Results also identified three distinct family conflict groups: no/low conflict, pre-treatment conflict, and post-treatment conflict who differed in pre- and post-treatment substance use. Post hoc investigation revealed that those who experienced pre-treatment conflict but low post-treatment conflict showed the greatest decrease in substance use.

Conclusions: Overall, findings suggest that for Latinos it may be beneficial for substance abuse treatment programs not only to screen and assess family conflict at intake, but to continue this assessment at follow-up. The assessment of family conflict post-treatment could identify individuals more at risk for relapse. Additionally, it may benefit substance abuse practitioners to regularly address family conflict when working with Latinos as those who reported the greatest change in family conflict from pre- to post-treatment also reported the greatest decrease in substance use at post-treatment follow-up. These findings, coupled with previous research highlighting the importance of family cohesion in Latino mental health and treatment outcomes, suggest that incorporating family members or family-based curriculum into treatment may help address family conflict in a way that improves Latino substance use outcomes.

Related protocols: CTN-0021

Abstract:

A fidelity measure was developed for use with Real Men Are Safe-Culturally Adapted (REMAS-CA), an HIV prevention intervention for ethnically diverse men in substance abuse treatment developed as an outgrowth of National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018 (Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment). The aims of this ancillary investigation of data from that project were to: 1) assess the reliability of the Fidelity Rating and Skill Evaluation (FRASE); 2) measure improvement in therapist competence and adherence over time while delivering REMAS-CA; and 3) identify which modules of REMAS-CA were most difficult to deliver.

Conclusions: Results showed that the FRASE was a reliable instrument for measuring the fidelity of REMAS-CA delivery, and therapists achieved adequate adherence and competence after training, demonstrating significant improvement over time. Sessions 4 and 5 of REMAS-CA were found to contain the most challenging modules for therapists to deliver. These findings offer some guidelines for increasing counselor competence in implementing REMAS-CA for research or clinical practice. Specifically, more effort should be spent on training the counselors to implement the emotionally charged discussion and the specific skill building present in Sessions 4 and 5.

Related protocols: CTN-0018

Abstract:

Hispanic Americans are substantially underrepresented in clinical and research samples for substance use treatment, with language cited as one of the major barriers to their participation, indicating a need for more validated assessments in Spanish. This study evaluated the psychometric properties of a Spanish version of the Short Inventory of Problems (SIP), used in a multisite, randomized trial conducted for Spanish-speaking substance users, National Drug Abuse Treatment Clinical Trials Network protocol CTN-0021. The sample included 405 Spanish-speaking treatment seekers, mostly male (88%) and legally mandated to treatment (71%). The Spanish version of the revised SIP (SIP-RS), as well as other commonly used assessment measures translated into Spanish, were administered at baseline and at the end of treatment. Internal consistency was excellent and construct validity was supported through correlations with composite scores from the Addiction Severity Index (ASI) and through differential SIP-RS scores according to diagnostic criteria. The SIP-RS also demonstrated an association with substance use and treatment retention, with higher baseline scores associated with significantly less abstinence during treatment and fewer days retained in treatment. However, the latter association was moderate by participants’ legal status.

Conclusions: This Spanish-translated version of the SIP (SIP-RS) appears to be a reliable and valid assessment of adverse consequences associated with alcohol and drug use, with psychometric properties comparable with the English version. This assessment may prove to be a useful outcome measure for evaluating the efficacy of treatments for substance use disorders, and it may have the potential to identify individuals at risk for early treatment drop-out. Given the growing population of Hispanics in the United States with limited English proficiency, greater effort should be placed toward validating substance abuse assessment instruments for Spanish-speakers, with a particular focus on diverse Hispanic populations.

Related protocols: CTN-0021

Abstract:

The development of effective treatments for African Americans and other ethnic minorities is essential for reducing health disparities in substance use. Despite research suggesting that Motivational Enhancement Therapy (MET) may reduce substance use among African Americans, the findings have been inconsistent. This research examined the extent to which readiness-to-change (RTC) affects response to MET among African American substance users. The study was a secondary analysis of the 194 African American substance users participating in National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0004, a multisite randomized clinical trial evaluating MET. The participants were randomly assigned to receive either three sessions of MET or Counseling-As-Usual (CAU) followed by the ordinary treatment and other services offered at the five participating outpatient programs. Participants were categorized as either high or lower on RTC based on their scores on the University of Rhode Island Change Assessment (URICA). The participants reported their substance use at baseline and throughout the 16 weeks after randomization. Among the high RTC participants, those in MET tended to report fewer days of substance use per week over time than participants in CAU. However, among the lower RTC participants, the CAU group tended to report fewer days of substance use over time than MET participants.

Conclusions: In contrast to previous thinking, the findings suggest that MET may be more effective for high than lower RTC African American participants. This study contributes to the public health need for more empirical evidence on effective substance abuse treatments for African Americans.

Related protocols: CTN-0004

Abstract:

This is the Results Article for CTN-0038-Ot.

This study examined motivations and barriers to substance abuse treatment entry and treatment continuation among Asian Americans and Pacific Islander (AAPI) substance users. APPI 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 fear of “losing face.” 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. It may be important to keep in mind the ideas of family harmony, solidarity, and subordination of individual goals for the sake of family goals while designing substance abuse treatments for this population. In addition, integrating culturally sensitive screening tools, brief interventions, and referral to substance abuse treatment in medical care settings and non-traditional settings (e.g., health fairs, community cultural celebrations) may increase the numbers of AAPIs who seek substance abuse treatment.

Related protocols: CTN-0038-Ot

Abstract:

The “Real Men Are Safe-Culturally Adapted” (REMAS-CA) study was an outgrowth of the National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018, which developed and evaluated Real Men Are Safe (REMAS), a safer sex skills training intervention for men in substance abuse treatment. The study aimed to develop an adherence scale for REMAS-CA, a modified version of the original REMAS intervention tailored for African Americans and Hispanics, measure improvement in counselors’ intervention delivery skills over time, and identify which modules of the new adapted intervention were hardest to deliver. REMAS-CA was piloted in four addiction treatment programs, with two counselors per site running 3 or 4 rounds of REMAS-CA groups over about 9 months. Group recordings were reviewed by a team of four (lead- and co-investigator plus two undergraduates) for 1) manual adherence, 2) avoidance of proscribed behaviors, 3) global empathy and co-therapy. Inter-rater reliability was calculated for all raters, and adherence and skill scores were compared for counselors’ first and last cohorts using paired t-tests.

Results found that counselors did not improve delivery of REMAS-CA over time, except in global empathy, which showed significant improvement from first cohort to last. Discussions of current and past relationships, and role plays of communication skills with partners, were most difficult for counselors.

Conclusions: A highly reliable system for rating counselor skill and adherence to REMAS-CA was developed for this study. Counselors’ lack of significant improvement in skill, co-therapy, global empathy, and avoidance of proscribed behaviors may have been because they scored relatively high even in their first round of intervention delivery. Results suggest that the 2-day training and subsequent certification process, manual structure, and early supervision may have solidified counselors’ skills, leaving little “room for improvement.”

Related protocols: CTN-0018

Abstract:

This is the Results Article for CTN-0033-Ot-1 and CTN-0033-Ot-5.

American Indians and Alaska Natives (AI/ANs) experience significant disparities in health status and access to care. Furthermore, only limited data are available on substance use, mental health disorders, and treatment needs for this population. Addressing such disparities and developing culturally relevant, effective interventions for AI/AN communities require participatory research. The Western States Node of the National Drug Abuse Treatment Clinical Trials Network (CTN) partnered with two American Indian substance abuse treatment programs as part of protocol CTN-0033-Ot-5: an urban health center and a reservation-based program to assess client characteristics, drug use patterns, and treatment needs. Data collected by staff members at the respective programs from urban (n=74) and reservation (n=121) clients were compared. Additional sub-analysis examined patients reporting regular opioid use and mood disorders. Findings indicate that urban clients were more likely to report employment problems, polysubstance abuse, and a history of abuse. Reservation-based clients reported having more severe medical problems and a greater prevalence of psychiatric problems. Clients who were regular opioid users were more likely to report having a chronic medical condition, suicidal thoughts, suicide attempts, polysubstance abuse, and IV drug use. Clients who reported a history of depression had twice as many lifetime hospitalizations and more than five times as many days with medical problems.

Conclusions: Findings from this project provide information about the patterns of substance abuse and the importance of comprehensive assessments of trauma and comorbid conditions. Results point to the need for integrative coordinated care and auxiliary services for AI/AN clients seeking treatment for substance use disorders. In addition to more details about the epidemiology of alcohol and drug use disorders among AI/ANs, there is also the need for more information about the treatment system this population has access to.

Related protocols: CTN-0033-Ot-1, CTN-0033-Ot-5

Abstract:

With high rates of substance abuse and barriers to treatment, American Indian/Alaska Native (AI/AN) clients could benefit from culturally sensitive web-based treatments. This study, CTN-0044-A-2, will examine culture and ethnicity in AI/AN clients enrolled in outpatient substance abuse treatment and how culture is related to the acceptability of the Therapeutic Education System (TES), a web-based version of the Community Reinforcement Approach. AI/AN clients from two programs (Northern Plains and Pacific Northwest) completed assessments at baseline and 1 week after the 8-week intervention phase. Participants completed the Scale of Ethnic Experience and questions from the ASI-Native American Version. Participants were also asked to complete 32 skills-based TES modules on acceptability and relevance. Sixty-eight clients were approached to participate in twice weekly TES and assessments; 4 agreed (58.8%). The sample was about half female, mean age 36. Over 80% participated in AI/AN cultural activities, including AI/AN religious ceremonies, dance activities, and church meetings. About half were familiar with their native language, and 73% had lived on a reservation. Analyses will include exploratory chi-square (categorical) and t-tests (continuous) to determine if cultural involvement variables are related to TES acceptability. This study will explore how culture and ethnicity relate to the acceptability of a web-based intervention.

Abstract:

The presentation reports on a study designed to revise the CDC recognized, evidence-based HIV prevention intervention, “Real Men Are Safe” (REMAS) to be more culturally relevant to African American and Hispanic men, and then conduct a pilot feasibility trial of the revised REMAS (REMAS-CA) in four CTN community treatment providers that have a high percentage of minority clients. Comparisons between the original REMAS manual and four culturally tailored interventions (Nia, d-up, Many Men Many Voice, and Cuidate) were made, focusing in particular on language/expressions of the target group; activities that enhance ethnic identity, consistency with the norms, knowledge, and cultural values of the target group; and understanding of the social context and living situations of the target group. Resultant changes to the original intervention are described, along with data and feedback from focus groups following pilot testing of the REMAS-CA.

Related protocols: CTN-0018