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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:

The impact of agonist dose and of physician, staff, and patient engagement on treatment have not been evaluated together in the analysis of treatment for opioid use disorder. The hypothesis for this study was that greater agonist dose and therapeutic engagement would be associated with reduced illicit opiate use in a time-dependent matter. Publicly available treatment data from six buprenorphine efficacy and safety trials from the federally-supported NIDA Clinical Trials Network were used to derive treatment variables. Three novel predictors were constructed to capture the time-weighted effects of buprenorphine dosage (mg buprenorphine per day), dosing protocol (whether physician could adjust dose), and clinic visits (whether patient attended clinic). Researchers used time-in-trial as a predictor to account for the therapeutic benefits of treatment persistence. The outcome was illicit opiate use defined by self-report or urinalysis. Trial participants (N=3022 patients with opioid dependence, mean age 36 years, 33% female, 14% Black, 16% Hispanic) were analyzed using a generalized linear mixed model. Treatment variables dose, Odds Ratio (OR) = 0.63, dosing protocol, OR = 0.79, time-in-trial, OR = 0.75, and clinic visits, OR = 0.81 were significant protective factors.

Conclusions: Treatment implications support higher doses of buprenorphine and greater engagement of patients with providers and clinic stuff.

Abstract:

Evidence-based interventions for treating opioid use disorder (OUD) in youth are limited and little is known about specific and general mechanisms of OUD treatments and how they promote abstinence. This study used data from the CTN-0010 trial to evaluate the mediating effects of psychosocial treatment-related variables (therapy dose and therapeutic alliance) on end-of-treatment opioid abstinence in a sample of youth with OUD (n=152, 40% female, mean age=19.7 years) randomized to receive either 12 weeks of treatment with Bup/Nal (“Bup-Nal”) or up to 2 weeks of Bup/Nal detoxification (“Detox”) with both treatment arms receiving weekly individual and group drug counseling +/- family therapy.

Participants in the Bup-Nal group attended more therapy sessions (16 vs 6 sessions), had increased therapeutic alliance at week 4, and had less opioid use by week 12 compared to those in the Detox group. In both treatment arms, youth who attended more therapy sessions were less likely to have a week 12 opioid positive urine. In a multiple mediator model, therapy dose mediated the association between treatment arm and opioid abstinence.

Conclusions: These findings provide preliminary support for a “dose-response” effect of addiction-focused therapy on abstinence in youth OUD. Further, the results identified a mediating effect of therapy dose on the relationship between treatment assignment and opioid treatment outcomes, suggesting that extended Bup-Nal treatment may enhance abstinence, in part, through a mechanism of therapy facilitation, by increasing therapy dose during treatment.

Related protocols: CTN-0010

Abstract:

This study examined associations of therapeutic alliance and treatment delivery fidelity with treatment retention in Stimulant Abusers to Engage in Twelve-Step (STAGE-12), a community-based trial of 12-Step Facilitation (TSF) conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN). The STAGE-12 trial randomized 234 stimulant abusers enrolled in 10 outpatient drug treatment programs to an eight-session, group and individual TSF intervention. During the study, TSF participants rated therapeutic alliance using the Helping Alliance questionnaire-II (HAq-II). After the study, independent raters evaluated treatment delivery fidelity of all TSF sessions on adherence, competence, and therapist empathy. Poisson regression modeling examined relationships of treatment delivery fidelity and therapeutic alliance with treatment retention (measured by number of sessions attended) for 174 participants with complete fidelity and alliance data. Therapeutic alliance (p=.005) and therapist competence (p=.010) were significantly associated with better treatment retention. Therapist adherence was associated with poorer retention in a nonsignificant trend (p=.061).

Conclusions: Stronger therapeutic alliance and higher therapist competence in the delivery of TSF intervention were associated with better treatment retention whereas treatment adherence was not. Training and fidelity monitoring of TSF should focus on general therapist skills and therapeutic alliance development to maximize treatment retention. This is the first study to show a relationship between therapeutic alliance and retention in TSF with substance abusers, and to identify a significant fidelity-retention relationship for manual-guided TSF treatment, a finding that has important implications for treatment delivery.

Related protocols: CTN-0031

Abstract:

Given high drop-out rates and difficulties with retention among women in treatment for co-occurring post-traumatic stress disorder (PTSD) and substance use disorders (SUD), research to determine the specific conditions under which this population can best be engaged and benefit from treatment is important. This study examined the relationship between racial/ethnic match and treatment outcomes for 224 women who participated in a National Drug Abuse Treatment Clinical Trials Network (CTN) study of group treatments for posttraumatic stress disorder (PTSD) and substance use disorders, “Women’s Treatment for Trauma and Substance Use Disorders” (CTN-0015). Generalized estimating equations were used to examine the effect of client-therapist racial/ethnic match on outcomes.

Results revealed racial/ethnic match was not significantly associated with session attendance. There was a significant three-way interaction between client race/ethnicity, baseline level of PTSD symptoms, and racial/ethnic match on PTSD outcomes. White clients, with severe PTSD symptoms at baseline, who attended treatment groups where they were matched with their therapist, had greater reductions in PTSD symptoms at follow-up than their counterparts who were racially/ethnically mismatched with their group therapist. Racial/ethnic match did not confer additional benefits for black clients in terms of PTSD outcomes. Racial/ethnic match interacted with baseline substance use to differentially influence substance use outcomes at follow-up for all women.

Conclusions: Overall, these findings revealed the complexity of racial/ethnic matching between client and therapist and its impact, particularly within a group treatment context. While racial/ethnic matching may provide, in some circumstances, a context that facilitates understanding, enhances trust, and strengthens the alliance; under other conditions, racial/ethnic matching may not confer additional benefits. These findings highlight the need for further examinations into individual and subgroup differences in the benefits of racial/ethnic matching.

Related protocols: CTN-0015

Abstract:

Analyses of the effectiveness of substance abuse treatments across racial/ethnic groups should ensure that outcome measures have the same conceptual meaning (i.e., measurement equivalence) across groups. Because racial groups differ in perceptions and experiences of the therapeutic alliance, this study investigated measurement equivalence properties of the Revised Helping Alliance Questionnaire (HAq-II) across racial groups. The sample included 138 African Americans and 133 non-Latino White participants, age 18-64 years, who participated in a randomized clinical trial investigating the effectiveness of Motivational Enhancement Therapy in the National Drug Abuse Treatment Clinical Trials Network (CTN-0004). Results demonstrated configural invariance and two forms of metric invariance (weak and strong/scalar), suggesting that conceptualizations of therapeutic alliance and overall levels of endorsement of therapeutic alliance were comparable across racial groups. The groups indicated partial, strict metric nonequivalence. No studies to date reported measurement equivalence properties of the HAq-II.

Conclusions: Findings support valid measurement and interpretation of HAq-II outcomes. This secondary analysis 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.

Related protocols: CTN-0004

Abstract:

In this secondary analysis of data from the National Drug Abuse Treatment Clinical Trials Network protocol CTN-0015 (“Women’s Treatment for Trauma and Substance Use Disorders”), researchers examined the association between the therapeutic alliance and treatment outcomes among 223 women with posttraumatic stress disorder (PTSD) and substance use disorders. General linear models indicated that women who received Seeking Safety, a cognitive-behavioral treatment, had significantly higher alliance ratings than those in Women’s Health Education, a control group. Alliance was related to significant decreases in PTSD symptoms and higher attendance in both interventions. Alliance was not related to substance use outcomes. In all, this study demonstrates that this typically challenging group of women can develop a strong therapeutic alliance within a relatively brief treatment episode in a group format, facilitating reductions in PTSD symptoms and leading to treatment retention.

Related protocols: CTN-0015

Abstract:

Although some research supports patient/therapist similarity in developing a therapeutic alliance more successfully, findings are mixed. The aim of this study was to examine the moderating effects of gender/race matching between therapists and patients on alliance and substance use outcomes. Identical measures were obtained in two CTN trials of MET (CTN-0004 and CTN-0021). Participants were patients (valid N=344) and therapists (valid N=24) participating in these trials who had complete data from the HAQ-II (measuring therapeutic alliance), ASI-Lite data at baseline and week 4 (post-treatment), and indicated perceptions of their provider’s race and gender on a post-treatment questionnaire. The authors hypothesized that patients’ perception of their therapists’ race and gender would (1) affect post-treatment substance use, and (2) moderate the relationship between therapeutic alliance, defined by patient and therapist scores on the HAQ-II, and substance use. The relationship among the variables was examined. Racially matched patients reported significantly fewer days of drug use. However, racial match was unrelated to patient perceived alliance. When HAQ-II therapists’ scores were included in the model, racially matched patients again reported significantly fewer days of drug use. Race matching significantly moderated the relationship between the alliance perceived by therapists and substance use. Gender matched patients reported significantly more days of drug use even after HAQ-II therapists’ scores were included in the model. Gender similarity did not significantly affect the level of alliance indicated by patients or therapists. In conclusion, findings from this study support racial, but not gender, matching.

Related protocols: CTN-0004, CTN-0021

Abstract:

This CTN platform study explored patient, therapist, and program variability in the alliance in relation to drug and alcohol use during treatment, and whether alliance mediates the relation of program characteristics to drug/alcohol use. Data (N = 1,613 patients) were drawn from a randomized clinical trial investigating the efficacy of an intervention that provided alliance and outcome feedback to 112 counselors across 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Program characteristics were measured using the Organization Readiness for Change scale.

Using multilevel modeling, alliance was found to be related to both drug and alcohol use during the past week at the patient and program levels of analysis, but not the counselor level. Several program characteristics were related to average drug and alcohol use. The alliance was not a mediator of these relationships. Program variability in the alliance is important to the alliance-outcome relationship in the treatment of substance abuse. Better outcomes can be achieved by improving both organizational functioning and the patient-counselor alliance.

Abstract:

Protocol CTN-0017, “HIV and HCV Prevention in Drug Treatment Settings” was a study of 632 drug injectors that tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors.

Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to six months; interventions added to standard treatment offered no improvement in risk behavior outcomes. The study supports the importance of access to detoxification for drug injectors followed by transition to continued treatment.

Related protocols: CTN-0017

Abstract:

This ancillary investigation examined the extent to which bilingual counselors initiated informal discussions about topics unrelated to the treatment of their monolingual Spanish-speaking Hispanic clients in a National Drug Abuse Treatment Clinical Trials Network protocol examining the effectiveness of motivational enhancement therapy (MET), protocol CTN-0021. Session audiotapes were independently rated to assess counselor treatment fidelity and the incidence of information discussions. Eighty-three percent of the 23 counselors participating in the trial initiated informal discussions at least once in one or more of their sessions. Counselors delivering MET in the trial initiated informal discussion significantly less often than the counselors delivering standard treatment. Counselors delivering standard treatment were likely to talk informally the most when they were ethnically non-Latin. In addition, informal discussion was found to have significant inverse correlations with client motivation to reduce substance use and client retention in treatment.

Together with the results from the English version of this study (Martino et al, 2009, record 320), these findings suggest that a meaningful proportion of counselors initiate discourse during sessions that is unrelated to the issues for which their clients sought treatment and that such discourse may be experienced negatively by clients. As in the English MET trials, training and supervision of counselors in MET for use with Spanish-speaking clients may help reduce the occurrence of informal discussions and keep conversations focused on those topics most pertinent to retaining clients in treatment and enhancing their motivation to change their substance use.

Related protocols: CTN-0021

Abstract:

Therapeutic alliance, treatment satisfaction, and treatment participation have been associated with patient outcomes in substance abuse treatment programs. Available literature contends treatment outcomes are impacted on multiple levels by the interaction of patient-, clinician-, and program-level variables. Evidence suggests relationships between: patients’ engagement in treatment and program characteristics and functioning; treatment quality and clinicians’ caseload size; and organizational functioning and patients’ treatment satisfaction and therapeutic alliance.

Results from this study, which used baseline data from the Patient Feedback study (protocol CTN-0016), support previous findings on the relationship between organizational functioning and patient outcomes, operationalized as patients’ ratings of therapeutic alliance, treatment satisfaction, treatment duration, and self-reported substance use. Results provide further evidence on clinician-level variables, such as clinicians’ background and demographics, impact on patient engagement in treatment and abstinence from substances.

Related protocols: CTN-0016

Abstract:

Evidence-based treatment has become a strong emphasis in the addiction field. From results of trials comparing one treatment to another, we now have many treatment methods that are science based. The science base also includes many studies showing that relationship matters; it makes a difference not just what treatment is delivered, but who provides it and how. One of the strongest determinants of addiction treatment outcome is the provider with whom the patient works. Therapeutic alliance, describing the quality of the relationship between the patient and provider, appears to be a strong contributing factor defining the quality of the relationship between the patient and provider.

Building on an examination of alliance tested in one of the National Drug Abuse Treatment Clinical Trials Network studies on motivational interviewing (MI) (CTN-0004, “MET (Motivational Enhancement Treatment) to Improve Treatment Engagement and Outcome in Subjects Seeking Treatment for Substance Abuse”), this study examined the impact of therapeutic alliance across three multi-site CTN MI/MET trials (CTN-0004, CTN-0005, and CTN-0021) to determine whether participants’ and therapists’ perceptions of therapeutic alliance were associated with self-reported days of use.

Related protocols: CTN-0004, CTN-0005, CTN-0021

Abstract:

Protocol CTN-0016 (“Patient Feedback: A Performance Improvement Study in Outpatient Addiction Treatment”) examined the feasibility of the implementation of a semiautomatic performance improvement system directed at clinicians in addiction treatment facilities called “patient feedback.” The study found that implementation of the program was generally feasible from both a research and a clinical perspective. This article reports on the results of a randomized, controlled trial evaluating the actual efficacy of the patient feedback system. The study involved 118 clinicians working at 20 community-based outpatient substance abuse treatment clinics in the northeastern United States (including some CTPs from the CTN). Ten clinics received 12 weeks of the patient feedback performance improvement intervention, and 10 clinics received no intervention during the 12 weeks. More than 1,500 patients provided anonymous ratings of therapeutic alliance, treatment satisfaction, and drug/alcohol use. There was no evidence of an intervention effect on the primary drug and alcohol use scales. There was also no evidence of an intervention effect on secondary measures of therapeutic alliance. Clinician-rated measures of organizational functioning and job satisfaction also showed no intervention effect. Possible insights from these findings and alternative methods of utilizing feedback reports to enhance clinical outcomes are proposed.

Related protocols: CTN-0016

Abstract:

This article examines variables that predicted outpatient treatment entry within six months of residential detoxification. Patient data were collected from 632 injection drug users enrolled in a randomized trial conducted at eight detoxification programs within the National Drug Abuse Treatment Clinical Trials Network (CTN) with follow-up assessments conducted at 2, 8, 16, and 24 weeks (protocol CTN-0017, “HIV and HCV Intervention in Drug Treatment Settings”). Detoxification program characteristics were collected during this study and from a survey of CTN treatment organizations. Survival analysis found that estimated proportions of reported outpatient treatment entry varied across sites from .06 to .72. A model-building approach determined variables significantly associated with outpatient treatment entry. The best predictive model contained five program-level variables: accreditation, fewer beds, longer stays, shorter distance between detoxification and outpatient unit, and the larger city population.

This study suggests that smaller detoxification units with longer lengths of stay and treatment services nearby may boost rates of continuing treatment beyond detoxification for injecting drug users. In addition, innovative research should combine what are typically separate areas of inquiry, for example, matching patients to program variations and examining multilevel interventions that target both patient-level change and programmatic quality improvement.

Related protocols: CTN-0017