The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome

Impact of substance use disorder on presentation and short-term course of schizophrenia

The aim of the present study was to compare a cohort of schizophrenia patients with substance use disorder (SUD) with a similar cohort of schizophrenia patients without SUD with regard to sociodemographic variables, clinical variables, psychopathology, anxiety symptoms, depressive symptoms, treatment outcome, and side effect profile of drugs. A total of 143 consecutive inpatients with ICD-10 DCR diagnosis of schizophrenia were included after obtaining informed consent. Patients were evaluated by a semistructured data sheet and Maudsley Addiction Profile. They were then rated by Positive and Negative Symptoms Scale, Calgary Depression Scale, Hamilton Anxiety Rating Scale, and Brief Psychiatric Rating Scale at presentation, three weeks, and six weeks. At three weeks and six weeks, they were also evaluated by UKU Side Effect Rating Scale. Substance abuse was detected in 63.6% schizophrenia patients. Nicotine was the commonest substance followed by cannabis and alcohol. Substance users had longer untreated illness and more depressive symptoms at presentation and six-week follow-up. Dual diagnosis patients had difficulty in abstraction at three and six weeks but not at presentation. Schizophrenia patients with SUD had more depressive symptoms. SUD appeared to mask abstraction difficulties at presentation. Schizophrenia patients with SUD should be carefully assessed for presence of depression.

Treatment retention, drug use and social functioning outcomes in those receiving 3 months versus 1 month of supervised opioid maintenance treatment. Results from the Super C randomized controlled trial

AIM

Supervised consumption of opioid maintenance treatment (OMT) is standard in many drug centres reducing drug diversion, but is costly. We aimed to determine whether supervised consumption of OMT improved retention and other measures of drug use.

DESIGN

Pragmatic randomized controlled trial comparing 3 months of daily supervised consumption of OMT with 1 month or less of daily supervised OMT, then daily unsupervised consumption.

SETTING

Four community drug services in the United Kingdom.

PARTICIPANTS

A total of 293 opioid-dependent patients entering OMT.

PRIMARY OUTCOME

retention in treatment at 12 weeks. Secondary: retention at 6 months; illicit drug use [Maudsley Addiction Profile (MAP)]; quality of life (SF-12 and MAP); criminality (MAP); and social functioning.

FINDINGS

No significant between-group difference was observed for the primary outcome: 69% (100 of 145) supervised and 74% (109 of 148) unsupervised were retained [odds ratio (OR) = 0.74, 95% confidence interval (CI) = 0.43-1.27]. Per protocol survival analysis suggested that supervised patients were less well retained (hazard ratio for retention = 0.71, 95% CI = 0.51-1.00). Illicit opioid use reduced in both groups and, while not statistically significant by intention-to-treat analysis, favoured unsupervised patients in per protocol analysis (odds of positive opioid screen for supervised versus unsupervised = 2.07, 95% CI = 1.05-4.06). Data on criminal activity also favoured unsupervised patients with 21% supervised patients committing crime versus 9% unsupervised (OR = 3.37, 95% CI = 1.28-8.86).

CONCLUSIONS

There was no evidence of a difference in treatment retention or opioid use rates between patients whose consumption of opioid maintenance treatment was supervised for 3 months daily (except Saturdays) compared with supervision for 1 month. There was some evidence that longer periods of supervised consumption were associated with higher levels of criminality.

Outcome evaluation of therapeutic community model in iran

BACKGROUND

Evaluation of treatment programs in addiction field is a prerequisite to improve the quality of care. This study aimed to investigate the effectiveness of Therapeutic Community (TC) program in Iran.

METHODS

Individuals who had voluntarily enrolled in the TC center within a period of seven years, from early 2005 to late 2011, entered the study. Those who successfully completed the 14-week residential course were considered as 'completers'. They were subsequently called in for urine test and interviews using Maudsley Addiction Profile. Urine test was conducted to determine if they were positive for heroin, opium, methadone, methamphetamine, bupronorphine, hashish, and tramadol.

RESULTS

A number of 378 individuals with mean (±SD) age of 32.5 ± 7.8 enrolled in the TC program during the study period, 240 individuals of whom completed the 14 weeks course (69.0%). At the end of the sixth year, 22% of the participants were in abstinence. Physical and mental health in abstainers proved to be of better conditions than those of non-abstainers (P<0.05).

CONCLUSION

Considering the TC outcome in other countries, it seems that TC maintains an acceptable effectiveness in Iran. Prospective controlled studies are warranted to investigate the outcomes in more details.

Depression, impulsiveness, sleep, and memory in past and present polydrug users of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy)

RATIONALE

Ecstasy (3,4-methylenedioxymethamphetamine, MDMA) is a worldwide recreational drug of abuse. Unfortunately, the results from human research investigating its psychological effects have been inconsistent.

OBJECTIVES

The present study aimed to be the largest to date in sample size and 5HT-related behaviors; the first to compare present ecstasy users with past users after an abstinence of 4 or more years, and the first to include robust controls for other recreational substances.

METHODS

A sample of 997 participants (52 % male) was recruited to four control groups (non-drug (ND), alcohol/nicotine (AN), cannabis/alcohol/nicotine (CAN), non-ecstasy polydrug (PD)), and two ecstasy polydrug groups (present (MDMA) and past users (EX-MDMA). Participants completed a drug history questionnaire, Beck Depression Inventory, Barratt Impulsiveness Scale, Pittsburgh Sleep Quality Index, and Wechsler Memory Scale-Revised which, in total, provided 13 psychometric measures.

RESULTS

While the CAN and PD groups tended to record greater deficits than the non-drug controls, the MDMA and EX-MDMA groups recorded greater deficits than all the control groups on ten of the 13 psychometric measures. Strikingly, despite prolonged abstinence (mean, 4.98; range, 4-9 years), past ecstasy users showed few signs of recovery. Compared with present ecstasy users, the past users showed no change for ten measures, increased impairment for two measures, and improvement on just one measure.

CONCLUSIONS

Given this record of impaired memory and clinically significant levels of depression, impulsiveness, and sleep disturbance, the prognosis for the current generation of ecstasy users is a major cause for concern.

Genetic influence on methadone treatment outcomes in patients undergoing methadone maintenance treatment for opioid addiction: a pilot study

INTRODUCTION

Treatment of opioid addiction with methadone is effective; however, it is known to produce interindividual variability. This may be influenced in part by genetic variants, which can increase the initial risk of developing opioid addiction as well as explain differences in response to treatment. This pilot study aimed to assess the feasibility of conducting a full-scale genetic analysis to identify genes that predict methadone treatment outcomes in this population.

METHODS

This was a cross-sectional observational study of patients admitted to a methadone maintenance treatment program for opioid addiction. We obtained demographic and clinical characteristics in addition to blood and urine samples, for the assessment of treatment outcomes.

RESULTS

The recruitment process yielded 252 patients, representing a 20% recruitment rate. We conducted genetic testing based on a 99.6% rate of provision of DNA samples. The average retention in treatment was 3.4 years, and >50% of the participants reported psychiatric and medical comorbidities. BDNF rs6265 and DRD2 rs1799978 were the common single nucleotide polymorphisms (SNPs) selected for the feasibility study.

DISCUSSION

This study met our predetermined feasibility criteria; recruitment, response rates, and genetic testing were feasible; treatment duration was sufficient for follow up; and the prevalence of comorbid conditions indicated the need for reliable psychiatric and chronic pain measures. The study strengths included effective collaboration with clinics and the generalizability of sample population. Key learning points show the need for assessment of treatment outcomes on multiple domains, implementation of follow up, and the development of standardized training for the study clinical staff.

Comparatively preserved impulse control in late-onset opiate users

RATIONALE

A substantial literature indicates that in alcohol addiction aspects of impulsive decision-making are typical of individuals with an early onset of addictive behaviour problems. It is not known whether the same applies to opiate addiction, and this insight has important theoretical and clinical implications.

OBJECTIVES

This study aims to examine the relationship between age at onset of addictive behaviour problems and decision-making in opiate addiction.

METHODS

Ninety-three opiate-dependent, treatment-seeking individuals were divided in three groups, early, late and intermediate onset of problems, and completed impulsivity questionnaires and delay discounting and gambling tasks.

RESULTS

Individuals with a late onset of opiate problems (25 years or above) had lower delay discounting rates than individuals with early (18 years or less) or intermediate onset. There were no differences in performance on the gambling tasks. Late-onset individuals were older and had shorter drug histories, but there was no relationship between either age or length of exposure to opiates and delay discounting rates.

CONCLUSIONS

In keeping with previous studies in alcohol addiction, these findings support the notion of at least two distinct subgroups of opiate-dependent individuals, characterised by a different onset of problems, different propensity to impulsive behaviour and perhaps distinct mechanisms leading to addiction.

Paranoia and post-traumatic stress disorder in the months after a physical assault: a longitudinal study examining shared and differential predictors

BACKGROUND

Being physically assaulted is known to increase the risk of the occurrence of post-traumatic stress disorder (PTSD) symptoms but it may also skew judgements about the intentions of other people. The objectives of the study were to assess paranoia and PTSD after an assault and to test whether theory-derived cognitive factors predicted the persistence of these problems.

METHOD

At 4 weeks after hospital attendance due to an assault, 106 people were assessed on multiple symptom measures (including virtual reality) and cognitive factors from models of paranoia and PTSD. The symptom measures were repeated 3 and 6 months later.

RESULTS

Factor analysis indicated that paranoia and PTSD were distinct experiences, though positively correlated. At 4 weeks, 33% of participants met diagnostic criteria for PTSD, falling to 16% at follow-up. Of the group at the first assessment, 80% reported that since the assault they were excessively fearful of other people, which over time fell to 66%. Almost all the cognitive factors (including information-processing style during the trauma, mental defeat, qualities of unwanted memories, self-blame, negative thoughts about self, worry, safety behaviours, anomalous internal experiences and cognitive inflexibility) predicted later paranoia and PTSD, but there was little evidence of differential prediction.

CONCLUSIONS

Paranoia after an assault may be common and distinguishable from PTSD but predicted by a strikingly similar range of factors.

Effectiveness of a web-based treatment program using intensive therapeutic support for female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified: study protocol of a randomized controlled trial

BACKGROUND

Disordered eating behavior and body dissatisfaction affect a large proportion of the Dutch population and account for severe psychological, physical and social morbidity. Yet, the threshold for seeking professional care is still high. In the Netherlands, only 7.5% of patients with bulimia nervosa and 33% of patients with anorexia nervosa are treated within the mental health care system. Easily accessible and low-threshold interventions, therefore, are needed urgently. The internet has great potential to offer such interventions. The aim of this study is to determine whether a web-based treatment program for patients with eating disorders can improve eating disorder psychopathology among female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified.

METHODS/DESIGN

This randomized controlled trial will compare the outcomes of an experimental treatment group to a waiting list control group. In the web-based treatment program, participants will communicate personally and asynchronously with their therapists exclusively via the internet. The first part of the program will focus on analyzing eating attitudes and behaviors. In the second part of the program participants will learn how to change their attitudes and behaviors. Participants assigned to the waiting list control group will receive no-reply email messages once every two weeks during the waiting period of 15 weeks, after which they can start the program. The primary outcome measure is an improvement in eating disorder psychopathology as determined by the Eating Disorder Examination Questionnaire. Secondary outcomes include improvements in body image, physical and mental health, body weight, self-esteem, quality of life, and social contacts. In addition, the participants' motivation for treatment and their acceptability of the program and the therapeutic alliance will be measured. The study will follow the recommendations in the CONSORT statement relating to designing and reporting on RCTs.

DISCUSSION

This study protocol presents the design of a RCT for evaluating the effectiveness of a web-based treatment program using intensive therapeutic support for female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified.

TRIAL REGISTRATION

The protocol for this study is registered with the Netherlands Trial Registry NTR2415.

Validation and implementation of the Australian Treatment Outcomes Profile in specialist drug and alcohol settings

INTRODUCTION AND AIMS

The measurement of clinical outcomes is an important, but lacking, component of drug and alcohol treatment in Australia. This study aimed to psychometrically validate the Treatment Outcomes Profile under Australian conditions, examining implementation and feasibility issues in three public opioid treatment program clinics in NSW.

DESIGN AND METHODS

The Treatment Outcomes Profile was modified to reflect Australian conditions and re-named the Australian Treatment Outcomes Profile (ATOP). The ATOP was introduced into the participating clinics and administered by clinic staff at 3-month intervals as part of routine clinical practice. Participants completed a research interview, consisting of the ATOP and a suite of 'gold standard' instruments assessing substance use and related health and welfare domains, in the 72 h following completion of a routine clinical ATOP. The researcher- and clinician-administered ATOPs were compared to assess interrater reliability, and the researcher-administered ATOP and 'gold standard' instruments were compared to assess concurrent validity. Implementation and feasibility issues were assessed using questionnaires and focus groups with clinician and clients.

RESULTS

The ATOP demonstrated acceptable concurrent validity and interrater reliability. It was well received by clients and clinicians, particularly for its ease of use, applicability and brevity.

CONCLUSIONS

The ATOP is a psychometrically valid instrument for the measurement of treatment outcomes in Australian opioid treatment populations and can feasibly be implemented as part of routine clinical practice in specialist opioid treatment program clinics. The role of the ATOP to measure outcomes in other drug and alcohol treatment modalities requires exploration.

Personalized risk assessment of drug-related harm is associated with health outcomes

Background

The Independent Scientific Committee on Drugs (ISCD) assigned quantitative scores for harm to 20 drugs. We hypothesized that a personalized, ISCD-based Composite Harm Score (CHS) would be associated with poor health outcomes in polysubstance users.

Methods

A prospective community sample (n=293) of adults living in marginal housing was assessed for substance use. The CHS was calculated based on the ISCD index, and the personal substance use characteristics over four weeks. Regression models estimated the association between CHS and physical, psychological, and social health outcomes.

Results

Polysubstance use was pervasive (95.8%), as was multimorbid illness (median 3, possible range 0–12). The median CHS was 2845 (interquartile range 1865–3977). Adjusting for age and sex, every 1000-unit CHS increase was associated with greater mortality (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.07–2.01, p = 0.02), and persistent hepatitis C infection (OR 1.29, 95% CI 1.02–1.67, p = 0.04). The likelihood of substance-induced psychosis increased 1.39-fold (95% CI 1.13–1.67, p = 0.001). The amount spent on drugs increased 1.51-fold (1.40–1.62, p < 0.001) and the odds of having committed a crime increased 1.74-fold (1.46–2.10, p < 0.001). Multimorbid illness increased 1.43-fold (95% CI 1.26–1.63, p < 0.001).

Conclusions

Greater CHS predicts poorer physical, psychological, and social health, and may be a useful quantitative, personalized measure of risk for drug-related harm.

Vancouver At Home: pragmatic randomized trials investigating Housing First for homeless and mentally ill adults

BACKGROUND

Individuals with mental illnesses are overrepresented among the homeless. Housing First (HF) has been shown to promote positive outcomes in this population. However, key questions remain unresolved, including: how to match support services to client needs, the benefits of housing in scattered sites versus single congregate building, and the effectiveness of HF with individuals actively using substances. The present study aimed to recruit two samples of homeless mentally ill participants who differed in the complexity of their needs. Study details, including recruitment, randomization, and follow-up, are presented.

METHODS

Eligibility was based on homeless status and current mental disorder. Participants were classified as either moderate needs (MN) or high needs (HN). Those with MN were randomized to HF with Intensive Case Management (HF-ICM) or usual care. Those with HN were randomized to HF with Assertive Community Treatment (HF-ACT), congregate housing with support, or usual care. Participants were interviewed every 3 months for 2 years. Separate consent was sought to access administrative data.

RESULTS

Participants met eligibility for either MN (n = 200) or HN (n = 297) and were randomized accordingly. Both samples were primarily male and white. Compared to participants designated MN, HN participants had higher rates of hospitalization for psychiatric reasons prior to randomization, were younger at the time of recruitment, younger when first homeless, more likely to meet criteria for substance dependence, and less likely to have completed high school. Across all study arms, between 92% and 100% of participants were followed over 24 months post-randomization. Minimal significant differences were found between study arms following randomization. 438 participants (88%) provided consent to access administrative data.

CONCLUSION

The study successfully recruited participants meeting criteria for homelessness and current mental disorder. Both MN and HN groups had high rates of substance dependence, suicidality, and physical illness. Randomization resulted in no meaningful detectable differences between study arms.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN57595077 (Vancouver at Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing First plus Intensive Case Management versus treatment as usual).

Housing first improves residential stability in homeless adults with concurrent substance dependence and mental disorders

OBJECTIVES

We examined the relationship between substance dependence and residential stability in homeless adults with current mental disorders 12 months after randomization to Housing First programs or treatment as usual (no housing or support through the study).

METHODS

The Vancouver At Home study in Canada included 2 randomized controlled trials of Housing First interventions. Eligible participants met the criteria for homelessness or precarious housing, as well as a current mental disorder. Residential stability was defined as the number of days in stable residences 12 months after randomization. We used negative binomial regression modeling to examine the independent association between residential stability and substance dependence.

RESULTS

We recruited 497 participants, and 58% (n = 288) met the criteria for substance dependence. We found no significant association between substance dependence and residential stability (adjusted incidence rate ratio = 0.97; 95% confidence interval = 0.69, 1.35) after adjusting for housing intervention, employment, sociodemographics, chronic health conditions, mental disorder severity, psychiatric symptoms, and lifetime duration of homelessness.

CONCLUSIONS

People with mental disorders might achieve similar levels of housing stability from Housing First regardless of whether they experience concurrent substance dependence.

Psychosocial interventions for alcohol use among problem drug users: protocol for a feasibility study in primary care

Background

Alcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users.

Objective

The objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use.

Methods

Psychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction treatment. Patient must meet the following inclusion criteria to participate in this study: 18 years of age or older, receiving addiction treatment/care (eg, methadone), or known to be a problem drug user. This study is based on a complex intervention supporting SBI for problem alcohol use among problem drug users (experimental group) compared to an “assessment-only” control group. Control practices will be provided with a delayed intervention after follow-up. Primary outcomes of the study are feasibility and acceptability of the intervention to patients and practitioners. Secondary outcome includes the effectiveness of the intervention on care process (documented rates of SBI) and outcome (proportion of patients with problem alcohol use at the follow-up). A stratified random sampling method will be used to select general practices based on the level of training for providing addiction-related care and geographical area. In this study, general practitioners and practice staff, researchers, and trainers will not be blinded to treatment, but patients and remote randomizers will be unaware of the treatment.

Results

This study is ongoing and a protocol system is being developed for the study. This study may inform future research among the high-risk population of problem drug users by providing initial indications as to whether psychosocial interventions for problem alcohol use are feasible, acceptable, and also effective among problem drug users attending primary care.

Conclusions

This is the first study to examine the feasibility and acceptability of complex intervention in primary care to enhance alcohol SBI among problem drug users. Results of this study will inform future research among this high-risk population and guide policy and service development locally and internationally.

Daily substance use and mental health symptoms among a cohort of homeless adults in Vancouver, British Columbia

Substance use can be a barrier to stable housing for homeless persons with mental disorders. We examined DSM-IV symptoms among homeless adults (N = 497), comparing those who reported daily substance use (DSU) with non-daily substance users. Multivariable linear regression modeling was used to test the independent association between DSU and symptoms using the Colorado Symptom Index total score. DSU was independently associated with higher symptoms (beta = 3.67, 95 % CI 1.55-5.77) adjusting for homelessness history, age, gender, ethnicity, education, marital status, and mental disorder sub-type (adjusted R (2) = 0.24). We observed a higher prevalence of DSU in our sample than has been previously reported in a Housing First intervention. DSU was also independently associated with more DSM-IV symptomatology. We have an opportunity to observe this cohort longitudinally and examine if there are changes in substance use based on treatment assignment and commensurate changes in housing stability, community integration, health status, and quality of life.

The Burnaby treatment center for mental health and addiction, a novel integrated treatment program for patients with addiction and concurrent disorders: results from a program evaluation

Background

Patients with addictions and concurrent disorders constitute the most underserved population in the system of care. There are numerous reasons why this population has so much difficulty accessing services, including behavioural issues, criminal engagement, and non-compliance with outpatient services. To improve services to this population which is marked by multiple morbidities, high mortality and insufficient access to health care, the government of British Columbia, Canada developed a program for people with both substance use disorder and one or more mental disorders who have not benefited from previous therapies.

Method

In July 2008, the Burnaby Treatment Centre for Mental Health and Addiction (BCMHA), a specialized and integrated tertiary care facility, was opened. The current article provides a description of the treatment program and a clinical profile of the population.

Results

The target population is being served, at intake clients present with high rates of psychopathology, childhood and adult trauma, and substance use.

Conclusion

While preliminary, these results indicate, that the novel approach of the Burnaby Centre may constitute a new path towards providing effective recovery for this population.

Does training in motivational interviewing for community pharmacists improve outcomes for methadone patients? A cluster randomised controlled trial

Objectives

Feasibility of pharmacist delivered motivational interviewing (MI) to methadone patients has been demonstrated, but its efficacy is untested. This study aimed to determine whether pharmacists trained in MI techniques can improve methadone outcomes.

Methods

A cluster randomised controlled trial by pharmacy, with community pharmacies across Scotland providing supervised methadone to &gt;10 daily patients, aged &gt;18 years, started on methadone &lt;24 months. Pharmacies were randomised to intervention or control. Intervention pharmacists received MI training and a resource pack. Control pharmacists continued with normal practice. Primary outcome was illicit heroin use. Secondary outcomes were treatment retention, substance use, injecting behaviour, psychological/physical health, treatment satisfaction and patient feedback. Data were collected via structured interviews at baseline and 6 months.

Key findings

Seventy-six pharmacies recruited 542 patients (295 intervention, 247 control), mean age 32 years; 64% male; 91% unemployed; mean treatment length 9 months. No significant difference in outcomes between groups for illicit heroin use (32.4% cf. 31.4%), although within-groups use reduced (P &lt; 0.001); treatment retention was higher in the intervention group but not significantly (88% cf. 81%; P = 0.34); no significant difference between groups in treatment satisfaction, although this improved significantly in intervention (P &lt; 0.05). More intervention than control patients said pharmacists had ‘spoken more,’ which approached statistical significance (P = 0.06), and more intervention patients found this useful (P &lt; 0.05).

Conclusions

Limited intervention delivery may have reduced study power. The intervention did not significantly reduce heroin use, but there are indications of positive benefits from increased communication and treatment satisfaction.

Using chi-Squared Automatic Interaction Detection (CHAID) modelling to identify groups of methadone treatment clients experiencing significantly poorer treatment outcomes

In times of scarce resources it is important for services to make evidence based decisions when identifying clients with poor outcomes. chi-Squared Automatic Interaction Detection (CHAID) modelling was used to identify characteristics of clients experiencing statistically significant poor outcomes. A national, longitudinal study recruited and interviewed, using the Maudsley Addiction Profile (MAP), 215 clients starting methadone treatment and 78% were interviewed one year later. Four CHAID analyses were conducted to model the interactions between the primary outcome variable, used heroin in the last 90 days prior to one year interview and variables on drug use, treatment history, social functioning and demographics. Results revealed that regardless of these other variables, males over 22 years of age consistently demonstrated significantly poorer outcomes than all other clients. CHAID models can be easily applied by service providers to provide ongoing evidence on clients exhibiting poor outcomes and requiring priority within services.

Drug spend and acquisitive offending by substance misusers

AIM

The need to generate income to fund drug misuse is assumed to be a driver of involvement in acquisitive crime. We examined the influence of drug misuse expenditure, and other factors, on acquisitive offending.

METHODS

Clients (N=1380) seeking drug treatment within 94 of 149 Drug Action Teams (DATs) across England completed a comprehensive survey, incorporating validated scales and self-report measures, such as levels of drug and alcohol use and offending.

RESULTS

Forty per cent (N=554) had committed acquisitive crime in the previous month. Regression analysis showed that acquisitive offending was associated with the presence of problematic use of crack cocaine, poly-drug use, sharing injecting equipment, unsafe sex, overdose risk, higher drug spend, unemployment, reduced mental wellbeing, and younger age.

CONCLUSIONS

Rates of acquisitive crime among drug users are high. Drug using offenders can be distinguished from drug using non-offenders by problematic crack cocaine use, younger age, income-related factors, and indicators of a chaotic life style and complex needs. Behavioural and demographic factors were associated more strongly with acquisitive crime than drug use expenditure, suggesting that the need to finance drug use is not necessarily the main factor driving acquisitive offending by drug users.

Computerised cognitive behavioural therapy: helping Ireland log on

OBJECTIVES

The aim of this article is to review and highlight evidence-based computerised cognitive behavioural therapy (cCBT) programmes that can potentially be used in Ireland for the treatment of mild-to-moderate mental health difficulties.

METHODS

The authors undertook a literature search using three databases, and consulted a recognised, university-developed web portal. For a programme to be included in this review, it had to (a) have at least one randomised controlled trial demonstrating its efficacy; (b) be available on the internet; and (c) be delivered in English. Findings Twenty-five cCBT programmes that met the inclusion criteria were profiled. Taken together, these programmes target various anxiety difficulties (i.e. generalised anxiety, panic/phobia, social anxiety and post-traumatic stress), depression (or low mood), eating problems, stress, insomnia, pain and alcohol misuse.

CONCLUSIONS

cCBT programmes, preferably administered as part of a stepped-care model, offer effective, low-cost and low-intensity interventions for a wide range of psychological problems. Their use could be beneficial given how underdeveloped primary care mental health services are in Ireland.

Web-based treatment program using intensive therapeutic contact for patients with eating disorders: before-after study

Background

Although eating disorders are common in the Netherlands, only a few patients are treated by mental health care professionals. To reach and treat more patients with eating disorders, Tactus Addiction Treatment developed a web-based treatment program with asynchronous and intensive personalized communication between the patient and the therapist.

Objective

This pilot study evaluated the web-based treatment program using intensive therapeutic contact in a population of 165 patients with an eating disorder.

Methods

In a pre-post design with 6-week and 6-month follow-ups, eating disorder psychopathology, body dissatisfaction, Body Mass Index, physical and mental health, and quality of life were measured. The participant’s satisfaction with the web-based treatment program was also studied. Attrition data were collected, and participants were classified as noncompleters if they did not complete all 10 assignments of the web-based treatment program. Differences in baseline characteristics between completers and noncompleters were studied, as well as reasons for noncompletion. Furthermore, differences in treatment effectiveness, treatment adherence, and baseline characteristics between participants of the three major eating disorder diagnostic groups EDNOS (n=115), BN purging (n=24), and BN nonpurging (n=24) were measured.

Results

Of the 165 participants who started the web-based treatment program, 89 participants (54%) completed all of the program assignments (completers) and 76 participants (46%) ended the program prematurely (noncompleters). Severe body dissatisfaction and physical and mental health problems seemed to have a negative impact on the completion of the web-based treatment program. Among the participants who completed the treatment program, significant improvements were found in eating disorder psychopathology (F=54.6, df = 68, P<.001, d=1.14). Body dissatisfaction, quality of life, and physical and mental health also significantly improved, and almost all of these positive effects were sustained up to 6 months after the participants had completed the web-based treatment program. Body Mass Index improved only within the group of participants suffering from obesity. The improvement in eating disorder psychopathology occurred in all three eating disorder diagnostic groups, and the percentage of completers did not differ significantly between these groups. Participants’ satisfaction with the treatment program, as well as with their therapist, was high, and participants indicated that they would recommend the program to other patients with eating disorders.

Conclusions

The results of this study suggest that the web-based treatment program has the potential to improve eating disorder psychopathology in patients with different types of eating disorders.

The effects of reducing worry in patients with persecutory delusions: study protocol for a randomized controlled trial

Background

Our approach to advancing the treatment of psychosis is to focus on key single symptoms and develop interventions that target the mechanisms that maintain them. In our theoretical research we have found worry to be an important factor in the development and maintenance of persecutory delusions. Worry brings implausible ideas to mind, keeps them there, and makes the experience distressing. Therefore the aim of the trial is to test the clinical efficacy of a cognitive-behavioral intervention for worry for patients with persecutory delusions and determine how the worry treatment might reduce delusions.

Methods/Design

An explanatory randomized controlled trial - called the Worry Intervention Trial (WIT) - with 150 patients with persecutory delusions will be carried out. Patients will be randomized to the worry intervention in addition to standard care or to standard care. Randomization will be carried out independently, assessments carried out single-blind, and therapy competence and adherence monitored. The study population will be individuals with persecutory delusions and worry in the context of a schizophrenia spectrum diagnosis. They will not have responded adequately to previous treatment. The intervention is a six-session cognitive-behavioral treatment provided over eight weeks. The control condition will be treatment as usual, which is typically antipsychotic medication and regular appointments. The principal hypotheses are that a worry intervention will reduce levels of worry and that it will also reduce the persecutory delusions. Assessments will be carried out at 0 weeks (baseline), 8 weeks (post treatment) and 24 weeks (follow-up). The statistical analysis strategy will follow the intention-to-treat principle and involve the use of linear mixed models to evaluate and estimate the relevant between- and within-subjects effects (allowing for the possibility of missing data). Both traditional regression and newer instrumental variables analyses will examine mediation. The trial is funded by the UK Medical Research Council (MRC)/NHS National Institute of Health Research (NIHR) Efficacy and Mechanism Evaluation (EME) Programme.

Discussion

This will be the first large randomized controlled trial specifically focused upon persecutory delusions. The project will produce a brief, easily administered intervention that can be readily used in mental health services.

Trial registration

Current Controlled Trials ISRCTN23197625

Does active referral by a doctor or 12-Step peer improve 12-Step meeting attendance? Results from a pilot randomised control trial

BACKGROUND

Active engagement in 12-Step self-help groups (SHG) is associated with improvements in substance use outcomes during and after treatment, yet levels of participation in SHG meetings in the U.K. remain low.

METHOD

An RCT investigating the impact of active referral to SHG, delivered by doctors or 12-Step peers during inpatient treatment on both inpatient and post-treatment meeting attendance was conducted. 151 inpatients with alcohol, opiate, crack-cocaine or benzodiazepine dependence undergoing detoxification, received one of two active referral interventions: 12-Step peer intervention (PI), doctor intervention (DI), or no intervention (NI). 83% of the sample was followed up, 2-3 months following discharge.

RESULTS

Active referral interventions significantly increased attendance at 12-Step meetings during inpatient treatment (88% versus 73%, p<.05). Rates of post-discharge meeting attendance were PI=64%, DI=48%, NI=33%, with those in the PI group significantly (OR=3.6; CI=1.3, 9.8) more likely to have attended. Inpatient meeting attenders were three times as likely to have attended meetings post-discharge (59% versus 20%, p<.01), and post-discharge meeting attenders reported significantly higher abstinence rates (60.8% versus 39.2%, p<.05) at follow-up. However, abstinence rates did not differ significantly across intervention groups (44% [PI], 41% [DI] and 36% [NI]).

CONCLUSION

Attendance at 12-Step SHGs is associated with greater rates of abstinence and active referral, especially by 12-Step peers, increases 12-Step SHG attendance rates. However, improved clinical outcomes among attendees might not occur until stronger recovery peer support networks are established. These results show promise for the benefit of incorporating Twelve Step Facilitation into U.K. treatment settings.

Self-reported traumatic brain injury and postconcussion symptoms in incarcerated youth

OBJECTIVES

To determine the prevalence rate of traumatic brain injury (TBI) in incarcerated youth and whether frequency and severity of TBI are associated with postconcussion symptoms (PCS), violent offending behaviors, age of first conviction, and substance abuse.

PARTICIPANTS

Sixty-one incarcerated male juvenile offenders with an average age of 16 years.

MAIN MEASURES

Self-rated measures of head injury, TBI, PCS (Rivermead Post-concussion Symptoms Questionnaire), history of alcohol and drug use, and criminal history.

RESULTS

More than 70% reported at least 1 head injury at some point in their lives, and 41% reported experiencing a head injury with loss of consciousness. Postconcussion symptoms reliably increased with the frequency and severity of TBI. The relation between frequency and symptoms was mostly accounted for by severity of TBI. Alcohol use reliably increased with the severity of TBI and was associated with PCS. Alcohol use did not account for the dose-response relation between TBI and PCS.

CONCLUSIONS

Findings indicate a need to account for TBI in offender populations in managing care needs, which may contribute to reduction in offending behaviors.

Primary outcome indices in illicit drug dependence treatment research: systematic approach to selection and measurement of drug use end-points in clinical trials

AIMS

Clinical trials test the safety and efficacy of behavioral and pharmacological interventions in drug-dependent individuals. However, there is no consensus about the most appropriate outcome(s) to consider in determining treatment efficacy or on the most appropriate methods for assessing selected outcome(s). We summarize the discussion and recommendations of treatment and research experts, convened by the US National Institute on Drug Abuse, to select appropriate primary outcomes for drug dependence treatment clinical trials, and in particular the feasibility of selecting a common outcome to be included in all or most trials.

METHODS

A brief history of outcomes employed in prior drug dependence treatment research, incorporating perspectives from tobacco and alcohol research, is included. The relative merits and limitations of focusing on drug-taking behavior, as measured by self-report and qualitative or quantitative biological markers, are evaluated.

RESULTS

Drug-taking behavior, measured ideally by a combination of self-report and biological indicators, is seen as the most appropriate proximal primary outcome in drug dependence treatment clinical trials.

CONCLUSIONS

We conclude that the most appropriate outcome will vary as a function of salient variables inherent in the clinical trial, such as the type of intervention, its target, treatment goals (e.g. abstinence or reduction of use) and the perspective being taken (e.g. researcher, clinical program, patient, society). It is recommended that a decision process, based on such trial variables, be developed to guide the selection of primary and secondary outcomes as well as the methods to assess them.

Sex work involvement among women with long-term opioid injection drug dependence who enter opioid agonist treatment

Background

Substitution with opioid-agonists (e.g., methadone) has shown to be an effective treatment for chronic long-term opioid dependency. Survival sex work, very common among injection drug users, has been associated with poor Opioid Agonist Treatment (OAT) engagement, retention and response. Therefore, this study was undertaken to determine factors associated with engaging in sex work among long-term opioid dependent women receiving OAT.

Methods

Data from a randomized controlled trial, the North American Opiate Medication Initiative (NAOMI), conducted in Vancouver and Montreal (Canada) between 2005-2008, was analyzed. The NAOMI study compared the effectiveness of oral methadone to injectable diacetylmorphine or injectable hydromorphone, the last two on a double blind basis, over 12 months. A research team, independent of the clinic services, obtained outcome evaluations at baseline and follow-up (3, 6, 9, 12, 18 and 24 months).

Results

A total 53.6% of women reported engaging in sex work in at least one of the research visits. At treatment initiation, women who were younger and had fewer years of education were more likely to be engaged in sex work. The multivariate logistic generalized estimating equation regression analysis determined that psychological symptoms, and high illicit heroin and cocaine use correlated with women's involvement in sex work during the study period.

Conclusions

After entering OAT, women using injection drugs and engaging in sex work represent a particularly vulnerable group showing poorer psychological health and a higher use of heroin and cocaine compared to women not engaging in sex work. These factors must be taken into consideration in the planning and provision of OAT in order to improve treatment outcomes.

Trial Registration

NCT00175357.

Craving and illicit heroin use among patients in heroin-assisted treatment

AIMS

To investigate in heroin-assisted treatment (HAT) compared to methadone maintenance treatment (MMT): the course of heroin craving and illicit heroin use, their mutual association, and their association with multi-domain treatment response.

DESIGN

RCTs on the efficacy of 12 months co-prescribed injectable or inhalable HAT compared to 12 months continued oral MMT.

SETTING

Outpatient treatment in MMT- or specialized HAT-centers in the Netherlands.

PARTICIPANTS

Chronic, treatment-refractory heroin dependent patients (n=73). STUDY PARAMETERS: General craving for heroin (Obsessive Compulsive Drug Use Scale); self-reported illicit heroin use; multi-domain treatment response in physical, mental and social health and illicit drug use.

FINDINGS

The course of heroin craving and illicit heroin use differed significantly, with strong reductions in HAT but not in MMT. General heroin craving was significantly related to illicit heroin use. Heroin craving was not and illicit heroin use was marginally related to multi-domain treatment response, but only in MMT and not in HAT.

CONCLUSIONS

Heroin craving and illicit heroin use were significantly associated and both strongly decreased in HAT but not in MMT. Craving was not related to multi-domain treatment response and illicit heroin use was marginally related to treatment response in MMT, but not in HAT. The latter was probably due to the strong reduction in illicit heroin use in most patients in HAT and the small sample size of the sub-study. It is hypothesized that the strong reductions in craving for heroin in HAT are related to the stable availability of prescribed, pharmaceutical grade heroin.

Attrition in web-based treatment for problem drinkers

Background

Web-based interventions for problem drinking are effective but characterized by high rates of attrition. There is a need to better understand attrition rates in order to improve the completion rates and the success of Web-based treatment programs.

Objective

The objectives of our study were to (1) examine attrition prevalence and pretreatment predictors of attrition in a sample of open-access users of a Web-based program for problem drinkers, and (2) to further explore attrition data from our randomized controlled trial (RCT) of the Web-based program.

Methods

Attrition data from two groups of Dutch-speaking problem drinkers were collected: (1) open-access participants enrolled in the program in 2009 (n = 885), and (2) RCT participants (n = 156). Participants were classified as noncompleters if they did not complete all 12 treatment sessions (9 assignments and 3 assessments). In both samples we assessed prevalence of attrition and pretreatment predictors of treatment completion. Logistic regression analysis was used to explore predictors of treatment completion. In the RCT sample, we additionally measured reasons for noncompletion and participants’ suggestions to enhance treatment adherence. The qualitative data were analyzed using thematic analysis.

Results

The open-access and RCT group differed significantly in the percentage of treatment completers (273/780, 35.0% vs 65/144, 45%, χ²₁ = 5.4, P = .02). Logistic regression analysis revealed a significant contribution of treatment readiness, gender, education level, age, baseline alcohol consumption, and readiness to change to predict treatment completion. The key reasons for noncompletion were personal reasons, dissatisfaction with the intervention, and satisfaction with their own improvement. The main suggestions for boosting strategies involved email notification and more flexibility in the intervention.

Conclusions

The challenge of Web-based alcohol treatment programs no longer seems to be their effectiveness but keeping participants involved until the end of the treatment program. Further research should investigate whether the suggested strategies to improve adherence decrease attrition rates in Web-based interventions. If we can succeed in improving attrition rates, the success of Web-based alcohol interventions will also improve and, as a consequence, their public health impact will increase.

Trial

International Standard Randomized Controlled Trial Number (ISRCTN): 39104853; http://www.controlled-trials.com/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/63IKDul1T)

A pilot randomised controlled trial of brief versus twice weekly versus standard supervised consumption in patients on opiate maintenance treatment

INTRODUCTION AND AIMS

Methadone maintenance remains the mainstay of treatment for opiate dependence in Scotland. Guidelines recommend supervised self-administration for at least 3 months, yet this is often interpreted as long-term supervision. However, there is no evidence base for deciding the optimal period of supervision. We tested the feasibility of conducting a randomised controlled trial (RCT) of different supervision models.

DESIGN AND METHODS

Three armed pilot RCT, set in three Scottish treatment areas, recruited opiate-dependent patients who had received methadone treatment for 3 months. Participants were randomised to: (i) no supervision; (ii) twice weekly supervision; or (iii) daily supervision for further 3 months. As a pilot, key process measures were: recruitment rates, follow-up rates and treatment fidelity. We also wanted to estimate effect sizes of two co-primary outcomes for a full RCT: treatment retention and illicit heroin use. The recruitment target was 60 participants.

RESULTS

One hundred and two eligible patients were identified, 60 (59%) participated, and 46 followed up (77%). Study fidelity was good with two participants moving group. Those randomised to no supervision were significantly happier with their group allocation. No significant differences were found in primary outcomes, although retention decreased with increased supervision, while illicit heroin use was least in those most supervised.

DISCUSSION AND CONCLUSIONS

It is possible to recruit and randomise participants to an RCT comparing different forms of supervised consumption. Pilot data suggest increased supervision may reduce illicit heroin use, but may decrease retention. This should now be tested in a large-scale multicentre RCT.

Substance use and predictors of substance dependence in homeless women

OBJECTIVE

To examine lifetime and current prevalence rates of substance use disorders and the demographic and clinical correlates of current drug dependence in a sample of homeless women.

METHODS

A cross-sectional study of 196 homeless women in three Canadian cities was done. Each subject was assessed using structured clinical interviews. A multivariate regression model was applied to determine predictors of substance use.

RESULTS

The mean age of the sample was 35.3 years, 54.4% identified as Aboriginal, 46.4% lived on the street Crack cocaine (58%) was the most common substance used, followed by alcohol (53%), cannabis (41%), and heroin (30%). Overall, 82.4% of the sample had at least one type of current substance use disorder, of which 70.5% had drug dependence and 37.8% had alcohol dependence. 58.3% had concurrent substance use and mental health disorders. 76.7% of those individuals with current alcohol dependence had concurrent drug dependence. Only 24.6% of those who had recovered from alcohol dependence had no current substance use disorder. Multivariate analyses showed that younger age, living on the street, engaging in sex work, and having ever attempted suicide were associated with current drug dependence.

CONCLUSION

Prevalence rates for alcohol and especially drug dependence were exceptionally high in this sample. Innovative programs need to be developed which are accessible and tailored to meet the needs of this specific population, accounting for high problem severity, polysubstance dependence, and high rates of psychiatric comorbidity.

Risky decision-making predicts short-term outcome of community but not residential treatment for opiate addiction. Implications for case management

BACKGROUND

Opiate addiction is associated with decision-making deficits and we previously showed that the extent of these impairments predicts aspects of treatment outcome. Here we aimed to establish whether measures of decision-making performance might be used to inform placement matching.

METHODS

Two groups of opiate dependent individuals, one receiving treatment in a community setting (n=48) and one in a residential setting (n=32) were administered computerised tests of decision-making, impulsivity and planning shortly after the beginning of treatment, to be followed up three months into each programme.

RESULTS

In the community sample, performance on the decision-making tasks at initial assessment predicted abstinence from illicit drugs at follow-up. In contrast, in the residential sample there was no relationship between decision-making and clinical outcome.

CONCLUSIONS

Intact decision-making processes appear to be necessary for upholding a resolve to avoid taking drugs in a community setting, but the importance of these mechanisms may be attenuated in a residential treatment setting. The results support the placement matching hypothesis, suggesting that individuals with more prominent decision-making deficits may particularly benefit from treatment in a residential setting and from the inclusion of aspects of cognitive rehabilitation in their treatment programme.

Cocaine Addiction Treatments to improve Control and reduce Harm (CATCH): new pharmacological treatment options for crack-cocaine dependence in the Netherlands

BACKGROUND

Cocaine, particularly in its base form ('crack'), has become one of the drugs of most concern in the Netherlands, being associated with a wide range of medical, psychiatric and social problems for the individual, and with significant public order consequences for society. Available treatment options for cocaine dependent users are limited, and a substantial part of the cocaine dependent population is not reached by the addiction treatment system. Psychosocial interventions for cocaine dependence generally show modest results, and there are no registered pharmacological treatments to date, despite the wide range of medications tested for this type of dependence. The present study (Cocaine Addiction Treatments to improve Control and reduce Harm; CATCH) investigates the possibilities and problems associated with new pharmacological treatments for crack dependent patients.

METHODS/DESIGN

The CATCH-study consists of three separate randomised controlled, open-label, parallel-group feasibility trials, conducted at three separate addiction treatment institutes in the Netherlands. Patients are either new referrals or patients already in treatment. A total of 216 eligible outpatients are randomised using pre-randomisation double-consent design and receive either 12 weeks treatment with oral topiramate (n = 36; Brijder Addiction Treatment, The Hague), oral modafinil (n = 36; Arkin, Amsterdam), or oral dexamphetamine sustained-release (n = 36; Bouman GGZ, Rotterdam) as an add-on to cognitive behavioural therapy (CBT), or receive a 12-week CBT only (controls: n = 3 × 36). Primary outcome in these feasibility trials is retention in the underlying psychosocial treatment (CBT). Secondary outcomes are acceptance and compliance with the study medication, safety, changes in cocaine (and other drug) use, physical and mental health, social functioning, and patient satisfaction.

DISCUSSION

To date, the CATCH-study is the first study in the Netherlands that explores new treatment options for crack-cocaine dependence focusing on both abstinence and harm minimisation. It is expected that the study will contribute to the development of new treatments for one of the most problematic substance use disorders.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR2576The European Union Drug Regulating Authorities Clinical Trials EudraCT2009-010584-16.

Assessing recovery and functioning in former problem drinkers at different stages of their recovery journeys

INTRODUCTION AND AIMS

Many studies which assess functioning in recovering problem drinkers are limited to early recovery within inpatient or detoxification settings, or focus on relapse rates and treatment outcomes. This study assesses how functioning varies according to recovery stage and abstinence duration.

DESIGN AND METHODS

Fifty-three recovering problem drinkers participated from mutual aid groups or snowball recruitment. Cross-sectional interviewer-administered structured questionnaires assessed quality of life (QoL), self-esteem, self-efficacy, psychological and physical health. Participants could also self-complete the questionnaire.

RESULTS

Those in 'stable recovery' (5 or more years into recovery, n = 18) reported higher ratings of: three aspects of QoL--social relationships, psychological health, environment, as well as self-esteem (P < 0.05 for all variables) than those in 'early' (up to 5 years into recovery, n = 35). Depression was lower in 'stable recovery' (P = 0.027). Those in 'stable recovery' were more likely to live in their own home without professional support (P = 0.010) and have partners who had never been problem drinkers (P = 0.024). Overall, the continuous scores of many functioning variables correlated with abstinence duration indicating a continuous gain in functioning.

DISCUSSION AND CONCLUSIONS

Although limited by sampling considerations, this paper shows a gradual growth in functioning over a prolonged recovery process, and provides positive findings that those in recovery may expect to experience improvements in many areas of life as abstinence duration increases. For two aspects of QoL--environment and social relationships--functioning reaches a level above population norms offering hope of moving to a functioning level beyond the pre-morbid state.[Hibbert LJ, Best DW. Assessing recovery and functioning in former problem drinkers at different stages of their recovery journeys.

Client satisfaction among participants in a randomized trial comparing oral methadone and injectable diacetylmorphine for long-term opioid-dependency

BACKGROUND

Substitution with opioid-agonists (e.g., methadone) has shown to be an effective treatment for chronic long-term opioid dependency. Patient satisfaction with treatment has been associated with improved addiction treatment outcomes. However, there is a paucity of studies evaluating patients' satisfaction with Opioid Substitution Treatment (OST). In the present study, participants' satisfaction with OST was evaluated at 3 and 12 months. We sought to test the relationship between satisfaction and patients' characteristics, the treatment modality received and treatment outcomes.

METHODS

Data from a randomized controlled trial, the North American Opiate Medication Initiative (NAOMI), conducted in Vancouver and Montreal (Canada) between 2005-2008, was analyzed. The NAOMI study compared the effectiveness of oral methadone vs. injectable diacetylmorphine over 12 months. A small sub-group of patients received injectable hydromorphone on a double blind basis with diacetylmorphine. The Client Satisfaction Questionnaire (CSQ-8) was used to measure satisfaction with treatment. CSQ-8 scores, as well as retention and response to treatment, did not differ between those receiving hydromorphone and diacetylmorphine at 3 or 12 months assessments; therefore, these two groups were analyzed together as the 'injectable' treatment group.

RESULTS

A total of 232 (92%) and 237 (94%) participants completed the CSQ-8 at 3 and 12 months, respectively. Participants in both groups were highly satisfied with treatment. Independent of treatment group, participants satisfied with treatment at 3 months were more likely to be retained at 12 months. Multivariate analysis indicated that satisfaction was greater among those randomized to the injection group after controlling for treatment effectiveness. Participants who were retained, responded to treatment, and had fewer psychological symptoms were more satisfied with treatment. Finally, open-ended comments were made by 149 (60.3%) participants; concerns about the randomization process and the study ending were most commonly reported by participants receiving the oral and injectable medications, respectively.

CONCLUSIONS

The higher satisfaction among those receiving medically prescribed injectable diacetylmorphine (or hydromorphone) supports current evidence regarding the attractiveness of this treatment for long-term, opioid-dependent individuals not benefiting sufficiently from other treatments. In addition, the measurement of treatment satisfaction provides valuable information about participants at risk of relapse and in need of additional services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00175357.

Smoking and predictors of nicotine dependence in a homeless population

OBJECTIVE

To assess prevalence rates of tobacco use and dependence in a sample of homeless individuals and to investigate trends for demographic and clinical characteristics across different levels of nicotine dependence (nonsmokers vs. lowly dependent smokers vs. highly dependent smokers).

METHODS

A cross-sectional study of 489 homeless men and women in 3 Canadian cities. Each subject was assessed using structured clinical interviews and the Fagerström Test for Nicotine Dependence (FTND). Cochran-Armitage trend tests were applied to determine unadjusted trends in sociodemographic and clinical variables across levels of nicotine dependence. A generalized logit model was computed to adjust for potential confounding.

RESULTS

The mean age was 37.9 years; 39.2% of the participants were women. About 80.8% were current smokers; the mean FTND score was 5.0. Although no significant differences were found between nonsmokers and smokers with low nicotine dependence, smokers with high nicotine dependence were only half as likely as nonsmokers to be Aboriginal, were 2.39 times more likely to have ever been incarcerated, and 2.44 times more likely to have current drug dependence. There were significant trends for the use of cocaine, opioids, and alcohol, with nonsmokers having the lowest and highly dependent smokers having the highest rates of using these substances.

CONCLUSIONS

Available public health smoking cessation treatment opportunities should be made available within health care services for the homeless. There is also a need for developing and implementing tobacco dependence treatment programs, which are accessible and tailored to meet the needs of this specific population, accounting for polysubstance use and concurrent substance dependence and mental health disorders.

Anxiety and depression among opiate users who misuse substances during treatment

OBJECTIVES

While treatment is known to improve drug and crime outcomes for opiate users, there is debate in the literature about the longitudinal effects of substance misuse and the comorbidity of mental health problems. We sought to describe and model anxiety and depression outcomes during opiate substance misuse treatment.

METHODS

The first national, longitudinal treatment outcome study of 404 opiate users entering a new episode of inpatient or outpatient treatment and followed up at one and three years and assessed using the Maudsley Addiction Profile instrument.

RESULTS

A total of 404 opiate users were recruited representing approximately 8.2% of all new treatments and 17% of all new methadone treatments at national level in Ireland in 2003. At three years 97% (n = 392) were followed-up. At one year, analysis revealed the odds of experiencing depression was between five and 15 times the odds for opiate users who also used cocaine than non cocaine using opiate users, but this had decreased at three years. At three years those who were drug free, that is, not in treatment and not using illicit drugs, were less likely to experience feeling hopeless about the future than those in treatment or those not in treatment and using, but they were also more likely to experience feeling tense. Those in treatment were more likely to feel lonely.

CONCLUSION

The concurrent misuse of cocaine and other substances during opiate treatment and the stage of the treatment pathway are associated with anxiety and depression among opiate users in treatment. These client factors need to be considered when implementing individualised treatment care plans.

Does concurrent cocaine use compromise 1-year treatment outcomes for opiate users?

The current study aimed to determine whether cocaine use compromises treatment outcomes for opiate users. Data were collected from 404 opiate users at treatment intake and 1-year follow-up as part of a national treatment outcome study. Because of higher intake measures, cocaine users improved in more outcomes than nonusers, but comparisons between groups found that cocaine users had more coexisting problems. Regression analysis revealed that those who used cocaine at intake were more likely to use cocaine at 1-year follow-up, to commit crime, and to be homeless. It is concluded that treatment for opiate use "works" even in the presence of concurrent cocaine use.

Evaluating equivalence and noninferiority trials

PURPOSE

The conceptual issues related to the design of equivalence and non-inferiority trials and considerations for interpreting the findings of such trials are described.

SUMMARY

Comparative effectiveness research (CER) has recently gained importance in the evaluation of different treatment alternatives. Large, prospective, randomized controlled trials (RCTs) conducted with patient populations under routine practice conditions can yield high-quality CER results. A Phase III RCT, usually conducted for establishing superiority of one treatment over another, is called a superiority trial, and the statistical test associated with it is known as a superiority test. In a pragmatic equivalence trial, a researcher aims to test if two treatments are identical (within a specified range) with respect to some predefined clinical criteria. Pragmatic noninferiority trials aim to show if a test therapy is no worse than a standard therapy with respect to achieving the primary treatment outcome. A nonsignificant result obtained from a superiority test does not indicate that the two treatment options are similar. In other words, the lack of evidence of superiority does not guarantee a lack of difference in the performance shown by the therapies. A researcher can only demonstrate identical effects of two treatments in an equivalence trial. In a noninferiority trial, the test therapy is preferred when there is evidence about its benefits over the standard treatment in terms of secondary outcomes such as cost, adherence, and adverse effects.

CONCLUSION

Equivalence and noninferiority trials are designed differently from superiority trials. The overall quality of equivalence and noninferiority studies depends on study design and the manner in which the results are reported.

Effectiveness of a web-based intervention for problem drinkers and reasons for dropout: randomized controlled trial

BACKGROUND

Online self-help interventions for problem drinkers show promising results, but the effectiveness of online therapy with active involvement of a therapist via the Internet only has not been examined.

OBJECTIVE

The objective of our study was to evaluate an e-therapy program with active therapeutic involvement for problem drinkers, with the hypotheses that e-therapy would (1) reduce weekly alcohol consumption, and (2) improve health status. Reasons for dropout were also systematically investigated.

METHOD

In an open randomized controlled trial, Dutch-speaking problem drinkers in the general population were randomly assigned (in blocks of 8, according to a computer-generated random list) to the 3-month e-therapy program (n = 78) or the waiting list control group (n = 78). The e-therapy program consisted of a structured 2-part online treatment program in which the participant and the therapist communicated asynchronously, via the Internet only. Participants in the waiting list control group received "no-reply" email messages once every 2 weeks. The primary outcome measures were (1) the difference in the score on weekly alcohol consumption, and (2) the proportion of participants drinking under the problem drinking limit. Intention-to-treat analyses were performed using multiple imputations to deal with loss to follow-up. A dropout questionnaire was sent to anyone who did not complete the 3-month assessment. Reasons for dropout were independently assessed by the first and third author.

RESULTS

Of the 156 individuals who were randomly assigned, 102 (65%) completed assessment at 3 months. In the intention-to-treat analyses, the e-therapy group (n = 78) showed a significantly greater decrease in alcohol consumption than those in the control group (n = 78) at 3 months. The e-therapy group decreased their mean weekly alcohol consumption by 28.8 units compared with 3.1 units in the control group, a difference in means of 25.6 units on a weekly basis (95% confidence interval 15.69-35.80, P < .001). The between-group effect size (pooled SD) was large (d = 1.21). The results also showed that 68% (53/78) of the e-therapy group was drinking less than 15 (females) or 22 (males) units a week, compared with 15% (12/78) in the control group (OR 12.0, number needed to treat 1.9, P < .001). Dropout analysis showed that the main reasons for dropouts (n = 54) were personal reasons unrelated to the e-therapy program, discomfort with the treatment protocol, and satisfaction with the positive results achieved.

CONCLUSIONS

E-therapy for problem drinking is an effective intervention that can be delivered to a large population who otherwise do not seek help for their drinking problem. Insight into reasons for dropout can help improve e-therapy programs to decrease the number of dropouts. Additional research is needed to directly compare the effectiveness of the e-therapy program with a face-to-face treatment program.