Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmations, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.
Motivational interviewing; Dually diagnosed; Substance abuse; Psychotic disorder; Treatment engagement
Clinical research is increasingly being conducted in community-based addiction treatment settings. While the primary focus of such research is on the development of effective clinical interventions, less attention has been paid to the potential impact of these projects on counseling staff who are involved in their implementation. Such involvement may be perceived as stressful or rewarding, and these perceptions may be associated with counselors’ turnover intention. Using data from 207 counselors involved in research projects conducted within the National Institute on Drug Abuse’s Clinical Trials Network (CTN), this study examines the associations between counselors’ reactions to research experiences and turnover intention. When counselors perceived that research projects resulted in organizational benefits, turnover intention was significantly lower. However, there was a positive association between perceptions of research-related stressors and turnover intention. These findings suggest that the impact of clinical trials on treatment organizations and staff members warrants continued study.
clinical trials; turnover intention; substance abuse treatment counselors
Drug users are marginalized from typical primary care, often resulting in emergency department (ED) usage and hospitalization due to late-stage disease. Though data suggest methadone decreases such fragmented healthcare utilization (HCU), the impact of buprenorphine maintenance treatment (BMT) on HCU is unknown. Chart review was conducted on opioid dependent patients seeking BMT, comparing individuals (N=59) who left BMT ≤ 3 days with those retained on BMT (N=150), for ED use and hospitalization. Using negative binomial regressions, including comparison of time before BMT induction, ED utilization and hospitalization was assessed. Overall, ED utilization was 0.93 events per person year and was significantly reduced by BMT, with increasing time (retention) on BMT. BMT had no significant effect on hospitalizations or average length of stay.
buprenorphine; methadone; substance abuse; opioid dependence; healthcare utilization; emergency department utilization; hospitalization; longitudinal cohort
Chronic hepatitis C virus (HCV) infection is highly prevalent among current and former drug users. However, the minority of patients enrolled in drug treatment programs have initiated HCV treatment. New models are needed to overcome barriers to care. In this retrospective study, we describe the implementation and outcomes of 42 patients treated in a Concurrent Group Treatment (CGT) program. Patients participated in weekly provider-led group treatment sessions which included review of side effects; discussion of adherence and side effect management; administration of interferon injections; brief physical exam; and ended with brief meditation. Of the first 27 patients who initiated CGT, 42% achieved a sustained viral response. Additionally, 87% (13/15) of genotype-1 infected patients treated with direct acting antiviral agent achieved an undetectable viral load at 24 weeks. The CGT model may be effective in overcoming barriers to treatment and improving adherence and outcomes among patients enrolled in drug treatment programs.
We examinedthe effect ofthe quality of primary care-basedchronic disease management (CDM)for alcohol and/or other drug (AOD) dependenceonaddiction outcomes.We assessed qualityusing 1)avisit frequencybased measure and 2) a self-reported assessment measuring alignment with the chronic care model. The visit frequency based measure had no significant association with addiction outcomes. Theself-reported measure of care - when care was at a CDM clinic - was associated with lower drug addiction severity.The self-reported assessment of care from any healthcare source (CDM clinic or elsewhere)was associated with lower alcoholaddiction severity and abstinence.These findings suggest that high quality CDM for AOD dependence may improve addiction outcomes.Quality measuresbased upon alignment with the chronic care model may better capture features of effective CDM care than a visitfrequency measure.
Brief intervention (BI) can reduce harmful and hazardous drinking among emergency department patients. However, no psychometrically-validated instrument for evaluating the extent to which practitioners correctly implement BIs in clinical practice (e.g., adherence) exists. We developed and subsequently examined the psychometric properties of a scale that measures practitioner adherence to a BI, namely the Brief Negotiation Interview (BNI). Ratings of 342 audio-taped BIs in the emergency department demonstrated that the BNI Adherence Scale (BAS) has: 1) excellent internal consistency and discriminant validity; 2) good to excellent inter-rater reliability, and 3) good construct validity, with an 8-item, 2-factor structure accounting for 62% of the variance, but 4) no predictive validity in this study. The BAS provides practitioners with a brief, objective method to evaluate their BNI skills and give feedback to them about their performance.
Brief Intervention; Practitioner Adherence; Harmful and Hazardous Drinking; Emergency Department; Assessment; Psychometrics
In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of College policy targeting integrated substance abuse treatment at trauma centers.
Devising interventions to provide integrated treatment for addiction and medical problems is an urgent issue. This study piloted a structural intervention, Directly Administered Antiretroviral Therapy (DAART), to assist methadone-maintenance patients in HIV medication adherence. Twenty-four participants received: 1) antiretroviral medications at the methadone clinic daily before receiving their methadone; 2) take-home antiretroviral medication for days they were not scheduled to attend the methadone clinic, and 3) brief adherence counseling to address adherence barriers. DAART lasted 24 weeks, with a planned step-down to twice-weekly administration in weeks 25–36, followed by self-administration in weeks 37–48. Retention rates at weeks 24, 36, and 48 were 83%, 92%, and 75% respectively. DAART was associated with improvement in the proportion of participants achieving viral suppression as well as with high medication adherence rates (clinic-verified; 85% and self-reported 97%) during the active intervention phase. DAART was effective as an intervention but did not promote transition to self-administration. This study demonstrates that DAART is adaptable and simple enough to be implemented into methadone treatment programs interested in providing HIV adherence services.
HIV/AIDS; Drug Abuse Treatment; Antiretroviral Therapy
Computer-based brief motivational interventions may be able to reach a high proportion of at-risk individuals and thus have potential for significant population impact. The present studies were conducted to determine the acceptability and preliminary efficacy of a computer-based brief motivational intervention (the motivation enhancement system, or MES). In Study 1, quantitative and qualitative feedback from 30 postpartum women and 17 women in treatment for drug use were used to modify the software. In Study 2, 50 urban postpartum women who reported drug use in the month before pregnancy completed the intervention and provided repeated within-session ratings of state motivation. In Study 3, 30 women were randomly assigned to intervention or control conditions with 1-month follow-up. Overall, women rated the MES as highly acceptable and easy to use and reported significant increases in state motivation at postintervention and at 1-month follow-up (d = .49). These preliminary results are encouraging and suggest that further work in this area is warranted.
Drugs; Computer-based; Perinatal; Motivation; Brief intervention
Group Motivational Interviewing (MI) interventions that target youth at-risk for alcohol and other drug (AOD) use may prevent future negative consequences. Youth in a teen court setting (n=193; 67% male, 45% Hispanic; mean age 16.6 (SD = 1.05) were randomized to receive either a group MI intervention, Free Talk, or usual care (UC). We examined client acceptance, intervention feasibility and conducted a preliminary outcome evaluation. Free Talk teens reported higher quality and satisfaction ratings, and MI integrity scores were higher for Free Talk groups. AOD use and delinquency decreased for both groups at three months, and 12-month recidivism rates were lower but not significantly different for the Free Talk group compared to UC. Results contribute to emerging literature on MI in a group setting. A longer term follow-up is warranted.
In 1995, Miller and C’de Baca created a 50-item measure, the Alcohol Education Inventory (AEI), to assess mental health professionals’ basic knowledge of alcohol and alcohol problems. The purpose of this study was to update the AEI based on advances in the field since its publication. The AEI-Revised (AEI-R) consists of 13 of the original AEI items, 30 items that were revised and updated, and 7 new items. The AEI-R was administered to 90 mental health trainees with percentage correct ranging from 60% (psychology postdoctoral fellows) to 70% (psychiatry residents). The percent correct is very similar to that found on the original AEI (64%–70%). Survey results suggest that alcohol-related knowledge by mental health professionals in general training is less than adequate. The AEI-R may be useful as a tool to assess basic knowledge of alcohol among mental health professionals.
Alcohol Education Inventory; Alcohol Education Inventory—Revised
The Hmong are a distinct ethnic group from Laos. Little is known about how opiate addicted Hmong respond to methadone maintenance treatment. Therefore, opium addicted Hmong (exclusive route of administration: smoking) attending an urban methadone maintenance program in Minneapolis, Minnesota were matched by gender and date of admission with predominately heroin addicted non-Hmong (predominant route of administration: injection) attending the same program and both groups were evaluated for 1-year treatment retention, stabilization dose of methadone, and urine drug screen results. Hmong had greater 1-year treatment retention (79.8%) than non-Hmong (63.5%; p<0.01). In both groups, methadone dose was significantly associated with retention (p=0.005). However, Hmong required lower doses of methadone for stabilization (mean 49.0 mg versus 77.1 mg; p<0.0001). For both groups, positive urine drug screens were associated with stopping treatment. Further research to determine levels of tolerance, psychosocial, and pharmacogenetic factors contributing to differences methadone treatment outcome and dosing in Hmong may provide further insight into opiate addiction and its treatment.
Methadone; opiate dependence; treatment outcome; ethnicity; Hmong
Employment is commonly upheld as an important outcome of addiction treatment. To explore this attribution we assessed whether treatment enrolment predicts employment initiation among participants enrolled in a community-recruited Canadian cohort of people who inject drugs (IDU) (n=1579). Survival analysis initially found no association between addiction treatment enrolment and employment initiation. However, when methadone maintenance therapy (MMT) was separated from other treatment modalities, non-MMT treatment positively predicted employment transitions, while MMT was negatively associated with employment initiation. Sub-analyses examining transitions into temporary, informal and under-the-table income generation echo these results. Findings suggest that individual factors impacting employment transitions may systematically apply to MMT clients, and that, in this setting, the impact of treatment on employment outcomes is contingent on treatment type and design. Treatment-specific differences underscore the need to expand low-threshold MMT, explore MMT alternatives and evaluate the impact of treatment design on the social and economic activity of IDU.
employment; addiction treatment; methadone maintenance therapy; Vancouver; injection drug use
The therapeutic alliance is deemed to be integral to psychotherapeutic interventions, yet little is known about the nature of its role in treatment for substance use disorders (SUD), especially among young people. We investigated baseline predictors of the therapeutic alliance measured mid-treatment, and tested whether the alliance influenced during-treatment changes in key process variables (psychological distress, motivation, self-efficacy, coping skills, and commitment to AA/NA) independent of these baseline influences. Young adults in residential treatment (N=303; age 18-24) were assessed at intake, mid-treatment, and discharge. Older age and higher baseline levels of motivation, self-efficacy, coping skills, and commitment to AA/NA predicted a stronger alliance. Independent of these influences, participants who developed a stronger alliance achieved greater reductions in distress during treatment. Findings clarify a role for alliance in promoting during-treatment changes through reducing distress.
young adults; substance use treatment; therapeutic alliance; motivation
The relationship between fatherhood and both psychiatric distress and severity of substance abuse (SA) among men entering SA treatment has not been well explored. This study was designed to (a) examine differences in symptoms of men presenting for SA assessment based on fatherhood status and (b) determine how PTSD symptoms and severity of SA were associated with parenting for men who were fathers.
PTSD symptoms, severity of SA and parenting data reported on structured questionnaires were collected from 126 men presenting for an SA evaluation at a forensic drug diversion clinic.
There were no differences in severity of alcohol or drug use between fathers and non-fathers; however fathers with more PTSD symptoms reported greater severity of alcohol and drug use. Among the fathers, PTSD symptoms correlated significantly and positively with negative parenting behaviors, while SA did not. Fathers with more significant PTSD symptoms were more likely to want help with parenting.
Further exploration of the impact of trauma related symptoms on the parenting behaviors of substance-abusing men is warranted.
Prescription opioid (PO) dependent treatment presentations are becoming increasingly common, however, most research on the treatment of opioid dependent populations has been conducted in heroin users. The aim of this secondary data analysis was to compare the buprenorphine induction experience of 167 heroin and 61 PO users. Results demonstrate that although the groups differed on some baseline characteristics, many of the key induction experience variables were comparable between the groups. Heroin users were found to have significantly higher pre-induction Clinical Opiate Withdrawal Scale (COWS) scores (p = .014) and post-induction COWS score (p = .008) compared to the PO users. No differences between groups were found for self-reported craving and withdrawal scores, mean buprenorphine dose on day 1, or retention at the end of the first week. The findings of this study suggest existing buprenorphine induction practices developed for heroin users appear to be equally effective with PO users.
Buprenorphine induction; prescription opioid; treatment
A new skin and needle hygiene intervention, designed to reduce high-risk injection practices associated with bacterial and viral infections, was tested in a pilot, randomized controlled trial. Participants included 48 active heroin injectors recruited through street outreach and randomized to either the two-session intervention or an assessment-only condition (AO) and followed for six months. The primary outcome was skin and needle cleaning behavioral skills measured by videotaped demonstration. Secondary outcomes were high-risk injection practices, intramuscular injection, and bacterial infections. Intervention participants had greater improvements on the skin (d = 1.00) and needle cleaning demonstrations (d = .52) and larger reductions in high-risk injection practices (d = .32) and intramuscular injection (d = .29), with a lower incidence rate of bacterial infections (HR = .80), at 6-months compared to AO. The new intervention appears feasible and promising as a brief intervention to reduce bacterial and viral risks associated with drug injection.
injection drug use; bacterial infections; intervention; randomized controlled trial; risk reduction; heroin
This is a randomized, double blind, placebo-controlled study of modafinil treatment for cocaine dependence. Patients (n=210), who were actively using cocaine at baseline, were randomized to 8-weeks of modafinil (0 mg/day, 200 mg/day or 400 mg/day) combined with once-weekly cognitive behavioral therapy (CBT). Our primary efficacy measure was cocaine abstinence, based on urine benzoylecgonine (BE) levels, with secondary measures of craving, cocaine withdrawal, retention and tolerability. We found no significant differences between modafinil and placebo patients on any of these measures. However, there was a significant gender difference in that male patients treated with 400 mg/day tended to be more abstinent than their placebo-treated counterparts (p=0.06). Our negative findings might be explained by gender differences and/or inadequate psychosocial treatment intensity in patients with severe cocaine dependence.
modafinil; cocaine; pharmacotherapy; abstinence; addiction
The current study examined the longitudinal association between substance use and depressive symptoms, in veterans receiving outpatient treatment for comorbid substance use disorder and major depression. Veterans (N =237, mean age = 48.2 years, 90% male, 70% Caucasian) received either six months of group Integrated Cognitive-Behavioral Therapy or Twelve-Step Facilitation. Hamilton Depression Rating Scale scores and Percent Days Using any substance were assessed every 3 months up to one year post-treatment. Greater substance use predicted time-varying elevations in depression above individual patterns of change in depression. Moreover, change in depressive symptoms was associated with change in both the likelihood of any substance use and the frequency of use during the treatment and follow-up periods. Changes in these symptoms appear to be linked, such that individuals with greater reductions in substance use have greater reductions in depressive symptoms (and vice versa).
Comorbidity; latent growth curve; parallel process; depressive symptoms; substance use
Light smoking is particularly prevalent among Latino smokers. Nicotine replacement (NRT) and varenicline are effective medications for smoking cessation for moderate-heavy smokers, but have not been tested in light smokers and thus there are no treatment guidelines for use with light smokers. This pilot trial tested the efficacy of NRT and varenicline in increasing smoking abstinence among Latino light smokers. A 3-group (NRT, varenicline, varenicline-placebo) randomized design was used and Latino light smokers (≤10 cpd) received 12 weeks of treatment which included a culturally-informed behavioral health session and ongoing medication management visits. At follow-up, there were no abstinent participants in the placebo and NRT groups. However, 30% of participants in the varenicline group were abstinent at the 3, 4, and 6 month follow-up. This study represents the only investigation that specifically targets Latino light smokers using these treatments and characterizing their treatment adherence.
Latinos; Hispanics; light smokers; varenicline; adherence; NRT
Interventions for alcohol and substance dependent adults with comorbid depressive disorders are needed, but few have been empirically tested. In a randomized clinical trial of two psychotherapy interventions for these disorders, we examined whether initial focus of treatment was related to retention, substance use, and depression outcomes. Both interventions, Integrated Cognitive Behavioral Therapy (ICBT; n=105) and Twelve Step Facilitation (TSF; n=92), were delivered in group formats with entry points every four weeks at the beginning of three content-distinct modules. Entry module (i.e., initial treatment focus) was not related to percentage days abstinent, proportion of the sample abstinent, or depression symptoms for either intervention. This was true at both 12 and 24 weeks post baseline. Furthermore, attendance was similar for both treatments, regardless of initial treatment focus, with a single exception in the ICBT condition. Our findings support the use of modular formats with multiple or rotating entry points for psychotherapy group interventions.
Previous research has documented the difficulty individuals with alcohol use disorders have initiating alcohol treatment. This study assessed the feasibility of a brief, cognitive behavioral intervention designed to increase treatment initiation among individuals with alcohol use disorders.
This randomized controlled trial included one hundred and ninety six participants who screened positive for a possible alcohol use disorder on the AUDIT. Randomly assigned intervention participants were administered a brief cognitive-behaviorally-based intervention by phone designed to modify beliefs that may interfere with treatment-seeking behavior. Beliefs about treatment and treatment-seeking behavior were assessed post-intervention.
Participants receiving the intervention had significantly improved their attitudes toward addiction treatment (p < 0.002) and increased their reported intention to seek treatment (p < 0.000) post-intervention. Further, intervention participants were almost three times more likely to attend treatment within a three-month period (OR = 2.60, p < 0.025) than participants in the control group.
A brief, cognitive-behavioral intervention delivered by phone and focused on modifying treatment interfering beliefs holds promise for increasing alcohol treatment-seeking among individuals in need.
This study examined the system-level effects of implementing a promising treatment for adolescent substance abuse in juvenile drug courts (JDCs). Six JDCs were randomized to receive training in the experimental intervention (contingency management-family engagement, CM-FAM) or to continue their usual services (US). Participants were 104 families served by the courts, 51 therapists, and 74 JDC stakeholders (e.g., judges, prosecutors, defense attorneys). Assessments included repeated measurements of CM-FAM implementation by therapists as well as therapist and stakeholder perceptions of incentive-based interventions and organizational characteristics. Results revealed greater use of CM and family engagement techniques among CM-FAM relative to US therapists. In addition, therapists and stakeholders in the CM-FAM condition reported more favorable attitudes toward the use of incentives and greater improvement on several domains of organizational functioning relative to US counterparts. Taken together, these findings suggest that JDC professionals’ are amenable to the adoption and implementation of a treatment model that holds promise for improving youth outcomes.
Contingency management; substance use; drug court; adolescent; family
This study evaluates the effectiveness of Motivational Enhancement Therapy/Cognitive Behavioral Therapy-5 (MET/CBT-5) when delivered in community practice settings relative to standard community-based adolescent treatment. A quasi-experimental strategy was used to adjust for pre-treatment differences between the MET/CBT-5 sample (n = 2293) and those who received standard care (n = 458). Results suggest that youth who received MET/CBT-5 fared better than comparable youth in the control group on five out of six 12-month outcomes. A low follow-up rate (54%) in the MET/CBT-5 sample raised concerns about nonresponse bias in the treatment effect estimates. Sensitivity analyses suggest that while modest differences in outcomes between the MET/CBT-5 nonrespondents and respondents would yield no significant differences between the two groups on two of the six outcomes, very large differences in outcomes between responders and nonresponders would be required for youth receiving MET/CBT-5 to have fared better had they received standard outpatient care.
adolescent outpatient treatment; marijuana; outcomes; evidence supported treatments; quality assurance
Contingency management (CM) is widely recognized as an evidence-based practice, but it is not widely used in either treatment settings or justice settings. CM is perceived as adaptable in justice settings given the natural inclination to use contingencies to improve compliance to desired behaviors. In the Justice Steps implementation study, five federal district court jurisdictions agreed to consider implementing CM in specialized problem-solving courts or probation settings. A baseline survey (n=186) examined the acceptance and feasibility of using rewards as a tool to manage offender compliance. The results of the survey revealed that the majority of respondents believe that rewards are acceptable, with little difference between social and material rewards. Survey findings also showed that female justice workers and those who were not Probation Officers were more accepting of material rewards than their counterparts. Findings are consistent with prior research in drug treatment settings where there is little concern about using rewards.