Faculty Bibliography

OBJECTIVE:Training through traditional workshops is relatively ineffective for changing counseling practices. Teleconferencing supervision (TCS) was developed to provide remote, live supervision for training motivational interviewing (MI). METHOD/METHODS:Ninety-seven drug treatment counselors completed a 2-day MI workshop and were randomized to live supervision via teleconferencing (TCS; n = 32), standard tape-based supervision (tape; n = 32), or workshop alone (workshop; n = 33). Supervision conditions received 5 weekly supervision sessions at their sites using actors as standard patients. Sessions with clients were rated for MI skill with the Motivational Interviewing Treatment Integrity (MITI) Coding System pre-workshop and 1, 8, and 20 weeks post-workshop. Mixed-effects linear models were used to test training condition on MI skill at 8 and 20 weeks. RESULTS:TCS scored better than workshop on the MITI for spirit (mean difference = 0.76; p < .0001; d = 1.01) and empathy (mean difference = 0.68; p < .001; d = 0.74). TCS was superior to workshop in reducing MI non-adherence and was superior to workshop and tape in increasing reflection to question ratio. Tape was superior to TCS in increasing complex reflections. Percentage of counselors meeting proficiency differed significantly between training conditions for the most stringent threshold (spirit and empathy scores ≥ 6). CONCLUSIONS:TCS shows promise for promoting new counseling behaviors following participation in workshop training. However, further work is needed to improve supervision methods to bring more clinicians to high levels of proficiency and facilitate dissemination of evidence-based practices.

OBJECTIVE:To investigate the association between substance use disorders (SUDs) and the clinical presentation, risk factors, and correlates of major depressive disorder (MDD) by examining differences among 3 groups: (1) individuals with lifetime MDD and no comorbid SUD (MDD-NSUD); (2) individuals with comorbid MDD and SUD (MDD-SUD); and (3) individuals with substance-induced depressive disorder (SIDD). METHOD/METHODS:Data were derived from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093). Diagnoses were made using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. RESULTS:The lifetime prevalence of MDD-NSUD was 7.41%, whereas those of MDD-SUD and SIDD were 5.82% and 0.26%, respectively. Overall, risk factors for MDD were more common among individuals with MDD-SUD and SIDD than among those with MDD-NSUD. Individuals with MDD-SUD and SIDD had similar rates of comorbidity with any psychiatric disorder, but both groups had higher rates than individuals with MDD-NSUD (odds ratio [OR] = 2.3; 95% CI, 1.9-2.7 and OR = 2.5; 95% CI, 1.4-4.4, respectively). Individuals with SIDD were significantly less likely to receive medication than those with MDD-SUD or MDD-NSUD (OR = 0.5; 95% CI, 0.3-0.9 for both groups). CONCLUSIONS:MDD-SUD is associated with high overall vulnerability to additional psychopathology, a higher number of and more severe depressive episodes, and higher rates of suicide attempts in comparison to individuals with MDD-NSUD. SIDD has low prevalence in the general population but is associated with increased clinical severity and low rates of medication treatment. Similar patterns of comorbidity and risk factors in individuals with SIDD and those with MDD-SUD suggest that the 2 conditions may share underlying etiologic factors.

BACKGROUND:Opioid dependence is a significant public health problem associated with high risk for relapse if treatment is not ongoing. While maintenance on opioid agonists (i.e., methadone, buprenorphine) often produces favorable outcomes, detoxification followed by treatment with the μ-opioid receptor antagonist naltrexone may offer a potentially useful alternative to agonist maintenance for some patients. METHOD/METHODS:Treatment approaches for making this transition are described here based on a literature review and solicitation of opinions from several expert clinicians and scientists regarding patient selection, level of care, and detoxification strategies. CONCLUSION/CONCLUSIONS:Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days up to the target dose of naltrexone. However, more research is needed to empirically validate the best approach for making this transition.

The authors conducted systematic searches in standard databases using key search terms related to epidemiology, prevalence, and co-occurring substance use and other mental disorders (COD), as well as specific combinations of drug and mental disorders. The authors targeted high-quality, large sample epidemiological surveys so as to utilize studies of high methodological rigor in the construction of recommendations for clinical identification. Further refined searches to identify these studies revealed common themes and related research gaps. Findings suggest that clinicians should have increased expectation that a patient with a substance use disorder (SUD) has a co-occurring mental disorder if the SUD is relatively severe, if the patient began using substances (including tobacco) at an early age, is female, is dependent on nicotine, or has a drug use disorder. Patients identified as having at least one SUD and one co-occurring mental disorder should be assessed to identify other likely CODs, because disorders are not normally distributed and tend to cluster in relatively few individuals.

BACKGROUND:Psychosocial interventions for substance dependence have demonstrated efficacy. However, the mechanisms by which specific intervention strategies exert their effect have not been clearly identified. OBJECTIVE:This study investigated the prospective relationships between two psychological processes, an attentional bias toward cocaine stimuli and beliefs about the consequences of cocaine use, and treatment outcome. METHOD/METHODS:Twenty-five cocaine-dependent participants enrolled in a 6-month outpatient treatment program that included voucher incentives for abstinence. All participants were asked to complete two implicit assessment procedures, a Drug Stroop protocol and an Implicit Relational Assessment Procedure (IRAP), as well as explicit measures of cocaine craving and the consequences of cocaine use, prior to beginning treatment. Pearson's correlation coefficients tested the prospective relationships between treatment outcome and the implicit and explicit assessments. RESULTS:Stronger implicit beliefs about the positive effects of cocaine use prior to treatment were associated with poorer treatment outcome when an escalating voucher-incentive program was in place. Further, an attentional bias for cocaine-related stimuli was associated with better treatment outcome when an escalating voucher-incentive program was removed. No association between cocaine use beliefs and treatment outcome was found when beliefs were measured with self-report instruments. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE/CONCLUSIONS:These findings highlight the potential utility of performance-based measures for delineating the psychological mechanisms associated with variation in response to treatment for drug dependence.

OBJECTIVE:This study uses data from the largest effectiveness trial to date on treatment of co-occurring posttraumatic stress and substance use disorders, using advances in statistical methodology for modeling treatment attendance and membership turnover in rolling groups. METHOD/METHODS:Women receiving outpatient substance abuse treatment (N = 353) were randomized to 12 sessions of Seeking Safety or a health education control condition. Assessments were completed at baseline and at 1 week, 3, 6, and 12 months posttreatment. Outcome measures were alcohol and cocaine use in the prior 30 days captured using the Addiction Severity Index. Latent class pattern mixture modeling (LCPMM) was used to estimate attendance patterns and to test for treatment effects within and across latent attendance patterns and group membership turnover. RESULTS:Across LCPMM analyses for alcohol and cocaine use, similar treatment attendance patterns emerged: Completers never decreased below an 80% probability of attendance, droppers never exceeded a 41% probability of attendance, and titrators demonstrated a 50% to 80% probability of attendance. Among completers, there were significant decreases in alcohol use from baseline to 1-week posttreatment, followed by nonsignificant increases in alcohol during follow-up. No differences between treatment conditions were detected. Titrators in Seeking Safety had lower rates of alcohol use from 1-week through 12-month follow-up compared with control participants. Droppers had nonsignificant increases in alcohol during both study phases. Cocaine use findings were similar but did not reach significance levels. CONCLUSIONS:The impact of client self-modulation of treatment dosage and group membership composition may influence behavioral treatment outcomes among this population.

Computer-assisted interventions hold the promise of minimizing two problems that are ubiquitous in substance abuse treatment: the lack of ready access to treatment and the challenges to providing empirically-supported treatments. Reviews of research on computer-assisted treatments for mental health and substance abuse report promising findings, but study quality and methodological limitations remain an issue. In addition, relatively few computer-assisted treatments have been tested among illicit substance users. This manuscript describes the methodological considerations of a multi-site effectiveness trial conducted within the National Institute on Drug Abuse's (NIDA's) National Drug Abuse Treatment Clinical Trials Network (CTN). The study is evaluating a web-based version of the Community Reinforcement Approach, in addition to prize-based contingency management, among 500 participants enrolled in 10 outpatient substance abuse treatment programs. Several potential effectiveness trial designs were considered and the rationale for the choice of design in this study is described. The study uses a randomized controlled design (with independent treatment arm allocation), intention-to-treat primary outcome analysis, biological markers for the primary outcome of abstinence, long-term follow-up assessments, precise measurement of intervention dose, and a cost-effectiveness analysis. Input from community providers during protocol development highlighted potential concerns and helped to address issues of practicality and feasibility. Collaboration between providers and investigators supports the utility of infrastructures that enhance research partnerships to facilitate effectiveness trials and dissemination of promising, technologically innovative treatments. Outcomes from this study will further the empirical knowledge base on the effectiveness and cost-effectiveness of computer-assisted treatment in clinical treatment settings.

Novel approaches to the treatment of stimulant abuse and dependence are needed. Clinical data examining the use of exercise as a treatment for the abuse of nicotine, alcohol, and other substances suggest that exercise may be a beneficial treatment for stimulant abuse. In addition, exercise has been associated with improvements in many other health-related areas that may be adversely affected by stimulant use or its treatment, such as sleep disturbance, cognitive function, mood, weight, quality of life, and anhedonia. Neurobiological evidence provides plausible mechanisms by which exercise could positively affect treatment outcomes in stimulant abuse. The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) CTN-0037 Stimulant Reduction Intervention using Dosed Exercise (STRIDE) study is a multisite randomized clinical trial that compares exercise to health education as potential treatments for stimulant abuse or dependence. If effective, exercise may provide an additional approach to the treatment of stimulant use disorders.

Although the selection of appropriate clinical sites has a significant impact on the successful conduct of clinical trials, no generally accepted model is available for site selection. Use of an appropriate site selection process is even more pertinent when conducting large scale, practical clinical trials in practice settings. This report provides a rationale for selecting sites by identifying both a set of basic site selection criteria important to most trials as well as criteria specific to the features of a particular study's design. In this two-tier system, although all these criteria must be met, some criteria are firm and viewed as essential for a site to conduct the trial. Other criteria, such as those that support study recruitment or participant retention, are flexible. These flexible criteria may be addressed through several alternative solutions that meet the original intent of the criterion. We illustrate how the study specific features and requirements of Stimulant Reduction Intervention using Dosed Exercise (STRIDE), a multisite clinical trial evaluating the efficacy of exercise or health education, added to treatment as usual for stimulant abuse are linked to firm and flexible site selection criteria. We also present an iterative, multi-step approach to site selection including building awareness about the study and screening and evaluating sites using these criteria. This simple model could maximize the chance that selected sites will implement a study successfully and achieve trial aims. It may be helpful to researchers who are developing criteria and methods for site selection for specific clinical trials.

OBJECTIVES/OBJECTIVE:To compare the progression of substance use milestones between cocaine- and cannabis-dependent patients. METHODS:Using data gathered from two separate clinical studies for treatment of cocaine dependence and cannabis dependence, 130 cannabis-dependent and 112 cocaine-dependent individuals were compared on milestones related to their substance use. RESULTS:In cannabis- vs. cocaine-dependent patients, the mean age of first use, regular use and first treatment contact differed significantly. No statistically significant differences were found between the two groups for other measured milestones. CONCLUSIONS:These results differ from most epidemiologic studies that suggest cocaine users progress more rapidly to regular use and treatment contact.