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Goodwin S, Kirby KC, Raiff BR. Evolution of the substance use landscape: Implications for contingency management. J Appl Behav Anal 2024. [PMID: 39193870 DOI: 10.1002/jaba.2911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 07/31/2024] [Indexed: 08/29/2024]
Abstract
Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.
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Affiliation(s)
- Shelby Goodwin
- Department of Psychology, Rowan University, Glassboro, New Jersey, USA
| | | | - Bethany R Raiff
- Department of Psychology, Rowan University, Glassboro, New Jersey, USA
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Pfund RA, Ginley MK, Boness CL, Rash CJ, Zajac K, Witkiewitz K. Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2024; 31:136-150. [PMID: 38863566 PMCID: PMC11164545 DOI: 10.1037/cps0000121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Several professional organizations and federal agencies recommend contingency management (CM) as an empirically supported treatment for drug use disorder. However, the release of the "Tolin criteria" warrants an updated recommendation. Using this methodology, five meta-analyses (84 studies, 11,000 participants) were reviewed. Two meta-analyses were rated moderate quality, and three were rated low or critically low quality. Comparator conditions included active treatment, placebo, treatment as usual, and no treatment. The primary outcome was abstinence. Considering only the moderate quality meta-analyses, the effect of CM versus control on posttreatment abstinence was d = 0.54 [0.43, 0.64] and follow-up abstinence was d=0.08 [0.00, 0.16]. A "strong" recommendation was provided for CM as an empirically supported treatment for drug use disorder.
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Affiliation(s)
- Rory A. Pfund
- Center on Alcohol, Substance use, And Addictions, University of New Mexico
| | | | | | - Carla J. Rash
- Calhoun Cardiology Center, University of Connecticut School of Medicine
| | - Kristyn Zajac
- Calhoun Cardiology Center, University of Connecticut School of Medicine
| | - Katie Witkiewitz
- Center on Alcohol, Substance use, And Addictions, University of New Mexico
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Minozzi S, Saulle R, Amato L, Traccis F, Agabio R. Psychosocial interventions for stimulant use disorder. Cochrane Database Syst Rev 2024; 2:CD011866. [PMID: 38357958 PMCID: PMC10867898 DOI: 10.1002/14651858.cd011866.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016. OBJECTIVES To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred. AUTHORS' CONCLUSIONS This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Rosella Saulle
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Laura Amato
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Francesco Traccis
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
| | - Roberta Agabio
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
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Klemperer EM, Evans EA, Rawson R. A call to action: Contingency management to improve post-release treatment engagement among people with opioid use disorder who are incarcerated. Prev Med 2023; 176:107647. [PMID: 37499918 PMCID: PMC10808263 DOI: 10.1016/j.ypmed.2023.107647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for illicit opioid use and overdose after release. A growing number of correctional facilities offer medication for OUD (MOUD), which is effective in reducing these risks. However, a recent evaluation found that <50% of those prescribed MOUD during incarceration continued MOUD within 30 days after release, demonstrating a need to improve post-release continuity of care. We describe available evidence on contingency management (CM), an intervention wherein patients receive incentives contingent on behavior change, to achieve this goal. A prior systematic review reported strong evidence in support of CM for increasing treatment adherence in MOUD programs, but the trials reviewed did not include incarcerated participants. Research on CM to increase treatment adherence among participants in the criminal justice system is limited with mixed findings. However, in comparison to the trials that supported CM's efficacy in the community, CM trials in the criminal justice system provided smaller rewards with greater delays in the delivery of rewards to patients, which likely contributed to null findings. Indeed, a prior meta-analysis demonstrates a dose-response relationship between the magnitude and immediacy of reward and CM effectiveness. Thus, CM involving larger and more immediately delivered rewards are likely necessary to improve MOUD adherence during the critical period following release from incarceration. Future research on the effectiveness and implementation of CM to improve MOUD retention after release from incarceration is warranted.
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Affiliation(s)
- Elias M Klemperer
- University of Vermont, College of Medicine, Department of Psychiatry, United States of America.
| | - Elizabeth A Evans
- University of Massachusetts Amherst, School of Public Health & Health Sciences, United States of America
| | - Richard Rawson
- University of Vermont, College of Medicine, Department of Psychiatry, United States of America
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Glover‐Wright C, Coupe K, Campbell AC, Keen C, Lawrence P, Kinner SA, Young JT. Health outcomes and service use patterns associated with co-located outpatient mental health care and alcohol and other drug specialist treatment: A systematic review. Drug Alcohol Rev 2023; 42:1195-1219. [PMID: 37015828 PMCID: PMC10946517 DOI: 10.1111/dar.13651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 12/13/2022] [Accepted: 02/24/2023] [Indexed: 04/06/2023]
Abstract
ISSUES Despite long-standing recommendations to integrate mental health care and alcohol and other drug (AOD) treatment, no prior study has synthesised evidence on the impact of physically co-locating these specialist services on health outcomes. APPROACH We searched Medline, PsycINFO, Embase, Web of Science and CINAHL for studies examining health outcomes associated with co-located outpatient mental health care and AOD specialist treatment for adults with a dual diagnosis of substance use disorder and mental illness. Due to diversity in study designs, patient populations and outcome measures among the included studies, we conducted a narrative synthesis. Risk of bias was assessed using the MASTER scale. KEY FINDINGS Twenty-eight studies met our inclusion criteria. We found provisional evidence that integrated care that includes co-located mental health care and AOD specialist treatment is associated with reductions in substance use and related harms and mental health symptom severity, improved quality of life, decreased emergency department presentations/hospital admissions and reduced health system expenditure. Many studies had a relatively high risk of bias and it was not possible to disaggregate the independent effect of physical co-location from other common aspects of integrated care models such as care coordination and the integration of service processes. IMPLICATIONS There are few high-quality, peer-reviewed studies establishing the impact of co-located mental health care and AOD specialist treatment on health outcomes. Further research is required to inform policy, guide implementation and optimise practice. CONCLUSION Integrated care that includes the co-location of mental health care and AOD specialist treatment may yield health and economic benefits.
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Affiliation(s)
- Clare Glover‐Wright
- Centre for Health Equity, Melbourne School of Population and Global HealthThe University of MelbourneMelbourneAustralia
| | - Kym Coupe
- Centre for Health Equity, Melbourne School of Population and Global HealthThe University of MelbourneMelbourneAustralia
| | - Alexander Charles Campbell
- Centre for Health Equity, Melbourne School of Population and Global HealthThe University of MelbourneMelbourneAustralia
| | - Claire Keen
- Centre for Health Equity, Melbourne School of Population and Global HealthThe University of MelbourneMelbourneAustralia
| | | | - Stuart A. Kinner
- Centre for Health Equity, Melbourne School of Population and Global HealthThe University of MelbourneMelbourneAustralia
- Centre for Adolescent Health, Murdoch Children's Research InstituteMelbourneAustralia
- School of Population HealthCurtin UniversityPerthAustralia
- Griffith Criminology InstituteGriffith UniversityBrisbaneAustralia
| | - Jesse T. Young
- Centre for Health Equity, Melbourne School of Population and Global HealthThe University of MelbourneMelbourneAustralia
- Centre for Adolescent Health, Murdoch Children's Research InstituteMelbourneAustralia
- School of Population and Global HealthThe University of Western AustraliaPerthAustralia
- National Drug Research InstituteCurtin UniversityPerthAustralia
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Getty CA, Weaver T, Metrebian N. A qualitative exploration of patients' experience of mobile telephone-delivered contingency management to promote adherence to supervised methadone. Drug Alcohol Rev 2023; 42:641-651. [PMID: 36269110 DOI: 10.1111/dar.13555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/08/2022] [Accepted: 09/07/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Despite an increasing evidence base for mobile telephone-delivered contingency management (mCM), there had been no previous qualitative exploration of patients' experience of receiving mCM and the factors that might influence that experience and outcome in a UK setting. The aim of this study was to understand patients' views and experience of receiving mCM by exploring their beliefs, expectations and perceived benefits within the context of the UK's first mCM intervention. METHODS Qualitative interviews (N = 15) were conducted with patients undergoing opioid agonist treatment in a UK drug treatment service and receiving mCM to encourage adherence with supervised methadone as part of an existing study. Interviews were conducted at two time points and analysed using Framework to explore patients' expectations and beliefs during the early stage of the intervention (2 weeks) and their perceived benefits and experience at the end of the intervention (12 weeks). RESULTS The mCM was perceived as a motivator, providing validation of achievement, and involving discreet and positive interactions. Perceived benefits included enhanced methadone adherence, reduced drug use and the development of a supportive and non-judgemental connection that resembled a therapeutic alliance. DISCUSSION AND CONCLUSIONS The mechanisms underpinning contingency management appeared to operate in the absence of human interaction, and the mCM intervention was deemed to be meaningful, acceptable and well received by patients. These findings not only provide support for the application of mCM in this context but also offer insight into the factors that influence outcomes and should be considered in the development of future mCM interventions.
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Affiliation(s)
- Carol-Ann Getty
- National Addiction Centre, King's College London, London, UK
| | - Tim Weaver
- Department of Mental Health and Social Work at Middlesex University, London, UK
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Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis. Drug Alcohol Depend 2022; 238:109551. [PMID: 35797876 DOI: 10.1016/j.drugalcdep.2022.109551] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/12/2022] [Accepted: 06/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD. METHODS We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics. FINDINGS Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates. INTERPRETATION Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.
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Contingency management for treatment attendance: A meta-analysis. J Subst Abuse Treat 2022; 133:108556. [PMID: 34210566 PMCID: PMC8702584 DOI: 10.1016/j.jsat.2021.108556] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/12/2021] [Accepted: 06/14/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Treatment providers have applied contingency management (CM) treatment, an intervention that often rewards individuals for drug abstinence (i.e., ABS CM), to treatment engagement as well. However, we know little about the magnitude of treatment effects when providers target attendance behaviors (i.e., ATT CM). METHODS This study conducted a systematic search to identify studies that included ATT CM, either in isolation or in combination with ABS CM. The study used meta-analysis to estimate the effect size of ATT CM and ABS CM + ATT CM on treatment attendance and drug abstinence. We identified a total of 10 studies including 12 CM treatments (6 ATT CM and 6 ABS CM + ATT CM) with 1841 participants. RESULTS Results indicated a moderate effect (d = 0.47, 95% confidence interval (CI) [0.25, 0.69]) of ATT CM on attendance relative to non-reward active comparison conditions. Frequency of rewards was significantly associated with larger effect sizes. Results also indicated a small effect (d = 0.22, 95% CI [0.12, 0.33]) of ATT CM on abstinence outcomes relative to nonreward comparisons, p < 0.001. The study found no significant differences in attendance or abstinence between ATT CM and ABS CM + ATT CM (p's > 0.05). CONCLUSION Overall, the results supported ATT CM for increasing treatment engagement, with smaller effects on abstinence. Effects on abstinence were smaller than those observed in prior meta-analyses focused on ABS CM. No significant differences existed in attendance or abstinence outcomes between ATT CM and ABS + ATT CM. However, future studies are needed to experimentally compare ABS CM + ATT CM to ABS CM, and ATT CM to determine additive effects. Clinics implementing CM should consider the differential effects between ATT CM and ABS CM when selecting target behavior(s).
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Bolívar HA, Klemperer EM, Coleman SRM, DeSarno M, Skelly JM, Higgins ST. Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-analysis. JAMA Psychiatry 2021; 78:1092-1102. [PMID: 34347030 PMCID: PMC8340014 DOI: 10.1001/jamapsychiatry.2021.1969] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/29/2021] [Indexed: 12/21/2022]
Abstract
Importance Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy. Objective To examine the association of contingency management, a behavioral intervention wherein patients receive material incentives contingent on objectively verified behavior change, with end-of-treatment outcomes for these comorbid behavioral problems. Data Sources A systematic search of PubMed, Cochrane CENTRAL, Web of Science, and reference sections of articles from inception through May 5, 2020. The following search terms were used: vouchers OR contingency management OR financial incentives. Study Selection Prospective experimental studies of monetary-based contingency management among participants receiving MOUD. Data Extraction and Synthesis Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis. Main Outcomes and Measures Primary outcome was the association of contingency management at end-of-treatment assessments with 6 clinical problems: stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence. Random-effects meta-analysis models were used to compute weighted mean effect size estimates (Cohen d) and corresponding 95% CIs separately for each clinical problem and collapsing across the 3 categories assessing abstinence and the 2 assessing treatment adherence outcomes. Results The search identified 1443 reports of which 74 reports involving 10 444 unique adult participants met inclusion criteria for narrative review and 60 for inclusion in meta-analyses. Contingency management was associated with end-of-treatment outcomes for all 6 problems examined separately, with mean effect sizes for 4 of 6 in the medium-large range (stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86]; medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]), and 2 in the small-medium range (polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62]; therapy attendance, d = 0.43 [95% CI, 0.22-0.65]). Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls. Conclusions and Relevance These results provide evidence supporting the use of contingency management in addressing key clinical problems among patients receiving MOUD, including the ongoing epidemic of comorbid psychomotor stimulant misuse. Policies facilitating integration of contingency management into community MOUD services are sorely needed.
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Affiliation(s)
- Hypatia A. Bolívar
- Vermont Center on Behavior and Health, University of Vermont, Burlington
- Department of Psychiatry, University of Vermont, Burlington
| | - Elias M. Klemperer
- Vermont Center on Behavior and Health, University of Vermont, Burlington
- Department of Psychiatry, University of Vermont, Burlington
| | - Sulamunn R. M. Coleman
- Vermont Center on Behavior and Health, University of Vermont, Burlington
- Department of Psychiatry, University of Vermont, Burlington
| | | | - Joan M. Skelly
- Medical Biostatistics, University of Vermont, Burlington
| | - Stephen T. Higgins
- Vermont Center on Behavior and Health, University of Vermont, Burlington
- Department of Psychiatry, University of Vermont, Burlington
- Department of Psychological Science, University of Vermont, Burlington
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Kidorf M, Salazzo S, Brooner RK, Peirce J, Gandotra J, Leoutsakos JM. Impact of Personality Disorder on the Treatment of Psychiatric Disorders in People Receiving Methadone-Assisted Treatment. J Pers Disord 2021; 35:114-126. [PMID: 30920940 DOI: 10.1521/pedi_2019_33_429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study evaluates personality disorder as a moderator of psychiatric treatment response in people receiving methadone-assisted treatment. Participants (N = 125) were enrolled in a 12-week parent study that evaluated the impact of incentives on attendance to psychiatric care. All participants had a current DSM IV-R Axis I disorder and were classified based on presence of an Axis II disorder: Axis I-only (n = 46) versus Axis I + II (n = 79). All participants received an identical protocol of psychiatric and substance use disorder care. Although Axis I + II participants endorsed more psychiatric distress (on the Hopkins Symptom Checklist-Revised) throughout treatment, they reported significant reductions in distress that paralleled reductions reported by Axis I-only participants. Rates of substance use were low and similar across groups. Results support the benefits of integrated psychiatric and substance use care for people with opioid use disorder, with or without a co-occurring personality disorder.
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Affiliation(s)
- Michael Kidorf
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Robert K Brooner
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Peirce
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jim Gandotra
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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11
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Ellis JD, Struble CA, Fodor MC, Cairncross M, Lundahl LH, Ledgerwood DM. Contingency management for individuals with chronic health conditions: A systematic review and meta-analysis of randomized controlled trials. Behav Res Ther 2020; 136:103781. [PMID: 33302054 DOI: 10.1016/j.brat.2020.103781] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/24/2020] [Accepted: 11/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Contingency management (CM) interventions involve providing reinforcement for engaging in a desired behavior, and have been shown to increase treatment adherence and promote abstinence in the treatment of substance use disorders. This review was conducted to systematically review the literature on the effectiveness of CM when applied to a range of medical conditions outside of substance use disorders. METHOD The authors identified a total of 24 randomized studies examining the effects of CM on four outcomes: weight change, physical activity, medication/device adherence, and viral load that were included in the qualitative summary, and 20 studies included in the meta-analysis. RESULTS CM was associated with positive outcomes for physical activity and medication/device adherence compared to control conditions. Findings with weight loss and viral load were more mixed, and evidence for publication bias was found for both outcomes. The effects of CM tend to dissipate when the contingency is removed. Heterogeneity was observed across most outcomes. LIMITATIONS AND CONCLUSIONS This review provides preliminary support for the use of CM in increasing physical activity and improving adherence to medication for chronic health conditions while reinforcement is ongoing. Future studies should examine potential moderators and identify strategies to maintain these changes over time.
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Affiliation(s)
- Jennifer D Ellis
- Department of Psychiatry & Behavioral Neurosciences, Wayne State University, USA; Department of Psychiatry & Behavioral Sciences, Johns Hopkins University, USA
| | - Cara A Struble
- Department of Psychiatry & Behavioral Neurosciences, Wayne State University, USA
| | - Marina C Fodor
- Department of Psychiatry & Behavioral Neurosciences, Wayne State University, USA
| | - Molly Cairncross
- Division of Physical Medicine and Rehabilitation, The University of British Columbia, Canada
| | - Leslie H Lundahl
- Department of Psychiatry & Behavioral Neurosciences, Wayne State University, USA
| | - David M Ledgerwood
- Department of Psychiatry & Behavioral Neurosciences, Wayne State University, USA.
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Hunt GE, Siegfried N, Morley K, Brooke‐Sumner C, Cleary M. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev 2019; 12:CD001088. [PMID: 31829430 PMCID: PMC6906736 DOI: 10.1002/14651858.cd001088.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. SEARCH METHODS The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. MAIN RESULTS Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence). AUTHORS' CONCLUSIONS We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
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Affiliation(s)
- Glenn E Hunt
- The University of SydneyDiscipline of PsychiatryConcord Centre for Mental HealthHospital RoadSydneyNSWAustralia2139
| | - Nandi Siegfried
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitTybergCape TownSouth Africa
| | - Kirsten Morley
- The University of SydneyAddiction MedicineSydneyAustralia
| | - Carrie Brooke‐Sumner
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitTybergCape TownSouth Africa
| | - Michelle Cleary
- University of TasmaniaSchool of Nursing, College of Health and MedicineSydney, NSWAustralia
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Tardelli VS, Lago MPPD, Mendez M, Bisaga A, Fidalgo TM. Contingency Management with pharmacologic treatment for Stimulant Use Disorders: A review. Behav Res Ther 2018; 111:57-63. [DOI: 10.1016/j.brat.2018.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/30/2018] [Accepted: 10/03/2018] [Indexed: 11/29/2022]
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Kidorf M, Solazzo S, Yan H, Brooner RK. Psychiatric and Substance Use Comorbidity in Treatment-Seeking Injection Opioid Users Referred From Syringe Exchange. J Dual Diagn 2018; 14:193-200. [PMID: 30332349 DOI: 10.1080/15504263.2018.1510148] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The present study evaluated rates of co-occurring current psychiatric and substance use disorders in a sample of opioid-dependent treatment-seeking injection drug users referred from syringe exchange. METHODS Participants (N = 208) completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-R to assess current (within the past year) psychiatric and substance use disorders and the two most commonly diagnosed personality disorders (antisocial and borderline personality disorders). RESULTS Forty-eight percent of the sample had a current Axis I psychiatric disorder, and 67% had a co-occurring current substance use disorder. Posttraumatic stress disorder (21%), major depression (17%), and bipolar I (12%) were the most prevalent Axis I psychiatric disorders, and cocaine use disorder (53%) was the most commonly co-occurring substance use disorder. Women were more likely to have diagnoses of most anxiety disorders and less likely to have diagnoses of alcohol use disorder or antisocial personality disorder. The presence of a personality disorder was associated with higher rates of cocaine and sedative use disorder. CONCLUSIONS Findings suggest the importance of evaluating and treating co-occurring psychiatric and substance use disorders in the treatment of injection drug users with opioid dependence.
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Affiliation(s)
- Michael Kidorf
- a Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Stephanie Solazzo
- a Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Haijuan Yan
- a Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Robert K Brooner
- a Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center , Johns Hopkins University School of Medicine , Baltimore , MD , USA
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Kidorf M, Brooner RK, Leoutsakos JM, Peirce J. Treatment initiation strategies for syringe exchange referrals to methadone maintenance: A randomized clinical trial. Drug Alcohol Depend 2018; 187:343-350. [PMID: 29709732 DOI: 10.1016/j.drugalcdep.2018.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 11/26/2022]
Abstract
This randomized clinical trial evaluated the efficacy of three treatment initiation strategies for improving retention to methadone maintenance for opioid-dependent individuals referred from a syringe exchange program (SEP). New admissions (n = 212) were randomly assigned to one of three 3-month initiation strategies: 1) Low Threshold (LTI), 2) Voucher Reinforcement (VRI), or 3) Standard Care (SCI). LTI was modeled on interim methadone maintenance to transition SEP admissions to the structure of medication-assisted treatment while maximizing exposure to methadone pharmacotherapy. VRI used monetary incentives to reinforce adherence to pharmacotherapy and adaptive counseling. SCI participants received standard methadone dosing and adaptive counseling. All participants were stabilized on methadone pharmacotherapy with a target dose of 80 mg. Following the initiation phase, participants in each condition received standard adaptive counseling from months 4-6. Results showed that most participants failed to achieve the target methadone dose. While no condition differences were observed in retention rates over the 3-month and 6-month observation periods, participants across conditions exhibited reductions in objective and self-report measures of drug use. Results support the benefits of referring syringe exchangers to methadone maintenance, and demonstrate the challenge of retaining these individuals in treatment.
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Affiliation(s)
- Michael Kidorf
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States.
| | - Robert K Brooner
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
| | - Jeannie-Marie Leoutsakos
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
| | - Jessica Peirce
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
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16
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Zou X, Xu Y, Chen W, Xia Y, Liu Y, Gong C, Ling L. Strategies to control HIV and HCV in methadone maintenance treatment in Guangdong Province, China: a system dynamic modeling study. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2018; 13:1. [PMID: 29321039 PMCID: PMC5763976 DOI: 10.1186/s13011-017-0140-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/27/2017] [Indexed: 12/31/2022]
Abstract
Background Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among methadone maintenance treatment (MMT) participants remain high. Optimized HIV and HCV prevention strategies for MMT clinics in resource-limited regions are urgently needed. This study aims to develop an MMT system dynamic model (SDM) to compare and optimize HIV and HCV control strategies in the MMT system. Methods We developed an MMT-SDM structure based on literature reviews. Model parameters were estimated from a cohort study, cross-sectional surveys and literature reviews. We further calibrated model outputs to historical data of HIV and HCV prevalence among MMT participants in 13 MMT clinics of Guangdong Province. Lastly, we simulated the impact of integrated interventions on HIV and HCV incidence among MMT participants using the MMT-SDM. Results The MMT-SDM comprises MMT clinics, MMT participants, detoxification centers, and HIV and HCV transmission, testing and treatment systems. We determined that condom promotion was the most effective way to reduce HIV infection (2013-2020: 2.86% to 1.76%) in MMT setting, followed by needle exchange program (2013-2020: 2.86% to 2.56%), psychological counseling (2013-2020: 2.86% to 2.71%) and contingency management (2013-2020: 2.86% to 2.72%). Health education had marginal impact on reducing HIV incidence among MMT participants (2013-2020:2.86% to 2.84%) from 2013 to 2020. By contrast, psychological counseling (2013-2020: 7.54% to 2.42%) and contingency management (2013-2020: 7.54% to 2.96%) had been shown to be the most effective interventions to reduce HCV incidence among MMT participants, followed by needle exchange program (2013-2020: 7.54% to 5.76%), health education (2013-2020: 7.54% to 6.35%), and condom promotion program (2013-2020: 7.54% to 6.40%). Notably, HCV treatment reduced HCV incidence by 0.32% (2013-2020: 7.54% to 7.22%). Conclusions In conclusion, we generated a valuable system dynamic model to analyze the Chinese MMT system and to guide the decision-making process to further improve this system. This study underscores the importance of promoting condom use in MMT clinics and integrating psychosocial interventions to reduce HIV and HCV infections in MMT clinics in China. Electronic supplementary material The online version of this article (10.1186/s13011-017-0140-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xia Zou
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yong Xu
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Wen Chen
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yinghua Xia
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yin Liu
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Cheng Gong
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li Ling
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China. .,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China.
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18
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Stitzer M, Matheson T, Cunningham C, Sorensen JL, Feaster DJ, Gooden L, Hammond AS, Fitzsimons H, Metsch LR. Enhancing patient navigation to improve intervention session attendance and viral load suppression of persons with HIV and substance use: a secondary post hoc analysis of the Project HOPE study. Addict Sci Clin Pract 2017. [PMID: 28651612 PMCID: PMC5485550 DOI: 10.1186/s13722-017-0081-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Interventions are needed to improve viral suppression rates among persons with HIV
and substance use. A 3-arm randomized multi-site study (Metsch et al. in JAMA 316:156–70, 2016) was conducted to evaluate the effect on HIV outcomes of usual care referral to HIV and substance use services (N = 253) versus patient navigation delivered alone (PN: N = 266) or together with contingency management (PN + CM; N = 271) that provided financial incentives targeting potential behavioral mediators of viral load suppression. Aims This secondary analysis evaluates the effects of financial incentives on attendance at PN sessions and the relationship between session attendance and viral load suppression at end of the intervention. Methods Frequency of sessions attended was analyzed over time and by distribution of individual session attendance frequency (PN vs PN + CM). Percent virally suppressed (≤200 copies/mL) at 6 months was compared for low, medium and high rate attenders. In PN + CM a total of $220 could be earned for attendance at 11 PN sessions over the 6-month intervention with payments ranging from $10 to $30 under an escalating schedule. Results The majority (74%) of PN-only participants attended 6 or more sessions but only 28% attended 10 or more and 16% attended all eleven sessions. In contrast, 90% of PN + CM attended 6 or more visits, 69% attended 10 or more and 57% attended all eleven sessions (attendance distribution χ2[11] = 105.81; p < .0001). Overall (PN and PN + CM participants combined) percent with viral load suppression at 6-months was 15, 38 and 54% among those who attended 0–5, 6–9 and 10–11 visits, respectively (χ2(2) = 39.07, p < .001). Conclusion In this secondary post hoc analysis, contact with patient navigators was increased by attendance incentives. Higher rates of attendance at patient navigation sessions was associated with viral suppression at the 6-month follow-up assessment. Study results support use of attendance incentives to improve rates of contact between service providers and patients, particularly patients who are difficult to engage in care. Trial Registration clinicaltrials.govIdentifier: NCT01612169.
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Affiliation(s)
- Maxine Stitzer
- Department of Psychiatry and Behavioral Sciences, Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA.
| | - Tim Matheson
- San Francisco Department of Public Health, 25 Van Ness Avenue Suite 500, San Francisco, CA, 94102, USA
| | - Colin Cunningham
- Department of Psychiatry and Behavioral Sciences, Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - James L Sorensen
- UCSF Department of Psychiatry, Zuckerberg San Francisco General Hospital and Trauma Center, 1001 Potrero Avenue SFGH Building 20, Rm. 2117, San Francisco, CA, 94110, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB 1059, Miami, FL, 33136, USA
| | - Lauren Gooden
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 918, New York, NY, 10032, USA
| | - Alexis S Hammond
- Department of Psychiatry and Behavioral Sciences, Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Heather Fitzsimons
- Department of Psychiatry and Behavioral Sciences, Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 918, New York, NY, 10032, USA
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Stitzer M, Calsyn D, Matheson T, Sorensen J, Gooden L, Metsch L. Development of a Multi-Target Contingency Management Intervention for HIV Positive Substance Users. J Subst Abuse Treat 2017; 72:66-71. [PMID: 27624618 PMCID: PMC5154853 DOI: 10.1016/j.jsat.2016.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/24/2016] [Indexed: 12/23/2022]
Abstract
Contingency management (CM) interventions generally target a single behavior such as attendance or drug use. However, disease outcomes are mediated by complex chains of both healthy and interfering behaviors enacted over extended periods of time. This paper describes a novel multi-target contingency management (CM) program developed for use with HIV positive substance users enrolled in a CTN multi-site study (0049 Project HOPE). Participants were randomly assigned to usual care (referral to health care and SUD treatment) or 6-months strength-based patient navigation interventions with (PN+CM) or without (PN only) the CM program. Primary outcome of the trial was viral load suppression at 12-months post-randomization. Up to $1160 could be earned over 6 months under escalating schedules of reinforcement. Earnings were divided among eight CM targets; two PN-related (PN visits; paperwork completion; 26% of possible earnings), four health-related (HIV care visits, lab blood draw visits, medication check, viral load suppression; 47% of possible earnings) and two drug-use abatement (treatment entry; submission of drug negative UAs; 27% of earnings). The paper describes rationale for selection of targets, pay amounts and pay schedules. The CM program was compatible with and fully integrated into the PN intervention. The study design will allow comparison of behavioral and health outcomes for participants receiving PN with and without CM; results will inform future multi-target CM development.
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Affiliation(s)
- Maxine Stitzer
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Baltimore, MD, 21224.
| | - Donald Calsyn
- Department of Psychiatry and Behavioral Science, University of Washington
| | - Timothy Matheson
- San Francisco Department of Public Health, 25 Van Ness Avenue Suite 500, San Francisco, CA, 94102.
| | - James Sorensen
- UCSF Department of Psychiatry, Zuckerberg San Francisco General Hospital and Trauma Center, 1001 Potrero Avenue SFGH Building 20, Rm. 2117, San Francisco, CA, 94110.
| | - Lauren Gooden
- Department of Sociomedical Sciences Mailman School of Public Health, Columbia University Columbia University, 722 West 168th Street, Room 918, New York, NY, 10032.
| | - Lisa Metsch
- Department of Sociomedical Sciences Mailman School of Public Health, Columbia University Columbia University, 722 West 168th Street, Room 918, New York, NY, 10032.
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Davis DR, Kurti AN, Skelly JM, Redner R, White TJ, Higgins ST. A review of the literature on contingency management in the treatment of substance use disorders, 2009-2014. Prev Med 2016; 92:36-46. [PMID: 27514250 PMCID: PMC5385000 DOI: 10.1016/j.ypmed.2016.08.008] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 08/04/2016] [Accepted: 08/06/2016] [Indexed: 10/21/2022]
Abstract
This report describes a systematic literature review of voucher and related monetary-based contingency management (CM) interventions for substance use disorders (SUDs) over 5.2years (November 2009 through December 2014). Reports were identified using the search engine PubMed, expert consultations, and published bibliographies. For inclusion, reports had to (a) involve monetary-based CM; (b) appear in a peer-reviewed journal; (c) include an experimental comparison condition; (d) describe an original study; (e) assess efficacy using inferential statistics; (f) use a research design allowing treatment effects to be attributed to CM. Sixty-nine reports met inclusion criteria and were categorized into 7 research trends: (1) extending CM to special populations, (2) parametric studies, (3) extending CM to community clinics, (4) combining CM with pharmacotherapies, (5) incorporating technology into CM, (6) investigating longer-term outcomes, (7) using CM as a research tool. The vast majority (59/69, 86%) of studies reported significant (p<0.05) during-treatment effects. Twenty-eight (28/59, 47%) of those studies included at least one follow-up visit after CM was discontinued, with eight (8/28, 29%) reporting significant (p<0.05) effects. Average effect size (Cohen's d) during treatment was 0.62 (95% CI: 0.54, 0.70) and post-treatment it was 0.26 (95% CI: 0.11, 0.41). Overall, the literature on voucher-based CM over the past 5years documents sustained growth, high treatment efficacy, moderate to large effect sizes during treatment that weaken but remain evident following treatment termination, and breadth across a diverse set of SUDs, populations, and settings consistent with and extending results from prior reviews.
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Affiliation(s)
- Danielle R Davis
- Vermont Center of Behavior & Health, University of Vermont, United States; Departments of Psychiatry, University of Vermont, United States; Psychological Science, University of Vermont, United States
| | - Allison N Kurti
- Vermont Center of Behavior & Health, University of Vermont, United States; Departments of Psychiatry, University of Vermont, United States
| | - Joan M Skelly
- Medical Biostatistics, University of Vermont, United States
| | - Ryan Redner
- Vermont Center of Behavior & Health, University of Vermont, United States; Behavior Analysis and Therapy Program, Rehabilitation Institute, Southern Illinois University, United States
| | | | - Stephen T Higgins
- Vermont Center of Behavior & Health, University of Vermont, United States; Departments of Psychiatry, University of Vermont, United States; Psychological Science, University of Vermont, United States.
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Minozzi S, Saulle R, De Crescenzo F, Amato L. Psychosocial interventions for psychostimulant misuse. Cochrane Database Syst Rev 2016; 9:CD011866. [PMID: 27684277 PMCID: PMC6457581 DOI: 10.1002/14651858.cd011866.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Psychostimulant misuse is a continuously growing medical and social burden. There is no evidence proving the efficacy of pharmacotherapy. Psychosocial interventions could be a valid approach to help patients in reducing or ceasing drug consumption. OBJECTIVES To assess the effects of psychosocial interventions for psychostimulant misuse in adults. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive); Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science and PsycINFO, from inception to November 2015. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA We included randomised controlled trials comparing any psychosocial intervention with no intervention, treatment as usual (TAU) or a different intervention in adults with psychostimulant misuse or dependence. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included a total of 52 trials (6923 participants).The psychosocial interventions considered in the studies were: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study), 12-step facilitation (4 studies).We judged most of the studies to be at unclear risk of selection bias; blinding of personnel and participants was not possible for the type of intervention, so all the studies were at high risk of performance bias with regard to subjective outcomes; the majority of studies did not specify whether the outcome assessors were blind. We did not consider it likely that the objective outcomes were influenced by lack of blinding.The comparisons made were: any psychosocial intervention versus no intervention (32 studies), any psychosocial intervention versus TAU (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of included studies did not provide any useful data for inclusion in statistical synthesis.We found that, when compared to no intervention, any psychosocial treatment: reduced the dropout rate (risk ratio (RR): 0.83, 95% confidence interval (CI) 0.76 to -0.91, 24 studies, 3393 participants, moderate quality evidence); increased continuous abstinence at the end of treatment (RR: 2.14, 95% CI 1.27 to -3.59, 8 studies, 1241 participants, low quality evidence); did not significantly increase continuous abstinence at the longest follow-up (RR: 2.12, 95% CI 0.77 to -5.86, 4 studies, 324 participants, low quality evidence); significantly increased the longest period of abstinence: (standardised mean difference (SMD): 0.48, 95% CI 0.34 to 0.63, 10 studies, 1354 participants, high quality evidence). However, it should be noted that the in the vast majority of the studies in this comparison the specific psychosocial treatment assessed in the experimental arm was given in add on to treatment as usual or to another specific psychosocial or pharmacological treatment which was received by both groups. So, many of the control groups in this comparison were not really untreated. Receiving some amount of treatment is not the same as not receiving any intervention, so we could argue that the overall effect of the experimental psychosocial treatment could be smaller if given in add on to TAU or to another intervention than if given to participants not receiving any intervention; this could translate to a smaller magnitude of the effect of the psychosocial intervention when it is given in add on.When compared to TAU, any psychosocial treatment reduced dropout rate (RR: 0.72, 95% CI 0.59 to 0.89, 6 studies, 516 participants, moderate quality evidence), did not increase continuous abstinence at the end of treatment (RR: 1.27, 95% CI 0.94 to 1.72, 2 studies, 224 participants, low quality evidence), did not increase longest period of abstinence (MD -3.15 days, 95% CI -10.35 to 4.05, 1 study, 110 participants, low quality evidence). No studies in this comparison assessed the outcome of continuous abstinence at longest follow-up.There were few studies comparing two or more psychosocial interventions, with small sample sizes and considerable heterogeneity in terms of the types of interventions assessed. None reported significant results.None of the studies reported harms related to psychosocial interventions. AUTHORS' CONCLUSIONS The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces the dropout rate and increases the longest period of abstinence. It may increase the number of people achieving continuous abstinence at the end of treatment, although this might not be maintained at longest follow-up. The most studied and the most promising psychosocial approach to be added to treatment as usual is probably contingency management. However, the other approaches were only analysed in a few small studies, so we cannot rule out the possibility that the results were not significant because of imprecision. When compared to TAU, any psychosocial treatment may improve adherence, but it may not improve abstinence at the end of treatment or the longest period of abstinence.The majority of the studies took place in the United States, and this could limit the generalisability of the findings, because the effects of psychosocial treatments could be strongly influenced by the social context and ethnicity. The results of our review do not answer the most relevant clinical question, demonstrating which is the most effective type of psychosocial approach.Further studies should directly compare contingency management with the other psychosocial approaches.
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Affiliation(s)
- Silvia Minozzi
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | - Rosella Saulle
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | - Franco De Crescenzo
- Catholic University of the Sacred HeartInstitute of Psychiatry and PsychologyL.go A. Gemelli 8RomeItaly00168
| | - Laura Amato
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
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Substance Abuse Treatment Patients in Housing Programs Respond to Contingency Management Interventions. J Subst Abuse Treat 2016; 72:97-102. [PMID: 27492676 DOI: 10.1016/j.jsat.2016.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/21/2016] [Accepted: 07/11/2016] [Indexed: 11/20/2022]
Abstract
Use of homeless and transitional housing (e.g., recovery homes) programs can be associated with success in substance abuse treatment, perhaps because many of these programs encourage or mandate sobriety. In this study, we examined whether contingency management (CM) protocols that use tangible incentives for submission of drug-free specimens or other specific behaviors are effective for treatment-seeking substance abusers whose behavior may also be shaped by housing programs. Of 355 participants in randomized trials of CM, 56 (16%) reported using transitional housing during the 12-week treatment period. Main and interaction effects of housing status and treatment condition were evaluated for the primary substance abuse treatment outcomes: a) longest duration of abstinence from alcohol, cocaine, and opioids, b) percentage of samples submitted that were negative for these substances, and c) treatment retention. After controlling for demographic and clinical characteristics, those who accessed housing programs submitted a higher percentage of negative samples (75%) compared to those who did not access housing programs (67%). Housing status groups did not differ in terms of longest duration of abstinence (accessed housing: M=3.1 weeks, SE=0.6; did not access housing: M=3.9 weeks, SE=0.3) or retention in substance abuse treatment (accessed housing: M=6.4 weeks, SE=0.6; did not access housing: M=6.6 weeks, SE=0.3). Regardless of housing status, CM was associated with longer durations of abstinence and treatment retention. No interactive effects of housing and treatment condition were observed (p>.05). Results suggest that those who accessed housing programs during substance abuse treatment benefit from CM to a comparable degree as their peers who did not use such programs. These effects suggest that CM remains appropriate for those accessing housing in community-based programs.
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The Effectiveness of Ultra-Low Magnitude Reinforcers: Findings From a "Real-World" Application of Contingency Management. J Subst Abuse Treat 2016; 72:111-116. [PMID: 27422452 DOI: 10.1016/j.jsat.2016.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/07/2016] [Accepted: 06/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Research has consistently found contingency management (CM) to be an effective tool in increasing desired patient behaviors in substance use disorder (SUD) treatment. Despite the strong evidence for the effectiveness of this intervention, practical issues and the cost of implementing CM in treatment programs have been significant barriers to adoption. OBJECTIVES To evaluate the impact of a CM program designed and implemented by university-affiliated methadone clinic staff to increase patient group attendance. The CM program consisted of a weekly raffle for patients attending clinician-led group counseling and/or in-clinic Methadone Anonymous (MA) groups in which slips with patient ID#s were entered and one ID slip was drawn per week with a fee credit for a dose of methadone ($15) as the prize. METHODS The CM program continued for 12 months. Group attendance was tracked before, during, and after CM implementation as part of ongoing clinic service utilization monitoring. RESULTS Following the implementation of CM, attendance at any clinician-led or MA groups increased significantly from baseline to month 1 (X2=5.78, p<0.05) but this increase was not sustained beyond month 6. Analysis of attendance by type of group revealed that clinician-led group attendance did not increase significantly but there was a significant increase in in-clinic MA group attendance from baseline to month 1 (X2=20.27, p<0.001), which was sustained through the 12-month implementation period (X2=11.21, p<0.001) and through 3 months post-implementation (X2=14.73; p<0.001). CONCLUSIONS A low-cost, simple CM intervention implemented by clinic staff was associated with significant increases in the target behavior of increasing group attendance.
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Thakarar K, Weinstein ZM, Walley AY. Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist. Postgrad Med J 2016; 92:356-63. [PMID: 27004476 PMCID: PMC4967553 DOI: 10.1136/postgradmedj-2015-133720] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/29/2016] [Indexed: 12/20/2022]
Abstract
The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated injection drug use. Unsafe injection practices among people who inject drugs (PWID) can lead to several complications requiring acute care encounters in the emergency department and inpatient hospital. Our objective is to provide a narrative review to help medical providers recognise and address key health issues in PWID, who are being released from the emergency department and inpatient hospital. In the midst of rises in overdose deaths and infections such as hepatitis C, we highlight several health issues for PWID, including overdose and infection prevention. We provide a clinical checklist of actions to help guide providers in the care of these complex patients. The clinical checklist includes strategies also applicable to low-resource settings, which may lack addiction treatment options. Our review and clinical checklist highlight key aspects of optimising the health and safety of PWID.
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Affiliation(s)
- Kinna Thakarar
- Department of Medicine/Infectious Diseases, Maine Medical Center, Portland, Maine, USA
| | - Zoe M Weinstein
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
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Dugosh K, Abraham A, Seymour B, McLoyd K, Chalk M, Festinger D. A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction. J Addict Med 2016; 10:93-103. [PMID: 26808307 PMCID: PMC4795974 DOI: 10.1097/adm.0000000000000193] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 12/06/2015] [Indexed: 11/26/2022]
Abstract
Opioid use and overdose rates have risen to epidemic levels in the United States during the past decade. Fortunately, there are effective medications (ie, methadone, buprenorphine, and oral and injectable naltrexone) available for the treatment of opioid addiction. Each of these medications is approved for use in conjunction with psychosocial treatment; however, there is a dearth of empirical research on the optimal psychosocial interventions to use with these medications. In this systematic review, we outline and discuss the findings of 3 prominent prior reviews and 27 recent publications of empirical studies on this topic. The most widely studied psychosocial interventions examined in conjunction with medications for opioid addiction were contingency management and cognitive behavioral therapy, with the majority focusing on methadone treatment. The results generally support the efficacy of providing psychosocial interventions in combination with medications to treat opioid addictions, although the incremental utility varied across studies, outcomes, medications, and interventions. The review highlights significant gaps in the literature and provides areas for future research. Given the enormity of the current opioid problem in the United States, it is critical to gain a better understanding of the most effective ways to deliver psychosocial treatments in conjunction with these medications to improve the health and well-being of individuals suffering from opioid addiction.
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Affiliation(s)
- Karen Dugosh
- Treatment Research Institute, Philadelphia, PA (KD, AA, BS, KML, MC, DF); Department of Health Policy and Management, University of Georgia, Athens, GA (AA)
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Perry AE, Neilson M, Martyn‐St James M, Glanville JM, Woodhouse R, Godfrey C, Hewitt C. Pharmacological interventions for drug-using offenders. Cochrane Database Syst Rev 2015; 2015:CD010862. [PMID: 26035084 PMCID: PMC11060505 DOI: 10.1002/14651858.cd010862.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use or criminal activity, or both, for illicit drug-using offenders. OBJECTIVES To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity or drug use, or both. SEARCH METHODS We searched Fourteen electronic bibliographic databases up to May 2014 and five additional Web resources (between 2004 and November 2011). We contacted experts in the field for further information. SELECTION CRITERIA We included randomised controlled trials assessing the efficacy of any pharmacological intervention a component of which is designed to reduce, eliminate or prevent relapse of drug use or criminal activity, or both, in drug-using offenders. We also report data on the cost and cost-effectiveness of interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS Fourteen trials with 2647 participants met the inclusion criteria. The interventions included in this review report on agonistic pharmacological interventions (buprenorphine, methadone and naltrexone) compared to no intervention, other non-pharmacological treatments (e.g. counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). Studies could not be combined all together because the comparisons were too different. Only subgroup analysis for type of pharmacological treatment were done. When compared to non-pharmacological, we found low quality evidence that agonist treatments are not effective in reducing drug use or criminal activity, objective results (biological) (two studies, 237 participants (RR 0.72 (95% CI 0.51 to 1.00); subjective (self-report), (three studies, 317 participants (RR 0.61 95% CI 0.31 to 1.18); self-report drug use (three studies, 510 participants (SMD: -0.62 (95% CI -0.85 to -0.39). We found low quality of evidence that antagonist treatment was not effective in reducing drug use (one study, 63 participants (RR 0.69, 95% CI 0.28 to 1.70) but we found moderate quality of evidence that they significantly reduced criminal activity (two studies, 114 participants, (RR 0.40, 95% CI 0.21 to 0.74).Findings on the effects of individual pharmacological interventions on drug use and criminal activity showed mixed results. In the comparison of methadone to buprenorphine, diamorphine and naltrexone, no significant differences were displayed for either treatment for self report dichotomous drug use (two studies, 370 participants (RR 1.04, 95% CI 0.69 to 1.55), continuous measures of drug use (one study, 81 participants, (mean difference (MD) 0.70, 95% CI -5.33 to 6.73); or criminal activity (one study, 116 participants, (RR 1.25, 95% CI 0.83 to 1.88) between methadone and buprenorphine. Similar results were found for comparisons with diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants, (RR 1.25, 95% CI 1.03 to 1.51) or naltrexone for dichotomous measures of reincarceration (one study, 44 participants, (RR 1.10, 95% CI 0.37 to 3.26), and continuous outcome measure of crime, (MD -0.50, 95% CI -8.04 to 7.04) or self report drug use (MD 4.60, 95% CI -3.54 to 12.74). AUTHORS' CONCLUSIONS When compared to non-pharmacological treatment, agonist treatments did not seem effective in reducing drug use or criminal activity. Antagonist treatments were not effective in reducing drug use but significantly reduced criminal activity. When comparing the drugs to one another we found no significant differences between the drug comparisons (methadone versus buprenorphine, diamorphine and naltrexone) on any of the outcome measures. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias.
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Affiliation(s)
- Amanda E Perry
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Matthew Neilson
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Marrissa Martyn‐St James
- University of SheffieldSchool of Health and Related Research (ScHARR)Regent Court, 30 Regent StreetSheffieldSouth YorkshireUKS1 4DA
| | - Julie M Glanville
- York Health Economics ConsortiumMarket SquareUniversity of York, HeslingtonYorkUKYO10 5NH
| | - Rebecca Woodhouse
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Christine Godfrey
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Catherine Hewitt
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
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Perry AE, Neilson M, Martyn-St James M, Glanville JM, Woodhouse R, Godfrey C, Hewitt C. Interventions for drug-using offenders with co-occurring mental illness. Cochrane Database Syst Rev 2015:CD010901. [PMID: 26034938 DOI: 10.1002/14651858.cd010901.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an updated version of an original Cochrane review published in Issue 3 2006 (Perry 2006). The review represents one from a family of four reviews focusing on interventions for drug-using offenders. This specific review considers interventions aimed at reducing drug use or criminal activity, or both for drug-using offenders with co-occurring mental illness. OBJECTIVES To assess the effectiveness of interventions for drug-using offenders with co-occurring mental illness in reducing criminal activity or drug use, or both. SEARCH METHODS We searched 14 electronic bibliographic databases up to May 2014 and 5 Internet resources (searched between 2004 and 11 November 2009). We contacted experts in the field for further information. SELECTION CRITERIA We included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and criminal activity, or both in drug-using offenders with co-occurring mental illness. We also reported data on the cost and cost-effectiveness of interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS Eight trials with 2058 participants met the inclusion criteria. The methodological quality of the trials was generally difficult to rate due to a lack of clear reporting. On most 'Risk of bias' items, we rated the majority of studies as unclear. Overall, we could not statistically combine the results due to the heterogenous nature of the different study interventions and comparison groups. A narrative summary of the findings identified that the interventions reported limited success with reducing self report drug use, but did have some impact on re-incarceration rates, but not re-arrest. In the single comparisons, we found moderate-quality evidence that therapeutic communities determine a reduction in re-incarceration but reported less success for outcomes of re-arrest, moderate quality of evidence and self report drug use. Three single studies evaluating case management via a mental health drug court (very low quality of evidence), motivational interviewing and cognitive skills (low and very low quality of evidence) and interpersonal psychotherapy (very low quality of evidence) did not report significant reductions in criminal activity and self report drug use respectively. Quality of evidence for these three types of interventions was low to very low. The trials reported some cost information, but it was not sufficient to be able to evaluate the cost-effectiveness of the interventions. AUTHORS' CONCLUSIONS Two of the five trials showed some promising results for the use of therapeutic communities and aftercare, but only in relation to reducing subsequent re-incarceration. Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. More evaluations are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.
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Affiliation(s)
- Amanda E Perry
- Department of Health Sciences, University of York, Heslington, York, UK, YO105DD
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Perry AE, Neilson M, Martyn-St James M, Glanville JM, Woodhouse R, Hewitt C. Interventions for female drug-using offenders. Cochrane Database Syst Rev 2015:CD010910. [PMID: 26035085 DOI: 10.1002/14651858.cd010910.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND This is an updated version of a Cochrane review first published in Issue 3, 2006 (Perry 2006). The review represents one in a family of four reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. This specific review considers interventions for female drug-using offenders. OBJECTIVES To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both. SEARCH METHODS We searched 14 electronic bibliographic databases up to May 2014 and five additional Website resources (between 2004 and November 2011). We contacted experts in the field for further information. SELECTION CRITERIA We included randomised controlled trials (RCTs) designed to reduce, eliminate or prevent relapse of drug use or criminal activity in female drug-using offenders. We also reported data on the cost and cost-effectiveness of interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS Nine trials with 1792 participants met the inclusion criteria. Trial quality and risks of bias varied across each study. We rated the majority of studies as being at 'unclear' risk of bias due to a lack of descriptive information. We divided the studies into different categories for the purpose of meta-analyses: for any psychosocial treatments in comparison to treatment as usual we found low quality evidence that there were no significant differences in arrest rates, (two studies; 489 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.45 to 1.52) or drug use (one study; 77 participants; RR 0.65, 95% CI 0.20 to 2.12), but we found moderate quality evidence that there was a significant reduction in reincarceration, (three studies; 630 participants; RR 0.46, 95% CI 0.34 to 0.64). Pharmacological intervention using buprenorphine in comparison to a placebo did not significantly reduce self reported drug use (one study; 36 participants; RR 0.58, 95% CI 0.25 to 1.35). No cost or cost-effectiveness evidence was reported in the studies. AUTHORS' CONCLUSIONS Three of the nine trials show a positive trend towards the use of any psychosocial treatment in comparison to treatment as usual showing an overall significant reduction in subsequent reincarceration, but not arrest rates or drug use. Pharmacological interventions in comparison to a placebo did not significantly reduce drug use and did not measure criminal activity. Four different treatment comparisons showed varying results and were not combined due to differences in the intervention and comparison groups. The studies overall showed a high degree of heterogeneity for types of comparisons and outcome measures assessed, which limited the possibility to pool the data. Descriptions of treatment modalities are required to identify the important elements for treatment success in drug-using female offenders. More trials are required to increase the precision of confidence with which we can draw conclusions about the effectiveness of treatments for female drug-using offenders.
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Affiliation(s)
- Amanda E Perry
- Department of Health Sciences, University of York, Heslington, York, UK, YO105DD
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Schiff M, Nacasch N, Levit S, Katz N, Foa EB. Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel. SOCIAL WORK IN HEALTH CARE 2015; 54:687-707. [PMID: 26399489 DOI: 10.1080/00981389.2015.1058311] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The aims of this pilot study were: (a) to test the feasibility of prolonged exposure (PE) therapy conducted by a social worker staff on female patients in methadone program clinics who were survivors of child sexual abuse or rape and (b) to examine preliminary outcomes of PE on posttraumatic stress disorder (PTSD), depression, and illicit drug use at pre- and posttreatment, and up to 12-month follow-ups. Twelve female methadone patients who were survivors of child sexual abuse or rape diagnosed with PTSD were enrolled in 13-19 weekly individual PE sessions. Assessments were conducted at pre-, mid-, and posttreatment, as well as at 3, 6, and 12-month follow-ups. The treatment outcomes measures included PTSD symptoms, depressive symptoms, and illicit drug use. Ten of the 12 study patients completed treatment. PTSD and depressive symptoms showed significant reduction. No relapse to illicit drug use was detected. These preliminary results suggest that PE may be delivered by methadone social workers with successful outcomes. Further research should test the efficacy of PE among methadone patients in a randomized control trial with standard care as the control condition.
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Affiliation(s)
- Miriam Schiff
- a Paul Baerwald School of Social Work and Social Welfare, Hebrew University , Jerusalem , Israel
| | | | - Shabtay Levit
- a Paul Baerwald School of Social Work and Social Welfare, Hebrew University , Jerusalem , Israel
| | - Noam Katz
- c Association for Public Health, Methadone Maintenance Treatment Programs in Ashdod , Ashdod , Israel
| | - Edna B Foa
- d Center for the Treatment and Study of Anxiety (CTSA), School of Medicine, University of Pennsylvania, Philadelphia , Pennsylvania , USA
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Kidorf M, King VL, Peirce J, Gandotra N, Ghazarian S, Brooner RK. Substance use and response to psychiatric treatment in methadone-treated outpatients with comorbid psychiatric disorder. J Subst Abuse Treat 2014; 51:64-9. [PMID: 25468006 DOI: 10.1016/j.jsat.2014.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 11/24/2022]
Abstract
The psychiatric care of opioid users receiving agonist therapies is often complicated by high rates of illicit drug use (Brooner et al., 2013). The present study evaluates if illicit drug use (i.e., opioids, cocaine, sedatives) detected at the start of psychiatric care affects treatment response. Methadone maintenance patients (n = 125) with at least one current psychiatric disorder completed a 3-month randomized clinical trial evaluating the efficacy of financial incentives on attendance to on-site integrated substance abuse and psychiatric services (Kidorf et al., 2013). The present study re-analyzes the data set by grouping participants into one of two conditions based on the 4-week baseline observation: (1) no illicit drug use (baseline negative; n = 50), or (2) any illicit drug use (baseline positive; n = 75). All participants received a similar schedule of psychiatric services, and had good access to prescribed psychiatric medications. The Global Severity Index (GSI) of the Hopkins Symptom Checklist-Revised was administered monthly to evaluate changes in psychiatric distress. Results showed that while both conditions evidenced similar utilization of on-site psychiatric services, baseline negative participants remained in treatment somewhat longer (80.7 vs. 74.8 days, p = .04) and demonstrated greater reductions in GSI scores than baseline positive participants at month 3 (p = .004). These results have implications for interpreting previous studies that have shown inconsistent efficacy of pharmacotherapy and other psychiatric treatments, and for providing clinical care for patients with co-occurring substance use and psychiatric disorders.
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Affiliation(s)
- Michael Kidorf
- Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD 21224, USA.
| | - Van L King
- Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD 21224, USA
| | - Jessica Peirce
- Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD 21224, USA
| | - Neeraj Gandotra
- Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD 21224, USA
| | - Sharon Ghazarian
- Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD 21224, USA
| | - Robert K Brooner
- Addiction Treatment Services-BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD 21224, USA
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Salom CL, Betts KS, Williams GM, Najman JM, Scott JG, Alati R. Do young people with comorbid mental and alcohol disorders experience worse behavioural problems? Psychiatry Res 2014; 219:372-9. [PMID: 24953903 DOI: 10.1016/j.psychres.2014.05.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 05/23/2014] [Accepted: 05/30/2014] [Indexed: 11/27/2022]
Abstract
This article examines whether young individuals in the general population with comorbid alcohol use and mental health disorders experience worse internalizing and externalizing behaviour problems than those with single disorders. A large cohort of women at the Mater Misericordiae Hospital in Brisbane, Australia, was enroled during pregnancy in a longitudinal study. Mother/offspring dyads were followed over 21 years. At age 21, offspring behaviour problems were examined using the Young Adult Self Report, alcohol and mental health disorders with the Composite International Diagnostic Interview. Associations between comorbidity and behaviour problems were assessed using multinomial logistic regression, accounting for life-course factors. Twelve per cent of young adults had alcohol/mental health DSM-IV disorders with significant temporal overlap. A further 16% had alcohol disorders only and 23% mental health disorders only. The comorbid group scored significantly higher on total and externalizing behaviour problems but not internalizing behaviour problems. Stronger associations of aggression/delinquency with comorbidity were not fully accounted for by factors known to influence separate development of mental health and alcohol disorders. Young adults with comorbid alcohol/mental health disorders experience more, and more severe, behavioural problems than those with single disorder types, indicating an increased burden from comorbidity, with implications for treatment and public order.
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Affiliation(s)
- Caroline L Salom
- School of Population Health, The University of Queensland, Herston Road, Herston 4006, Australia.
| | - Kim S Betts
- School of Population Health, The University of Queensland, Herston Road, Herston 4006, Australia
| | - Gail M Williams
- School of Population Health, The University of Queensland, Herston Road, Herston 4006, Australia
| | - Jackob M Najman
- School of Population Health, The University of Queensland, Herston Road, Herston 4006, Australia; School of Social Science, University of Queensland, Herston, Australia
| | - James G Scott
- The University of Queensland, UQCCR, Herston, Australia; Metro North Mental Health, Royal Brisbane & Women׳s Hospital, Herston, Australia
| | - Rosa Alati
- School of Population Health, The University of Queensland, Herston Road, Herston 4006, Australia; Centre for Youth Substance Abuse Research, The University of Queensland, Herston, Australia
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Wells EA, Donovan DM, Daley DC, Doyle SR, Brigham G, Garrett SB, Ingalsbe MH, Hatch-Maillette MA, Perl HI, Walker R. Is level of exposure to a 12-step facilitation therapy associated with treatment outcome? J Subst Abuse Treat 2014; 47:265-74. [PMID: 25064421 PMCID: PMC4138275 DOI: 10.1016/j.jsat.2014.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 06/03/2014] [Accepted: 06/08/2014] [Indexed: 10/25/2022]
Abstract
This study examined whether level of exposure to Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), a 12-Step facilitative therapy, is related to treatment outcome. Data were from a large National Drug Abuse Treatment Clinical Trials Network (CTN) study comparing STAGE-12 combined with treatment-as-usual (TAU) to TAU alone. These analyses include only those randomized to STAGE-12 (n=234). Assessments occurred at baseline and 30, 60, 90, and 180 days following randomization. High-exposure patients (n=158; attended at least 2 of 3 individual, and 3 of 5 group, sessions), compared to those with less exposure (n=76), demonstrated: (1) higher odds of self-reported abstinence from, and lower rates of, stimulant and non-stimulant drug use; (2) lower probabilities of stimulant-positive urines; (3) more days of attending and lower odds of not attending 12-Step meetings; (4) greater likelihood of reporting no drug problems; (5) more days of duties at meetings; and (6) more types of 12-Step activities. Many of these differences declined over time, but several were still significant by the last follow-up. Treatment and research implications are discussed.
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Affiliation(s)
- Elizabeth A Wells
- School of Social Work, University of Washington, Seattle, WA, USA; Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA.
| | - Dennis M Donovan
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Dennis C Daley
- Department of Psychiatry, University of Pittsburgh, and Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA
| | - Suzanne R Doyle
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | | | - Sharon B Garrett
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | - Michelle H Ingalsbe
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | | | | | - Robrina Walker
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Milward J, Lynskey M, Strang J. Solving the problem of non-attendance in substance abuse services. Drug Alcohol Rev 2014; 33:625-36. [PMID: 25196817 DOI: 10.1111/dar.12194] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 07/15/2014] [Indexed: 11/29/2022]
Abstract
ISSUES Rates of non-attendance are among the highest in substance misuse services. Non-attendance is costly and results in the inefficient use of limited resources. Patients who frequently miss their appointments have worse outcomes including treatment dropout and decreased likelihood of achieving long-term abstinence. APPROACH This narrative review evaluates interventions targeting non-attendance in addiction services and draws upon the wider health-care literature to identify interventions that could be adapted for substance-abusing populations. KEY FINDINGS Both fixed value and intermittent reinforcement contingency management demonstrate potential for improving attendance. However, small sample sizes and heterogeneous populations make it difficult to draw firm conclusions. Appointment reminders by letter or telephone have demonstrated moderate evidence for improving attendance in substance-abusing populations. Text message appointment reminders are extensively utilised in general health-care settings and consistently improve attendance; however, there is a paucity of research examining the feasibility and effectiveness of text message reminders in addiction services. IMPLICATIONS A lack of evidence for methods to improve attendance is reflected in the continuing challenge faced by addiction services attempting to manage high rates of non-attendance. CONCLUSIONS Non-attendance remains a persistent issue for addiction services. While there is limited evidence that contingency management improves attendance, more rigorous research is needed to determine the optimal intervention components and effectiveness in different populations, particularly those receiving maintenance treatments. Multicomponent text message interventions incorporating different delivery and content strategies demonstrate a promise for improving non-attendance and poor engagement.
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Affiliation(s)
- Joanna Milward
- Institute of Psychiatry, King's College London, London, UK
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King VL, Brooner RK, Peirce J, Kolodner K, Kidorf M. Challenges and outcomes of parallel care for patients with co-occurring psychiatric disorder in methadone maintenance treatment. J Dual Diagn 2014; 10:60-7. [PMID: 24976801 PMCID: PMC4070518 DOI: 10.1080/15504263.2014.906132] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Most opioid users seeking treatment in community-based substance abuse treatment programs have at least one co-occurring psychiatric disorder, and the presence of psychiatric comorbidity in this population is associated with increased psychological distress, poorer quality of life, and reduced response to substance abuse treatment. This observational study describes clinical outcomes of referring patients receiving methadone maintenance with at least one co-occurring psychiatric disorder to a community psychiatry program located on the same hospital campus. METHODS Participants (n = 156) were offered priority referrals to a community psychiatry program that included regularly scheduled psychiatrist appointments, individual and group therapy, and enhanced access to psychiatric medications for 1 year. Psychiatric distress was measured with the Symptom Checklist (SCL-90-R), which participants completed monthly. RESULTS While about 80% of the sample (n = 124) initiated psychiatric care, the average length of treatment was only 128.2 days (SD = 122.8), participants attended only 33% of all scheduled appointments (M = 14.9 sessions, SD = 14.1), and 84% (n = 104) did not complete a full year of care. Of those who did not complete a full year, over half (55%, n = 68) left psychiatric care while still receiving substance abuse treatment. Exploratory negative binomial regression showed that baseline cocaine and alcohol use disorder (p = .002 and .022, respectively) and current employment (p = .034) were associated with worse psychiatric treatment retention. Modest reductions in psychiatric distress over time were observed (SCL-90-R Global Severity Index change score = 2.5; paired t = 3.54, df = 121, p = .001). CONCLUSIONS Referral of patients with co-occurring psychiatric disorders receiving methadone maintenance to a community psychiatry program is often ineffective, even after reducing common barriers to care. Service delivery models designed to improve attendance and retention, such as integrated care models, should be evaluated. This study is part of a larger clinical trial, registered at www.clinicaltrials.gov under #NCT00787735.
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Affiliation(s)
- Van L King
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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