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Abstract: Background and aims: Despite similar substance use levels, Black adults experience greater family, legal, employment and other social-contextual challenges related to recovery than other groups. Substance use treatments that address both substance use and social-contextual factors are uniquely positioned to address these substance-related problems and produce more sustainable improvements in social functioning than treatment as usual (TAU) or behavioral controls (Control). The aim of this study was to evaluate changes in substance-related problems among Black adults, focusing on the comparative effectiveness between social-contextual treatments and TAU/Control. Design: Individual-level data synthesis based on secondary analysis of Black adults enrolled in the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN). Setting: All data were collected in the primary studies between 2001 and 2008 at clinics across the United States. Participants: Black adults who reported cocaine and/or opioid use across nine studies within the NIDA CTN. The sample used herein consisted of individuals from five of these studies who provided data on substance-related problems (n=532; mean age=39.34; standard deviation=9.6). Measurements: There were two treatment conditions: Social-contextual (e.g. Motivational Interviewing, Seeking Safety, STAGE 12) and TAU/Control. Moderated nonlinear factor analysis estimated latent scores for substance-related problems, using subscales from the Addiction Severity Index, while accounting for measurement noninvariance across studies, time and covariates. Linear mixed models estimated latent score differences over time between social-contextual treatments and TAU/Control during treatment and from the end of treatment through 12-month follow-up. Findings: Both treatment groups improved across substance-related problem areas from baseline to the end-of-treatment (Cohen’s d = -0.10 to d = -0.47), with effects maintained at 12-month follow-up. Although social-contextual treatments did not statistically significantly outperform TAU/Control from baseline to end-of-treatment, they showed greater effects from end of treatment to 12-month follow-up in family/social [Cohen’s d difference ( d) = -0.47, 95% confidence interval (CI) = -0.57 to -0.38], legal ( d = -0.20, 95% CI = -0.31 to -0.10) and psychiatric problems ( d = 0.29, 95% CI = -0.38 to -0.20) than TAU/Control. Sensitivity analyses indicated that Seeking Safety and STAGE 12 predominantly drove post-treatment improvements in family/social problems. Conclusions: Substance use treatment may yield broader, delayed benefits beyond substance use reduction among Black adults in the United States. Compared with treatment-as-usual, social-contextual treatments can yield more sustainable effects in legal, family and psychiatric areas among Black adults, with interventions such as Seeking Safety and STAGE 12 showing particular benefits in addressing family-related challenges. Related protocols: CTN-0125

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:

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:

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:

Watch recording on YouTube.

Presented by Erin Bonar, PhD

Dr. Bonar presents results from pilot work on behavioral interventions delivered via telemedicine and a patient portal-like system the are now being testing in a large RCT as part of the NIH Heal Prevention Initiative. The interventions are rooted in Motivational Interviewing, include an emphasis on cognitive-behavioral skills, and are highly tailored for adolescents and young adults. These promising interventions build on prior efficacious behavioral interventions that showed reductions in primary substance use outcomes and secondary effects on prescription drug misuse.

Abstract:

Motivational interviewing (MI) is an evidence-based practice shown to be effective when working with people in treatment for substance use disorders. However, MI is a complex treatment modality optimized by training with feedback. Feedback, assessment, and monitoring of treatment fidelity require measurement, which is typically done using audiotaped sessions. The gold standard for such measurement of MI skill has been an audiotaped interview, scored by a rate with a detailed structured instrument such as the Motivational Interviewing Treatment Integrity 2.0 (MITI 20.0) Coding System. The Helpful Responses Questionnaire (HRQ) is a pen-and-paper test of empathy (a foundational MI skill) that does not require an audiotaped session.

A randomized trial of three different regimens for training counselors in MI (live supervision using teleconferencing, tape-based supervision, and workshop only) offered the opportunity to evaluate the performance of the HRQ as a measure of MI ability, compared to the several MITI 2.0 global scores and subscales. Participants were counselors (N=97) from 26 community-based substance use treatment programs affiliated with the Long Island and New York Nodes of the NIDA Clinical Trials Network, whose MI proficiency was measured at 4 time points: baseline (before an initial 2-day MI workshop), post-workshop, 8 weeks post-workshop (i.e., post-supervision), and 20 weeks post-workshop with both MITI 2.0 and HRQ

HRQ total scores correlated significantly with the Reflection to Question Ratio from the MITI 2.0 at post-workshop, week 8, and week 20, and with the Spirit and Empathy global scores at week 20. Correlations of HRQ with other MITI 2.0 subscales and time points after workshop were small and not significant. As predicted, HRQ scores different between training conditions, with counselors assigned to live supervision achieving better HRQ scores than those in Workshop only.

Conclusions: The HRQ is a modestly accurate measure, mainly of the Reflection to Question ratio, considered a core marker of MI skill. It is sensitive to training effects and may help identify counselors needing more intensive supervision. Given its ease of administration and scoring, HRQ may be a useful marker of MI skill during training efforts.

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:

Contingency management (CM) interventions generally target a single behavior such as attendance or drug use. However, disease outcomes are mediated by complex chains of both healthy and interfering behaviors enacted over extended periods of time. This paper describes a novel multi-target contingency management (CM) program developed for use with HIV positive substance users enrolled in a CTN multi-site study (CTN-0049, Project HOPE). Participants were randomly assigned to usual care (referral to health care and SUD treatment) or 6-months strength-based patient navigation interventions with (PN+CM) or without (PN only) the CM program. Primary outcome of the trial was viral load suppression at 12-months post-randomization. Up to $1160 could be earned over 6 months under escalating schedules of reinforcement. Earnings were divided among eight CM targets: two PN-related (PN visits, paperwork completion; 26% of possible earnings), four health-related (HIV care visits, lab blood draw visits, medication check, viral load suppression; 47% of possible earnings), and two drug-use abatement (treatment entry, submission of drug negative UAs; 27% of earnings).

This paper describes the rationale for selection of targets, pay amounts, and pay schedules. The CM program was compatible with and fully integrated into the PN intervention. The Project HOPE CM program offers one example of how a multi-target CM intervention might be structured and deployed to impact a critical outcome in a difficult to treat population (in this case, HIV positive substance users). Subsequent data analysis examining the impact of the CM intervention on behavior frequencies will inform the structure and content of future multi-target CM interventions, while considerations of sustainability and cost-effectiveness will be needed to inform implementation policy.

Related protocols: CTN-0049

Abstract:

This is the primary outcomes article for CTN-0049.

Substance use is a major driver of the HIV epidemic and is associated with poor HIV care outcomes. Patient navigation (care coordination with case management) and the use of financial incentives for achieving predetermined outcomes are interventions increasingly promoted to engage patients in substance use disorders treatment and HIV care, but there is little evidence for their efficacy in improving HIV-1 viral suppression rates. This study aimed to assess the effect of a structured patient navigation intervention with or without financial incentives to improve HIV-1 viral suppression rates among patients with elevated HIV-1 viral loads and substance use recruited as hospital inpatients.

From July 2012 – January 2014, 801 patients with HIV infection and substance use from 11 hospitals across the United States were randomly assigned to receive patient navigation alone (n=266), patient navigation plus financial incentives (n=271), or treatment as usual (n=264). HIV-1 plasma viral load was measured at baseline and at 6 and 12 months. Patient navigation included up to 11 sessions of care coordination with case management and motivational interviewing techniques over 6 months. Financial incentives (up to $1160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment. The primary outcome was HIV viral suppression (less than or equal to 200 copies/mL) relative to viral nonsuppression or death at the 12-month follow-up.

Of 801 patients randomized, 261 (32.6%) were women (mean [SD] age, 44.6 years [10 years]). There were no differences in rates of HIV viral suppression versus nonsuppression or death among the 3 groups at 12 months. Eighty-five of 249 patients (34.1%) in the usual-treatment group experienced treatment success compared with 89 of 249 patients (35.7%) in the navigation-only group, for a treatment difference of 1.6%, and compared with 98 of 254 patients (38.6%) in the navigation-plus-incentives group, for a treatment difference of 4.5%. The treatment difference between the navigation-only and navigation-plus-incentives group was -2.8%.

Conclusions: Among hospitalized patients with HIV infection and substance use, patient navigation with or without financial incentives did not have a beneficial effect on HIV viral suppression relative to nonsuppression or death at 12 months vs. treatment as usual. These findings do not support these interventions in this setting and indicate that other approaches are needed to improve HIV outcomes in this vulnerable population.

Related protocols: CTN-0049

Abstract:

Despite considerable empirical evidence that psycho-social interventions improve addiction treatment outcomes across populations, implementation remains problematic. A small body of research points to the importance of research network participation as a facilitator of implementation; however, studies examined limited numbers of evidence-based practices. To address this gap, the present study examined factors impacting implementation of motivational interviewing (MI). This study used data from a national sample of privately funded treatment programs (n=345) and programs participating in the NIDA Clinical Trials Network (CTN) (n=156). Data were collected via face-to-face interviews with program administrators and clinical directors (2007-2009). Analysis included bivariate t tests and chi-square tests to compare private and CTN programs, and multivariable logistic regression of MI implementation.

A majority (68%) of treatment programs reported use of MI. Treatment programs participating in the CTN (88.9%) were significantly more likely to report use of MI compared with non-CTN programs (58.5%; P<0.01). CTN programs (82.1%) also were more likely to use trainers from the Motivational Interviewing Network of Trainers as compared with private programs (56.1%; P<0.05). Multivariable logic regression models reveal that CTN-affiliated programs and programs with a psychiatrist on staff were more likely to use MI. Programs that used the Stages of Change Readiness and Treatment Eagerness Scale assessment tool were also more likely to use MI, whereas programs placing greater emphasis on confrontational group therapy were less likely to use MI.

Conclusions: These findings suggest the critical role of research network participation, access to psychiatrists, and organizational compatibility in the adoption and sustained use of MI for the treatment of substance use disorders. Results suggest that as treatment programs begin the implementation process, special attention should be paid to creating an organizational climate receptive to innovation, and also the critical infrastructure necessary to facilitate implementation of psychosocial EBPs such as MI.

Abstract:

Motivational Interviewing (MI) is an empirically supported treatment for substance use disorders and a variety of other problematic behaviors. Over three decades of research have established the clinical effectiveness of MI and some of its mechanisms of action.

This webinar, presented by Steve Martino, PhD, and Theresa Moyers, PhD, described what MI is, how it works, MI-consistent and -inconsistent practices, standards of performance, clinician qualifications, and available training resources. The presentation is meant to provide a broad overview of MI and whet the appetites of participants to pursue further education and training in this treatment approach.

Additional Resources:

• Download slides (pdf)
• Download handout (pdf)

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:

Learning motivational interviewing (MI) is an ongoing process, involving much more than attendance at a single workshop. Once proficiency is achieved, therapists benefit from ongoing coaching with individual feedback based on observed practice to ensure continued fidelity. The aim of this study was to assess outcomes of the unique training and supervision model employed in a recent trial of MI. The intervention tested in the six-site National Drug Abuse Treatment Clinical Trials Network protocol CTN-0047 trial was a 30-minute MI-based brief intervention delivered in the emergency department followed by two telephone booster calls delivered from a centralized call center. Thirty-one counselors and 3 booster counselors were trained in the intervention using a 2-stage process: local training in the MI process of engagement followed one month later by a 2-day training in MI. We employed a two-level model in which the formal coding was separated from the clinical supervision. One audio file per interventionist per week was coded using the MITI 3.1.1 coding system. This written feedback was available to clinical supervisors, who reviewed coding results during telephone supervision sessions.

Eleven percent of sessions were coded on an ongoing basis during the trial, with a total of 380 initial sessions (90%) and 83 booster sessions (20%) coded upon completion of the trial. Mean global scores for initial sessions ranged from 4.25 to 4.67, and for the booster sessions from 4.64 to 4.86, well above the proficiency benchmark of 4.0. Inter-rater reliability assessed on a random sample of 124 tapes was excellent, with ICCs averaging 0.81 for global scores and 0.93 for behavior counts. On a therapist level, MITI scores tended to improve over time, demonstrating the strategies employed helped with adherence and continued learning in MI.

Conclusions: A comprehensive strategy for successfully learning and maintaining skills in MI emerged from the CTN-0047 study, which employed a rigorous and novel plan for ensuring therapists adhered to the style of MI.

Related protocols: CTN-0047

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.