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Director's Report to the National Advisory Council on Drug Abuse - February, 2008

Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse

Sleeping On the Job Relates to Productivity in Employed Abstinent Methadone Maintained Cocaine Users

Drug abusers are at high risk for being terminated from both competitive and supported employment positions. This issue is important because gainful employment is essential for full integration into society. This study examined professional demeanor in fifty-three methadone maintained cocaine abusers who were participating in a unique “therapeutic workplace” study in which cocaine abstinence was required for entry to training and employment as data entry operators. In the therapeutic workplace, professional demeanor was directly tied to training and payment opportunities. Staffs were instructed to record and provide written and standardized verbal corrections for all violations of professional demeanor including loud talking, vulgar language, unprofessional communication (such as threats or aggression towards staff or participants) sleeping on the job, or eating or drinking at a desk with an uncovered computer keyboard. If the behavior continued, sanctions including removal from the workplace for escalating time periods were implemented. Overall, the frequency of major disruptive behavior was low, but on average, each participant experienced close to 2 professional demeanor violations a week. Despite losing training opportunities and pay and advancement opportunities, sleeping was a serious problem for a number of participants. Sleeping was the main behavior related to training outcomes (typing achievement and accuracy) and hours worked. This study is important because it sheds light on behaviors drug abusers exhibit in workplaces which may increase their likelihood of termination. More research is needed on why sleeping violations for this population occurs at such high frequency and on ways to mitigate the effect of sleepiness on employed drug abusers attempting to maintain abstinence. Carpenedo, C., Needham, M., Knealing, T., Kolodner, K., Fingerhood, M., Wong, C.J., Silverman, K. Professional Demeanor of Chronically Unemployed Cocaine-Dependent Methadone Patients in a Therapeutic Workplace. Substance Use and Misuse, 42(7) pp. 1141-1159, 2007.

Directly Observed HIV Therapy Superior to Self-Administered Treatment

Adherence to antiretroviral therapy among HIV positive drug users is often poor. This study aimed to determine whether directly observed anti-retroviral therapy (DAART) administered under observation by workers from a mobile health van reduced surrogate HIV blood levels to low enough levels to show virologic and immunological improvements compared with standard (patient administered) therapy. Of the 141 people eligible for the trial, 62% were randomized to the DAART condition and the remainder was randomized to standard therapy. At the end of the six months of treatment a significantly greater proportion of participants assigned to DAART showed the primary outcome of either a reduction in HIV-1 RNA level of > or = 1.0 log10 copies/mL or an HIV-1 RNA level < or = 400 copies/mL. This finding is significant because this is the first study to show DAART’s effectiveness among HIV+ drug users. More research is needed to determine the essential components of a successful DAART program, especially regarding how much social and medical support the program should provide to ensure participation. Altice, F., Maru, D., Bruce, R., Springer, S., and Friedland, G. Superiority of Directly Administered Therapy over Self-Administered Therapy for HIV-Infected Drug Users: A Prospective Randomized, Controlled Trial. Clinical Infectious Diseases, 45(6), pp. 770-778, 2007.

Behavioral Incentives Improve Outpatient Treatment Participation/Retention for Pregnant Drug Abusers

Treating pregnant drug abusers poses unique challenges; compared with non-pregnant drug users they leave treatment more often and their attendance is often unreliable. This study examined the utility of providing 2 weeks of vouchers exchangeable for goods and services on an escalating schedule to motivate participation in a program comprised of seven days of residential and thirty days of outpatient treatment. Ninety-one pregnant women were assigned to either a standard treatment condition (ST) or a voucher reinforcement condition (VR) in which vouchers were earned for treatment program attendance. Voucher values began at $5.00 and increased by $5.00 for each day the participant attended up to a maximum value of $70.00 for 2 weeks. If a participant missed a single session they forfeited their voucher that day. Participant voucher value reset to $5.00 if more than one session was missed. VR assignment did not impact early treatment dropout; one third of participants in both groups left treatment against medical advice (AMA). Among those who did not leave AMA, those assigned to VR attended more treatment days than those in ST. Additionally, those assigned to VR were more likely to attend treatment consistently (12-14 full days) as opposed to the typical pattern of attendance for ST (only 4 or 6 full days). When all participants were categorized as either consistent or inconsistent attenders, consistent early attendance predicted better attendance in the 30 days following the intervention. Within five days of the voucher treatment ending, no consistent early attenders dropped out of treatment. However, 25% of inconsistent treatment attenders dropped out during the five days post-intervention. These findings are significant for several reasons. First, although inpatient treatment participation was not differentially impacted by vouchers, the voucher program begun during the inpatient treatment period appeared to have an important effect on pregnant women making the transition to outpatient treatment. Additionally, critics contend that voucher effects do not last after the treatment ends but in this case the voucher effect was sustained post-treatment. More research is needed to determine what if any effect vouchers can have on pregnant women entering treatment to reduce dropout AMA rates Svikis, D., Silverman K, Haug, N., Stitzer, M., Keyser-Marcus, L. Behavioral Strategies to Improve Treatment Participation and Retention by Pregnant Drug-dependent Women. Substance Use Misuse, 42(10), pp. 1527-1535, 2007.

Abstinent Contingent Employment Training Plus Work Better Than Work Alone for Maintaining Cocaine Abstinence in Methadone-Maintained Cocaine and Opiate Users

In clinical trials with chronically unemployed drug users, Silverman’s abstinence contingent therapeutic workplace has produced very high rates of cocaine abstinence. Researchers hypothesize that at least two elements, access to desirable work training followed by relatively high pay employment (trainees learn and then get paid for computer data entry) or the requirement of abstinence from cocaine to gain admission to the workplace may be responsible for its effects. In this study, fifty-six recent cocaine users were assigned to twenty-six weeks of either entry to the workplace (work only WO) or the therapeutic workplace contingent on abstinence as measured by a urine sample test (TW). Although both groups attended the workplace at high rates during the baseline period when the abstinence contingency was not in place (> 80% of available days), suggesting that WO motivated attendance, those assigned to the TW produced 19% more cocaine metabolite free urine samples than WO participants. However, TW also reduced participation rates with TW participants attending only 39% of days and TW participants attending 71% of days. These findings are significant because they suggest that modifications to supported employment programs that require abstinence are likely to produce higher rates of cocaine abstinence than those that do not. Additionally many researchers have suggested that programs that ensure high rates of attendance by default will produce high rates of abstinence; however, this study clearly shows an intervention may be highly engaging but less effective than one that, because of an abstinence contingency, effectively bars participation when a participant has had a recent slip or relapse. More research is needed to determine if contingencies can be manipulated to maximize engagement while motivating drug abstinence. Silverman, K., Wong, C., Needham, M., Diemer, K, Knealing, T., Crone-Todd, D., Fingerhood, M., Nuzzo, P., Kolodner, K. A Randomized Trial of Employment-based Reinforcement of Cocaine Abstinence in Injection Drug Users. Journal of Applied Behavior Analysis, 40(3), pp. 387-410, 2007.

Costs of Therapeutic Workplace Treatment Intervention Lower than Intensive Outpatient Treatment

In clinical trials with chronically unemployed drug users, Silverman’s abstinence contingent therapeutic workplace has produced comparatively high rates of cocaine abstinence but like many contingency management interventions has been criticized because of its cost. Over a one year period, this study examined the costs of running the Therapeutic Workplace by systematically assessing all major components including personnel, client earnings, facilities, supplies, and equipment. On average, the cost for treating one methadone-maintained client who continued to use cocaine while in methadone treatment including the cost for methadone programming was $362.00 per week (in 2004 dollars) This is significant because these costs are substantially less than residential treatment, estimated to be $746.00 per week or intensive outpatient treatment estimated at $492.00 and they are less than $300.00 more than methadone maintenance (which generally fails to produce any cocaine abstinence in this group). Additionally these costs were calculated based on the training portion of the workplace where participants learn job skills. If the workplace treatment continued in the context of a business, the employee earning costs might be mitigated somewhat as wages earned by workers could offset by profit to the business from selling products or providing services. More research is needed on how to implement the Therapeutic Workplace especially in terms of establishing a profitable business model. Knealing, T. Roebuck, M.C, Wong, C., and Silverman, K. Economic Cost of the Therapeutic Workplace Intervention Added to Methadone Maintenance Treatment. Substance Abuse Treatment, 2007 (e-pub ahead of print).

Development of a Telephone-Based Intervention for Support Persons to Help Smokers Quit

Dr. Patten and colleagues at the Mayo Clinic in Rochester developed and pilot tested a novel approach to smoking cessation utilizing a support person as the agent of change. The support person was a non-smoker who wanted to assist a smoker in quitting. This approach did not require the smoker to seek treatment. The support person was the sole recipient of the professional telephone-based intervention. Ten adult non-smoking females completed the treatment protocol, consisting of six 20-30 minute sessions and written materials. Feedback was obtained from 8 of the 10 participants and all 4 telephone counselors 1 week post- treatment (week 10). Results indicate that the telephone-based intervention was feasible and acceptable to participants. The intervention was refined based on participant and counselor feedback and will be tested in a randomized pilot trial. Patten, C.A., Petersen, L.R., Brockman, T.A., Gerber, T., Offord, K.P., Ebbert, J.O., Hughes, C.A., Decker, P.A., Beddow, C., Pyan, K., Quigg, S., and Boness, J. Development of a Telephone-based Intervention for Support Persons to Help Smokers Quit. Psychology, Health & Medicine, 12, pp. 1-12, 2007.

Bupropion and Cognitive-Behavioral Therapy for Smoking Cessation in Women

Dr. Schmitz and colleagues at the University of Texas Health Science Center at Houston conducted this study to examine the independent and interactive effects of medication (bupropion 300 mg/day vs. placebo) and psychotherapy (cognitive-behavioral therapy [CBT] vs. supportive therapy [ST]) in women in a two level factorial design. In addition to testing the hypothesis that bupropion with CBT would be the most effective of all the treatments, medication compliance and its role in the efficacy of bupropion was examined. Participants were 154 women who smoked more than 10 cigarettes/day. Compliance with study medication was assessed using Medication Event Monitoring Systems (MEMS) over 7 weeks of treatment. Psychological interventions were delivered in 60-min weekly group sessions. Longitudinal analysis of abstinence outcomes from end of treatment (EOT) through 12 months after treatment revealed a significant interaction of medication and therapy. Higher abstinence rates at EOT and 3, 6, 9, and 12-month follow-ups were observed when bupropion was delivered concurrently with CBT (44%, 24%, 30%, 23%, 17%) rather than with ST (18%, 1%, 8%, 5%, 2%). The bupropion-CBT combination, however, was not clearly superior to placebo, regardless of therapy assignment. Higher rates of medication compliance were positively predictive of abstinence, and this effect was most evident in the placebo condition. Findings provide only modest support for CBT as the preferred type of intensive therapy in conjunction with bupropion in women. Schmitz, J.M., Stotts, A.L., Mooney, M.E., DeLaune, K.A., and Moeller, F.G. Bupropion and Cognitive-Behavioral Therapy for Smoking Cessation in Women. Nicotine & Tobacco Research, 9, pp. 699-709, 2007.

Incremental Validity of Anxiety Sensitivity in Terms of Motivation to Quit, Reasons for Quitting, and Barriers to Quitting Among Community-Recruited Daily Smokers

Dr. Zvolensky and colleagues at the University of Vermont conducted the present investigation to examine the relationships between anxiety sensitivity and motivation to quit smoking, barriers to smoking cessation, and reasons for quitting smoking among 329 adult daily smokers. As expected, after covarying for the theoretically relevant variables of negative affectivity, gender, Axis I psychopathology, nonclinical panic attack history, number of cigarettes smoked per day, and current levels of alcohol consumption, it was found that anxiety sensitivity was significantly incrementally related to level of motivation to quit smoking as well as current barriers to quitting smoking. Partially consistent with the hypotheses, after accounting for the variance explained by other theoretically relevant variables, it was found that anxiety sensitivity was significantly associated with self-control reasons for quitting smoking (intrinsic factors) as well as immediate reinforcement and social influence reasons for quitting (extrinsic factors). These findings set the stage for additional research targeted at disentangling the specific mechanisms that underlie these documented associations between anxiety sensitivity and smoking, and should help guide the future development for specialized intervention programs for smokers with anxiety vulnerabilities. Zvolensky, M.J., Vujanovic, A.A., Bonn Miller, M.O., Bernstein, A., Yartz, A.R., Gregor, K.L., McLeish, A.C., Marshall, E.C., and Gibson, L.E. Incremental Validity of Anxiety Sensitivity in Terms of Motivation to Quit, Reasons for Quitting, and Barriers to Quitting Among Community-recruited Daily Smokers. Nicotine & Tobacco Research, 9, pp. 965-975, 2007.

HIV-Positive Smokers Considering Quitting: Differences by Race/Ethnicity

Investigators at Brown Medical School conducted this study to better characterize smoking in HIV-positive individuals and to identify critical components of a targeted smoking cessation intervention for multiethnic HIV-positive smokers. Differences in baseline characteristics of 444 HIV-positive smokers were examined by race, and a multivariate linear regression model evaluated factors associated with nicotine dependence in an HIV-positive population, with a particular emphasis on race/ethnic differences. The results showed that low smoking self-efficacy and higher contemplation of quitting were predictive of greater nicotine dependence. An interaction between age and race was noted, with older Hispanic Americans less likely to be nicotine dependent. The authors concluded that efforts should be made to tailor smoking cessation intervention content to HIV-positive racial/ethnic minority groups. Lloyd-Richardson, E.E., Stanton, C.A., Papandonatos, G.D., Betancourt, R.M., Stein, M., Tashima, K., Morrow, K., and Niaura, R. HIV-positive Smokers Considering Quitting: Differences by Race/Ethnicity. American Journal of Health Behavior, 32(1), pp. 3-15, 2008.

Maintenance of Effects of Motivational Enhancement Therapy to Improve Risk Behaviors and HIV-related Health in a Randomized Controlled Trial of Youth Living with HIV

Dr. Naar-King and colleagues examined the maintenance of effects of Motivational Enhancement Therapy (MET) shown to improve risk behaviors and viral load in youth living with HIV (YLH) immediately posttreatment. Sixty-five youth (ages 16-25 years) were randomized to Healthy Choices or a waitlist control. Frequency of substance use, frequency of unprotected intercourse, and viral load were obtained at baseline, 3, and 6 months after study entry. The waitlist control then received intervention. An additional data collection was obtained at 9 months for follow-up of the original treatment. The results indicated that the treatment group had greater reductions in viral load and alcohol use from baseline to 6 months. These reductions appeared to be maintained at 9-month follow-up. Improvements in sexual risk were not evident. The authors concluded that MET showed significant promise in reducing substance use and in improving HIV-related health in YLH immediately posttreatment. These effects were maintained after treatment termination. Naar-King, S., Lam, P., Wang, B., Wright, K., Parson, J.T. and Frey, M.A. Maintenance of Effects of Motivational Enhancement Therapy to Improve Risk Behaviors and HIV-related Health in a Randomized Controlled Trial of Youth Living with HIV. Journal of Pediatric Psychology, 2007, (Epub ahead of print).

The 5A’s vs. 3A’s Plus Proactive Quitline Referral in Private Practice Dental Offices: Preliminary Results

Dr. Gordon and colleagues conducted this study to evaluate the relative efficacy to two dental office based interventions compared to usual care. One intervention consisted of a combination of dental practitioner advice to quit and proactive telephone counseling (3A’s), and the other arm consisted of a dental practitioner delivered intervention based on the 5A’s of the Clinical Practice Guideline (5A’s). Participants included 2177 tobacco using patients enrolled from 68 dental practices in Mississippi. The results showed that smokers in the two intervention conditions quit at a higher rate than those in the usual care. Although not significant, more patients in the 5A’s condition quit than those in the 3A’s. Of patients in the 3A’s condition, 50% reported being asked by their dentist or hygienists about fax referral to the quitline, and 35% were referred. The authors concluded that there are both advantages and disadvantages to the use of quitlines as an adjunct to brief counseling provided by dental practitioners. Patients receiving quitline counseling quit at higher rates than those who did not; however, only a small percentage of patients received counseling from the quitline. Therefore, it appears that dental professionals may be most effective in helping their patients to quit by regularly providing the 5A’s plus proactively referring only those patients who are highly motivated to a quitline for more intensive counseling. Gordon, J.S., Andrews, J.A., Crews, K.M., Payne, T.J. and Severson, H.H. The 5A’s vs. 3A’s Plus Proactive Quitline Referral in Private Practice Dental Offices: Preliminary Results. Tobacco Control, 16, pp. 285-288, 2007.

Behavioral Impulsivity Predicts Treatment Outcome in a Smoking Cessation Program for Adolescent Smokers

Dr. Krishnan-Sarin and colleagues examined the relationship between impulsivity and smoking cessation treatment response among adolescents. Thirty adolescent smokers participated in a high school smoking cessation program combining contingency management and cognitive behavioral therapy. Several measures of impulsivity were assessed at treatment onset. Sixteen participants (53%) were abstinent from smoking at completion of the four-week study. Behavioral measures of impulsivity predicted treatment outcome. Compared to abstinent adolescents, those not achieving abstinence discounted monetary rewards more on the discounting task and committed more commission errors on the Continuous Performance Task. These preliminary results suggest that specific behavioral measures of impulsivity may be associated with the ability to initiate and/or maintain abstinence from smoking among adolescent smokers. Krishnan-Sarin, S., Reynolds, B., Duhig, A.M., Smith, A., Liss, T., McFetridge, A., Cavallo, D.A., Carroll, K.M. and Potenza, M.N. Behavioral Impulsivity Predicts Treatment Outcome in a Smoking Cessation Program for Adolescent Smokers. Drug and Alcohol Dependence, 88, pp. 79-82, 2007.

Relationship Between Self-Reported Task Persistence and History of Quitting Smoking, Plans for Quitting Smoking, and Current Smoking Status in Adolescents

Dr. Steinberg and colleagues conducted this study to examine the relationship between task persistence and smoking in adolescents. In contrast to most studies of task persistence, which used behavioral measures, this study used a brief, 2-item, internally consistent, self-report measure. It was hypothesized that because quitting smoking involves persisting in an effortful behavior (i.e., resisting desire to smoke), individuals scoring higher in task persistence would be more likely to be motivated to quit smoking and to be successful in quitting. Results indicate that task persistence is greater among adolescent non-smokers as compared to adolescent current smokers, and those planning to quit smoking as compared to those with no plans to quit. Contrary to hypotheses, task persistence was not found to be related to prior successful attempts to quit smoking. The authors concluded that the brief self-report measure of task persistence differentiated between smokers and non-smokers, and between those planning on quitting smoking and those feeling ambivalent or not planning on quitting. This study adds to the literature in that it shows that task persistence can be measured via self-report, can be evaluated in adolescents, and relates not just to smoking status, but also to motivation to quit smoking. Steinberg, M.L., Krejci, J.A., Collett, K., Brandon, T.H., Ziedonis, D.M. and Chen, K. Relationship Between Self-reported Task Persistence and History of Quitting Smoking, Plans for Quitting Smoking, and Current Smoking Status in Adolescents. Addictive Behaviors, 32, pp. 1451-1460, 2007.

Substantial Risk for Error in Random Drug Testing in Adolescent Substance Abuse Program

Dr. Sharon Levy and colleagues from Harvard Medical School and Children’s Hospital in Boston estimated the proportion of drug tests that are susceptible to interpretation errors in a random urine drug-testing program for adolescents. Secondary data analysis was conducted using a clinical database and chart review for 110 adolescents who participated in an outpatient substance abuse program. Of 710 urine drug tests, 40 negative tests were too dilute to interpret properly, and 45 of 217 positive tests resulted from prescription medication use for a total of 85 tests that were susceptible to error. Of 85 confirmatory laboratory reports reviewed, 43 were positive for oxycodone, but only 215 of these had produced a positive opiate screen. These findings suggest a substantial risk for error in interpreting laboratory testing for drugs in adolescent substance abuse programs. Levy, S., Sherritt, L., Vaughan, B. L., Germak, M., and Knight, J. R. Pediatrics, April, 119(4), pp. e843-e848, 2007.

Community Reinforcement Approach for Street-Living, Homeless Youth

Dr. Natasha Slesnick and colleagues from Ohio State University examined treatment outcomes for street living youth aged 14-22, randomly assigned to Community Reinforcement Approach (CRA) and treatment as usual (TAU). Findings suggest that compared to TAU, youth assigned to CRA reported significantly reduced substance use (by 37% vs. 17%), depression (by 40% vs. 23%), and increased social stability (by 58% vs. 13%). The results suggest that street living, homeless youth can be engaged in and respond positively to comprehensive treatment interventions. Slesnick, N., Prestopnik, J.L., Meyers, R.J., and Glassmann, M. Addictive Behaviors, 32, pp. 1237-1251, 2007.

Project CHAT: A Brief Motivational Intervention for High Risk Youth in Primary Care

Dr. Elizabeth D’Amico and colleagues from RAND Corporation examined the feasibility of adapting a brief motivational intervention (MI) for high risk adolescents aged 12-18 years in a primary care (PC) setting. A pilot study of Project CHAT was conducted with adolescents and small feedback sessions were conducted with adolescents, parents and clinic staff. Findings from the small feedback sessions indicated that adolescents would feel comfortable talking about substance use, despite concerns expressed about this by clinic staff. Concerns regarding being judged by the PC provider were also expressed by parents and teens. Findings from the pilot study indicated that high risk adolescents were willing to disclose information regarding their substance use and willingness to change. The results suggest the feasibility of a brief MI for high risk adolescents in a primary care setting. Stern, S.A., Meredith, L.S., Gholson, J., Gore, P., and D’Amico, E.J. Journal of Substance Abuse Treatment, 32, pp. 153-165, 2007.


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