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Abstract: The effectiveness of motivational enhancement therapy (MET) in comparison with counseling as usual (CAU) for increasing retention and reducing substance use was evaluated in the National Drug Abuse Treatment Clinical Trials Network protocol CTN-0004, a multisite randomized clinical trial. Participants were 461 outpatients treated by 31 therapists within 1 of 5 outpatient substance abuse programs. Contrary to the study hypothesis, MET did not appear to be more effective than CAU for either retention measure or urine drug outcome. However, though both 3-session interventions resulted in reductions in substance use during the 4-week therapy phase, MET resulted in sustained reductions during the subsequent 12 weeks whereas CAU was associated with significant increases in substance use over this follow-up period. MET also resulted in more sustained substance use reductions than CAU among primary alcohol users, but no difference was found for primary drug users. An independent evaluation of session audiotapes indicated that MET and CAU were highly and comparably discriminable across sites. Although the researchers did not directly assess the efficacy of their training model, the results of this study and its companion single-session protocol (Carroll et al, 2006) indicated that community-based therapists can learn to deliver MET effectively even in the absence of a priori allegiance, interest, or training in the model. Future analyses will evaluate the relationship between therapist experience, skill, adherence, and treatment outcomes.

Abstract:

This brochure, intended for clinicians participating in the CTN-0013 clinical trial (MET to Improve Treatment Utilization and Outcome in Pregnant Substance Users), provides an overview of Motivational Enhancement Therapy (MET) and answers to questions participants might have about being involved in the research project.

Abstract:

African Americans are less likely than other racial groups to engage in and complete outpatient substance abuse treatment. This secondary analysis of CTN-0004 examined whether Readiness to Change (RTC) over time influences retention and whether gender moderates the relationship between changes in RTC and retention among 194 African American women and men.

Participants completed the University of Rhode Island Change Assessment at baseline and at the end of the 16-week study. Positive increases in RTC from baseline to week 16 were associated with higher retention rates among African American substance users. This finding is consistent with the stage-of-change model suggesting that the emergence of positive behaviors may be associated with an increasing motivation (i.e., readiness) to change maladaptive behaviors. While previous research supports the stage-of-change model by demonstrating a link between initial readiness to change and retention, these findings further contribute to the model by providing convincing evidence that an increase in readiness to change is also associated with treatment retention.

The study also suggests that change in RTC is another factor that differentially influences retention for African American women and men. Nevertheless, additional research is needed to examine why change in RTC is more strongly associated with retention among African American men.

Conclusions: Consideration of changes in RTC during treatment may help to improve retention among African American substance users, especially men, and will contribute to the reduction of racial/ethnic health disparities found in rates of substance abuse treatment completion.

Related protocols: CTN-0004

Abstract:

Approximately 35% of pregnant substance users in treatment report alcohol abuse, which increases the risk of fetal alcohol spectrum disorders (FASD) in their offspring. The present study was a preliminary evaluation of the efficacy of motivational enhancement therapy (MET) in decreasing alcohol use in pregnant women attending substance use treatment, performed via a secondary analysis of a trial evaluating the efficacy of MET, relative to treatment as usual (TAU), in improving treatment outcomes in 200 pregnant substance users (CTN-0013: Motivational Enhancement Therapy to Improve Treatment Utilization and Outcome in Pregnant Substance Users). The analysis included the 41 women (n=27 MET and n=14 TAU) who reported alcohol use in the 28 days prior to randomization. Alcohol and illicit drug use days were assessed with self-report; illicit drug use was assessed with urine drug screens. All measures were obtained weekly for the 4 week active study phase and at 1 and 3 month follow-ups.

Significant treatment-by-time interaction effects were found for illicit drug use days during the active and follow-up phases and for alcohol use during the follow-up phase, all reflecting a beneficial effect for MET, relative to TAU. All other treatment effects were non-significant.

Conclusions: With FASD occurring in 2-5% of all U.S. live births, it is imperative that women who drink any amount of alcohol that could be risky to the developing fetus receive effective interventions to assist with decreased prenatal alcohol use. With approximately 35% of pregnant substance users in treatment reporting alcohol abuse, this study provides preliminary support for the use of MET to decrease prenatal alcohol use in substance using women. With a large proportion of these women abusing alcohol in combination with other substances, MET may also be useful in decreasing illicit drug use in the population, bettering outcomes for both mothers and children.

Related protocols: CTN-0013

Abstract:

Smoking is highly prevalent among individuals with drug and alcohol disorders. Concurrent tobacco dependence treatment during substance use disorder (SUD) treatment is supported yet the association between SUD treatment outcomes and smoking status has been understudied in minorities, including Latinos. Participants in this study were 322 Spanish-speaking Latinos enrolled in a substance use disorder treatment study in five U.S. cities, NIDA Clinical Trials Network protocol CTN-0021 (“Motivational Enhancement Treatment to Improve Treatment Engagement and Outcome for Spanish-Speaking Individuals Seeking Treatment for Substance Abuse”). Logistic regression examined associations between baseline smoking status and treatment outcomes for nontobacco substance use at follow-up. Covariates included age, gender, level of education, marital status, treatment group, and mandated treatment status.

Results indicated being a smoker during the first month of substance use treatment is associated with a significant increase in the odds of substance use relapse at follow-up. Smokers had a reduced likelihood of abstinence for all nontobacco substances and their primary drug of use.

Conclusions: The current study provides further evidence for the association between smoking status and substance use treatment outcomes. Findings contribute to the growing literature indicating a possible beneficial effect of smoking cessation services on SUD treatment, specifically among Latinos. They could, in fact, serve as a rationale for a conceptual shift with respect to how smoking is perceived and managed during SUD treatment; instead of seeing smoking as a comorbid “addiction,” a more progressive view might see it as conceptually inseparable from the full range of psychosocial factors, including other substance use and mental health conditions. Further research is needed to identify ideal smoking cessation treatments for Latinos.

Related protocols: CTN-0021

Abstract:

This ancillary investigation of data from NIDA Clinical Trials Network protocol CTN-0021 explored Hispanic subgroup differences in substance use treatment outcomes, and the relationship of acculturation characteristics to these outcomes. Data were from a multisite randomized clinical trial of motivational enhancement therapy versus treatment as usual in a sample of Spanish-speaking substance abusers. Participants were Cuban American (n=34), Mexican American (n=209), Puerto Rican (n=78), and other Hispanic American (n=54). Results suggested that Cuban Americans and individuals with more connection to Hispanic culture had lower treatment retention. Hispanics born in the U.S. and those who spoke English at home had a lower percentage of days abstinent during weeks 5-16, although Puerto Ricans born in the U.S. and Cuban Americans living more years in the U.S. had a higher percentage of days abstinent in weeks 1-4 and 5-16, respectively.

Conclusions: This study’s analysis of treatment outcomes and acculturation disaggregated by Hispanic subgroup begins to fill an important and large gap in the substance abuse treatment research literature. Results found that Cuban Americans and individuals with more connection to the Hispanic culture had lower treatment retention, and that acculturation measures such as U.S. birthplace and years living in the U.S. were associated with reduced abstinence in some but not other Hispanic subgroups. These findings provide evidence that the relationships between acculturation and abstinence outcomes are likely complicated and varied across Hispanic groups. Results may inform future hypothesis-driven studies in larger Hispanic treatment seeking samples of the relationship between acculturation and treatment outcome.

Related protocols: CTN-0021

Abstract:

In order to determine if expectations at pre-treatment are associated with substance use treatment outcomes, this study examined treatment expectations in two National Drug Abuse Treatment Clinical Trials Network (CTN) randomized controlled trials (RCTs) utilizing Motivational Enhancement Therapy (MET) for the treatment of substance use (CTN-0004 and CTN-0021). One RCT was delivered in English (MET-E) and one was delivered in Spanish (MET-S). There were 461 participants MET-E sample and 405 participants MET-S. Participants responded to the following item at pre-treatment: “Do you think you will reduce or stop your use of drugs or alcohol as a result of this treatment?” ANOVAs and chisquare tests were used to examine the relationship between treatment expectations and treatment outcomes in the two samples.

Treatment expectations were not associated with any of the treatment outcomes in MET-E. However, in MET-S, expectations were significantly associated with most of the post-treatment outcomes. Among these, treatment expectations were significantly associated with the percentage of drug positive urines within the treatment period, F (1, 1,163) = 18.83, p = .000, and the percentage of days abstinent from primary drug use while in treatment and through follow-up, F (1, 1,364) = 23.78, p = .000.

Conclusions: There are several possible interpretations to the divergent findings between samples. The first is that the MET-S sample had fewer previous treatments, and that when a treatment is novel, expectations may have more of an influence. The second interpretation is that there may be cultural components that may affect how an individual relates to the treatment process. These findings are preliminary and future research should examine treatment expectations across cultures.

Related protocols: CTN-0004, CTN-0021

Abstract:

Modern treatment options for substance use disorder are diverse. While studies have analyzed the adoption of individual evidence-based practices in treatment centers, little is known about the specific make-up of treatment strategy profiles in treatment centers throughout the United States. The current study used latent class analysis to profile underlying treatment strategies and to evaluate philosophical and structural supports associated with each profile. Using three aggregated and secondary datasets of national representative samples of substance use disorder treatment centers (N=775), including centers participating in the National Drug Abuse Treatment Clinical Trials Network, treatment strategy profiles were determined using via latent class analysis. Using multinomial logistic regression, organizational characteristics associated with each profile were also examined.

Three distinct treatment strategy profiles were found:

• Centers that primarily relied on Motivational Interviewing and Motivational Enhancement Therapy
• Centers that utilized psychosocial and alternative therapies, and
  Centers that employed comprehensive treatments including pharmacotherapy.

The multinomial logistic regression revealed that philosophical and structural center characteristics were associated with membership in the comprehensive class. Centers with philosophical orientations conducive to holistic care and pharmacotherapy-acceptance, resource-rich infrastructures, and an entrepreneurial reliance on insured clients were more likely to offer diverse interventions. All associations were significant at the .05 level.

Conclusions: The findings from this study clarify the general strategies of treatment centers and how those strategies are interconnected. Practitioners and clients should be aware of the variation in treatment center practices. Access to diverse treatment is beneficial and centers with limited offerings should consider widening their treatment, especially as the Affordable Care Act begins to increase the emphasis on integrated substance use disorder treatment with general health care practice. Centers offering medication-assisted treatment will be better able to integrate other medical services, and programs that make up the comprehensive class, which are able to offer a wide range of core and wraparound services, will be most competitive.

Abstract:

Despite previous reports of biased Short Inventory of Problems (SIP) items across racial groups of men who have sex with men, the assumption of measurement invariance has not yet been tested across African-American and non-Latino White outpatient groups for the SIP-R. This study investigated measurement invariance properties of the Short Inventory of Problems-Revised (SIP-R) across racial groups. The sample included 195 African-American and 194 non-Latino White adult participants in a clinical trial investigating the effectiveness of motivational enhancement therapy in the National Institute on Drug Abuse Clinical Trials Network (CTN-0004).

The SIP-R demonstrated configural invariance and weak metric invariance between racial groups, suggesting conceptualizations of adverse consequences of substance use are equivalent across racial groups. However, the SIP-R also indicated partial strong/scalar and strict metric invariance; that is, four of the five constructs suggested differences in the normative levels of the items across racial groups.

Conclusions: This study is the first to report measurement equivalence properties of the SIP-R across racial groups. This study contributes to the growing literature on how substance abuse treatment researchers can ensure unbiased assessment when studying treatment outcomes across racial/ethnic minority groups. Since MI and MET techniques have become standard social work practice in substance abuse treatment settings, the SIP-R is expected to continue to be one of the most prominent outcome measures in practices involving motivational techniques. The current findings encourage the valid use of the SIP-R with samples of African-American and non-Latino White adult outpatients to validly examine treatment outcomes and test potential differential effectiveness of treatments across racial groups.

Related protocols: CTN-0004

Abstract:

Large-scale dissemination efforts seek to expand opportunities for the addiction treatment community to receive training in empirically supported treatments (ESTs). Prospective consumers of such training are valuable sources of input about content of interest, preferences for how training events are structured, and obstacles that deter receipt of training. In this mixed-method study, data were collected in 64 semistructured individual interviews with personnel during site visits to 16 community opioid treatment programs (OTPs). At each OTP, interviews were completed with the executive director, a clinical supervisor, and 2 direct-service clinicians.

Topical interests were analyzed qualitatively in a cultural domain analysis. Likert ratings of training event preferences were analyzed via generalized linear mixed models (GLMMs), and unstructured interviewee comments were analyzed via narrative analysis. Obstacles to training receipt were analyzed qualitatively with both content coding and narrative analysis. Based on topics of reported interest, cultural domain analysis suggests as ESTs of note: Multidimentional Family Therapy, Motivational Enhancement Therapy, Relapse Prevention Therapy, “Seeking Safety,” and broad addiction-focused pharmacotherapy. Regarding training event preferences, GLMMs and narrative analysis revealed clear preferences for time-distributed trainings and use of participatory activities (e.g., trainer demonstrations, role plays, small group exercises). Content coding identified cost as the primary obstacle to receipt of EST trainings, followed by lack of time, logistical challenges, and disinterest, and narrative analysis elaborated on contextual issues underlying these obstacles.

Conclusions: As primary consumers of EST technologies, the treatment community has valuable input to offer. Dissemination efforts may be enhanced by greater consideration of their preferences for training content and event structure, as well as practical obstacles that challenge their receipt of training.

Abstract:

In randomized controlled trials (RCTs), the most compelling need is to determine whether the treatment condition was more effective than the control. However, it is generally recognized that not all participants in the treatment group of most clinical trials benefit equally. While subgroup analyses are often used to compare treatment effectiveness across pre-determined subgroups categorized by patient characteristics, methods to empirically identify naturally occurring clusters of persons who benefit most from the treatment group have rarely been implemented. This article provides a modeling framework to accomplish this important task.

Utilizing information about individuals from the treatment group who had poor outcomes, the present study proposes an a priori clustering strategy that classifies the individuals with initially good outcomes in the treatment group into: (a) group GE (good outcome, effective), the latent subgroup of individuals for whom the treatment is likely to be effective and (b) group GI (good outcome, ineffective), the latent subgroup of individuals for whom the treatment is not likely to be effective. The method is illustrated through a reanalysis of a publicly available data set from the National Institute on Drug Abuse’s National Drug Abuse Treatment Clinical Trials Network (protocol CTN-0004). That study examined the effectiveness of motivational enhancement therapy from 461 outpatients with substance use disorder problems. As a diagnostic means utilizing out-of-sample forecasting performance, the present study compared the relapse rates during the long-term follow-up period for the two subgroups. As expected, group GI, composed of individuals for whom the treatment was hypothesized to be ineffective, had a significantly higher relapse rate than group GE (63% vs. 27%).

Conclusions: The proposed method, LGEM, identified latent subgroups GE and GI, and the comparison between the two groups revealed several significantly different and informative characteristics even though both subgroups had good outcomes during the immediate post-therapy period. LGEM has potential as a means of further exploring reasons why individuals respond to treatment conditions, regardless of which treatment arm they are exposed to, and can be implemented after the trial is completed, without need for a pre-specified design and can be used by any type of RCT in a variety of topic areas.

Related protocols: CTN-0004

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:

Although a body of literature supports the effectiveness of Motivational Enhancement Therapy (MET) in reducing substance use for the general population, several studies report inconsistent findings, especially among African Americans (AA). In the National Drug Abuse Treatment Clinical Trials Network’s study on MET, CTN-0004, no overall difference was found between MET and counseling as usual. Among AA overall, MET showed significantly more days of primary substance use than CAU; however, this pattern was reversed among those with high baseline readiness to change (RTC). This ancillary investigation of CTN-0004 hypothesized a mediator relationship in AA patients, such that (1) MET would positively influence RTC over time and (2) increased RTC would be correlated with successful treatment outcomes. Secondary analyses of 194 African Americans in CTN-0004 were performed, assessing at baseline, 4, 8, and 16 weeks by the University of Rhode Island Change Assessment (URICA), based on precontemplation, contemplation, preparation, and action. The primary outcome assessed was the total number of days using the primary substance during the 16 week period.

Over the 16 week period, average total RTC score declined slightly, with no significant difference observed between MET and CAU treatment groups. Overall, the MET group reported 6.6 days of primary substance use vs. 3.1 days in the CAU group (p=0.08). An inconsistent role for RTC as a mediator was observed, with RTC change from baseline to 8 weeks significantly associated with substance use in the MET arm, but RTC change to other timepoints not significant. The MET treatment effect was similar in models with and without controlling for baseline RTC and RTC change over time.

Conclusions: These results provide limited evidence for readiness to change as a mediator of Motivational Enhancement Therapy effect in African American patients. It is possible that RTC plays a larger role in maintenance of abstinence at the beginning of treatment.

Related protocols: CTN-0004

Abstract:

Baseline patients’ characteristics are critical for treatment planning, as these can be moderators of treatment effects. In Mexico, information on treatment seekers with substance use disorders is scarce and limited to demographic characteristics. This paper presents and analyses demographic characteristics, substance use related problems, clinical features, and addiction severity in a sample of treatment seekers from the first multi-site randomized clinical trial implemented in the Mexican Clinical Trials Network on Addiction and Mental Health. The study was an adaptation of the U.S.’s National Drug Abuse Treatment Clinical Trials Network protocol CTN-0021, which evaluated the use of motivational enhancement treatment to improve treatment engagement and outcome for Spanish-speaking individuals seeking treatment for substance abuse.

A total of 120 participants were assessed prior to randomization. Chi square or F-tests were used to compare sites across variables. Spearman correlation was used to associate negative consequences of substance use and motivation to change. The majority of participants were men, and the most prevalent substances reported were alcohol, marijuana, and cocaine. Participants were predominantly on the contemplation or action stage of change, and this was correlated with the perception of the negative consequences associated with substance use. Participants reported a high prevalence of substance use related problems.

Conclusions: Data presented here constitutes the first attempt to characterize more widely the treatment-seeking population in outpatient addiction treatment settings in Mexico. Regardless of the limitations in sample size, this study uncovered special considerations that should be taken into account for outpatients in addiction treatment in Mexico, including substance use related problems, clinical features, and addiction severity. This study represents a novel approach to systematic assessment in addiction clinical studies in Mexico, and the establishment of the Mexican Clinical Trials Network on Addiction and Mental Health promises to help bridge the gap between research and practice and establish the opportunity for future implementation of evidence-based approaches in clinical practice and research.

Related protocols: CTN-0021

Abstract:

Few studies examine the helpfulness and effectiveness of substance abuse treatment from the clients’ perspective. This secondary analysis of data from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0004, a multisite, randomized clinical trial of Motivational Enhancement Therapy, examined the perceived helpfulness of substance abuse treatment components and its relationship to treatment outcomes among 387 black and white adult participants. Throughout the 16-week trial, participants self-reported substance use. Upon completion of treatment, they completed a self-report measure assessing the perceived helpfulness of treatment components. Black participants rated 9 out of 12 treatment components (e.g., “learning skills that will help me cope with my problems”) as being more helpful than their white counterparts, even after controlling for age, gender, employment status, primary drug type, and treatment assignment. However, perceived helpfulness ratings were not associated with substance use outcomes among black or white participants.

Conclusions: Overall, findings suggest that black adults perceive treatments that focus on teaching new coping skills and information about the intersection between drug use and interpersonal relationship to be more helpful than their white counterparts. Despite the fact this study did not find an association between ratings of helpfulness and decreased primary or other drug use during treatment for black or white participants, race does appear to be an important demographic characteristic to consider in substance abuse treatment preferences.

Related protocols: CTN-0004