Short and long-term improvements in psychiatric symptomatology to validate clinically meaningful treatment outcomes for cocaine use disorders

Mixed amphetamine salts-extended release (MAS-ER) as a behavioral treatment augmentation strategy for cocaine use disorder: A randomized clinical trial

Psychosocial interventions remain the primary strategy for addressing cocaine use disorder (CUD), although many individuals do not benefit from these approaches. Amphetamine-based interventions have shown significant promise and may improve outcomes among individuals continuing to use cocaine in the context of behavioral interventions. One hundred forty-five adults (122 males) who used cocaine a minimum of 4 days in the prior month and met the criteria for a CUD enrolled in a two-stage intervention. All participants received a computer-delivered skills intervention and contingency management for reinforcing abstinence for a 1-month period. Participants demonstrating less than 3 weeks of abstinence in the first month were randomized to receive mixed amphetamine salts-extended release (MAS-ER) or placebo (80 mg/day) for 10 weeks under double-blind conditions. All participants continued with the behavioral intervention. The primary outcome was the proportion of individuals who achieved 3 consecutive weeks of abstinence as measured by urine toxicology confirmed self-report at the study end. The proportion of participants demonstrating 3 consecutive weeks of abstinence at study end did not differ between the medication groups: MAS-ER = 15.6% (7/45) and placebo = 12.2% (5/41). Participants who received MAS-ER reported greater reductions in the magnitude of wanting cocaine, although no group differences were noted in either the perceived improvement or the frequency of wanting cocaine. Retention rates were greater for both medication groups compared to behavioral responders. Overall, augmenting a behavioral intervention with MAS-ER did not significantly increase the abstinence rate among individuals continuing to use cocaine following a month of behavioral therapy alone. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Percentage of negative urine drug screens as a clinically meaningful endpoint for RCTs evaluating treatment for cocaine use

BACKGROUND

This study examined a threshold based on the percentage of cocaine-negative (CN) urine drug screens (UDS) collected during treatment as a potential meaningful endpoint for clinical trials. We hypothesized that individuals providing at least 75% CN UDS would have better long-term outcomes than those providing less than 75% CN UDS.

METHODS

Two separate pooled datasets of randomized clinical trials conducted at different institutions were used for analyses: one composed of eight trials (N = 760) and the other composed of three trials (N = 416), all evaluating behavioral and/or pharmacological treatments for cocaine use. UDS were collected at least once per week (up to three times per week) during the 8- or 12-week treatment period across all trials, with substance use and psychosocial functioning measured up to 12 months following treatment. Chi-squares and ANOVAs compared within-treatment and follow-up outcomes between the groups.

RESULTS

Compared to those who did not achieve the threshold, participants who achieved the 75%-CN threshold were retained in treatment longer and had a longer period of continuous abstinence, and were more likely to report problem-free functioning. Additionally, participants who achieved the 75%-CN threshold were more likely to report sustained abstinence and better psychosocial functioning throughout a follow-up period up to 12 months than those who did not achieve the threshold.

CONCLUSIONS

A threshold of 75%-CN UDS is associated with short- and long-term clinical benefits. Future clinical trials may consider this a meaningful threshold for defining treatment responders.

Exploring the performance of during-treatment substance use outcome measures in predicting longer-term psychosocial functioning and post-treatment abstinence

BACKGROUND

The selection of appropriate efficacy endpoints in clinical trials has been a long-standing challenge for the substance use disorder field. Using data from a large, multi-site National Drug Abuse Treatment Clinical Trials Network trial (CTN-0044; n=474), this secondary data analysis aimed to explore whether specific proximal (during-treatment) substance use outcome measures predict longer-term improvements in psychosocial functioning and post-treatment abstinence, and whether predictions vary depending on the specific substance (cannabis, cocaine/stimulants, opioids, and alcohol).

METHODS

Generalized linear mixed models examined associations between six during-treatment substance use outcome measures and social functioning impairment (Social Adjustment Scale Self-Report) and severity of psychiatric symptoms (Brief Symptom Inventory-18) at end-of-treatment, and 3- and 6-months after treatment as well as post-treatment abstinence.

RESULTS

Maximum days of consecutive abstinence, proportion of days abstinent, ≥3 weeks of continuous abstinence, and the proportion of urine specimens negative for the primary substance were associated with post-treatment psychiatric and social functioning improvement and abstinence. However, only the effects of abstinence during the last 4 weeks of the treatment period on all three post-treatment outcomes was stable over time and did not differ between primary substance groups. In contrast, complete abstinence during the 12-week treatment period was not consistently associated with functioning improvements.

CONCLUSIONS

Substance use outcome measures capturing the duration of primary substance abstinence during treatment are suitable predictors of post-treatment abstinence and longer-term psychosocial functioning improvement. Binary outcomes, such as end-of-treatment abstinence, may be particularly stable predictors and attractive given their ease of computation and straightforward clinical interpretability.

Driving After Cannabis Use Among Young Adults in Michigan

Introduction: Driving after cannabis use is associated with a number of risks. Examination of driving after cannabis use among young adults is particularly important, as young adults have the highest rates of cannabis use and among the highest rates of traffic crashes. The current study examines rates and correlates of driving after cannabis use among young adults (aged 18-25) who reported past month cannabis use. Methods: Participants were from Michigan and recruited through paid Facebook and Instagram advertisements between February and March 2018 (n=461). Results: Nearly a third (31.9%) of the sample reported driving after cannabis use in the past month. Young adults who were employed (aOR=1.872, p=0.045), had medical cannabis cards (aOR=2.877, p<0.001), endorsed coping reasons for use (aOR=2.992, p=0.007), and endorsed social/recreational reasons for use (aOR=1.861, p=0.034) had greater odds of driving after cannabis use. Students had lower odds of driving after use (aOR=0.573, p=0.011). Conclusions: Employment and having a medical cannabis card may be important risk markers for identifying individuals more likely to drive after use of cannabis. Prevention efforts could provide psychoeducation at dispensaries to individuals with medical cannabis cards about the risks of driving after use. Coping motives for cannabis use may also be useful in identifying young adults at the greatest risk of driving after use of cannabis.

Detecting change in psychiatric functioning in clinical trials for cocaine use disorder: sensitivity of the Addiction Severity Index and Brief Symptom Inventory

BACKGROUND

Assessment instruments commonly used in clinical trials to measure functional outcomes in substance users may lack sensitivity to detect change during treatment, potentially limiting findings regarding benefits of reduced drug use. This study evaluated the sensitivity of the Addiction Severity Index (ASI) to detect change in psychiatric functioning among cocaine users.

METHODS

Data were pooled across five clinical trials for cocaine use disorder (N = 492) that included a 12-week treatment period and 6-month follow-up. Within-person cohen's d' was used to evaluate effect size of change on the Psychiatric Composite Score of the ASI (ASI-Psych) and Global Severity Index (GSI) of the Brief Symptom Inventory, as well as cocaine use.

RESULTS

Effect sizes were larger for GSI than ASI-Psych from baseline to week 12 (GSI d' = 0.59; ASI-Psych d' = 0.16), and 6-month follow-up (GSI d' = 0.48; ASI-Psych d' = 0.10). For those with non-zero ASI-Psych at baseline (n = 252), medium effect sizes were found over the 12-week period (d' = 0.53) and 6-month follow-up (d' = 0.47). Effect sizes for change in days of cocaine use were most similar to GSI in either sample.

CONCLUSIONS

The ASI Psychiatric Composite Score may have limited sensitivity to detect change in psychiatric functioning among clinical trial participants who reduce cocaine use. It may be useful for detecting change amongst those reporting some psychiatric problems at the start of treatment. Future research should consider an instrument's sensitivity to change when assessing the potential functional benefits of reducing cocaine use.

Effectiveness of incorporating contingency management into a public treatment program for people who use crack cocaine in Brazil. A single-blind randomized controlled trial

BACKGROUND

Smoked cocaine (i.e., crack use) is a severe health problem in Brazil, with the country being reported as having the largest crack market in the world. The objective of this study was to evaluate the effectiveness of incorporating Contingency Management targeting cocaine abstinence into a public treatment program in Brazil.

METHODS

Single-blind randomized controlled trial conducted at Unidade Recomeço Helvétia (URH), a public ambulatory treatment program for persons who use crack and live in the "Crackland" region in downtown São Paulo, Brazil. In total, 98 treatment-seeking individuals who use crack were randomized to one of two treatment conditions. Participants allocated to the control condition (n = 48) received 12 weeks of the standard treatment provided at URH. Participants allocated to the experimental condition (n = 50) received the same treatment in combination with Contingency Management (URH+CM). In URH+CM, participants were provided with vouchers with monetary value for submission of negative cocaine urinalysis twice weekly.

RESULTS

Compared to the URH group, the URH+CM group was significantly more likely to submit a negative cocaine urinalysis during treatment, with odds ratios ranging from 4.17 to 6.78, depending on how missing data was accounted for (p<0.01). Participants receiving Contingency Management also had higher odds of achieving three or more weeks of continuous abstinence (OR= 8.07; 95% CI [2.48, 26.24]), achieved longer durations of abstinence (B = 2.14; 95% CI [0.67, 3.61]), submitted a higher percentage of negative urinalysis (B = 19.85; 95% CI [6.89, 32.82]), and were retained in treatment for a longer period (B = 3.00; 95% CI [1.04, 4.97]), compared to those receiving URH alone (p<0.01 for all).

CONCLUSIONS

The incorporation of Contingency Management was effective in promoting cocaine abstinence and treatment retention. The large-scale dissemination of Contingency Management may be an effective strategy to treat Brazilians with cocaine use disorders.

Validating the clinical relevance of alternative stimulant use treatment outcome measures by examining their association with 3-month follow-up outcomes

The lack of a consensus on empirically supported and clinically meaningful outcome measures for stimulant use disorders (SUDs) continues to undermine the development and evaluation of effective behavioral and pharmacological treatment options. The aim of this study was to evaluate the clinical relevance of four stimulant use treatment outcome measures (longest duration of abstinence [LDA], percent of negative urinalysis submitted, abstinent in the last 2 weeks of treatment, and three or more weeks of continuous abstinence) by exploring their utility via association with stimulant and alcohol use, employment and legal problems, and severity of psychiatric symptomatology collected at follow-up. Data used in these secondary analyses came from a multisite randomized contingency management treatment trial for SUDs (n = 441) conducted through the NIDA Clinical Trials Network. Multiple regression analyses were conducted to explore the association of four stimulant use treatment outcome measures and eight 3-month follow-up outcomes. The percent of negative urinalysis outcomes showed the most consistent performance compared to alternative outcomes, being significantly associated with better responses in all eight 3-month follow-up outcomes (β range: -169 to -241, p < .01). Both dichotomous outcome measures showed similar performances being significantly associated with four follow-up outcomes (β range: -159 to -203, p < .01). All outcome measures were consistently associated with better outcome responses at the 3-month follow-up, adding support to their clinical relevance and their adoption in SUD treatment trials. The two dichotomous outcome measures are reliable candidates to be used as endpoint outcomes, as recommended by the U.S. Food and Drug Administration (FDA). (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Long-term functioning to provide empirical support for the clinical relevance of treatment outcomes for methamphetamine use disorders

BACKGROUND

Research has yet to empirically evaluate methamphetamine (MA) use outcome measures commonly used to indicate treatment success. Clinically meaningful outcomes must be associated with long-term functioning in important life domains. This study evaluated the association between different MA use outcomes and long-term life-functioning.

METHOD

The data that this study used in its secondary analyses were pooled from two treatment trials for MA use disorders (n = 237). The study conducted multiple regression analyses (with multiple imputation for missing data) to determine the association of six within-treatment MA use outcome measures with problem severity in seven life domains and a proxy measure for overall functioning, measured with the Addiction Severity Index (ASI) and assessed at an 8-month follow-up.

RESULTS

The longest duration of abstinence (LDA) outcome achieved the most consistent performance, being associated with better scores in five of eight ASI outcomes (β ranging from -0.203 to -0.291; p < .01). The complete abstinence during treatment demonstrated the poorest performance and was not significantly associated with any of the ASI outcomes. All other MA use outcome measures were significantly (p < .01) associated with at least one ASI outcome.

CONCLUSION

This study provides empirical support for the use of LDA as a clinically relevant indicator of treatment success for MA use disorders, while also indicating the limitations of using complete abstinence during treatment to determine treatment success. Based on these findings, providers and researchers should use LDA as a primary outcome for MA use disorder treatments and trials.

Prescription psychostimulants for the treatment of stimulant use disorder: a systematic review and meta-analysis

RATIONALE

Agonist-based pharmacologic intervention is an accepted approach in treatment of opioid and tobacco use disorders.

OBJECTIVES

We conducted a systematic review and meta-analysis to evaluate usefulness of an agonist approach as treatment of (psycho)stimulant use disorder (PSUD).

METHODS

We reviewed PubMed/Medline, LILACS, and ClinicalTrials.gov databases searching for randomized, double-blind, placebo-controlled, parallel-design studies evaluating outcomes of individuals treated for cocaine- or amphetamine-type substance use disorder. We combined results of all trials that included the following prescription psychostimulants (PPs): modafinil, methylphenidate, or amphetamines (mixed amphetamine salts, lisdexamphetamine, and dextroamphetamine). The combined sample consisted of 2889 patients. Outcomes of interest included the following: drug abstinence (defined as 2-3 weeks of sustained abstinence and the average maximum days of consecutive abstinence), percentage of drug-negative urine tests across trial, and retention in treatment. We conducted random-effects meta-analyses and assessed quality of evidence using the GRADE system.

RESULTS

Thirty-eight trials were included. Treatment with PPs increases rates of sustained abstinence [risk ratio (RR) = 1.45, 95% confidence interval (CI) = (1.10, 1.92)] and duration of abstinence [mean difference (MD) = 3.34, 95% CI = (1.06, 5.62)] in patients with PSUD, particularly those with cocaine use disorder (very low-quality evidence). Prescription amphetamines were particularly efficacious in promoting sustained abstinence in patients with cocaine use disorder [RR = 2.44, 95% CI = (1.66, 3.58)], and higher doses of PPs were particularly efficacious for treatment of cocaine use disorder [RR = 1.95, 95% CI = (1.38, 2.77)] (moderate-quality evidence). Treatment with prescription amphetamines also yielded more cocaine-negative urines [MD = 8.37%, 95% CI = (3.75, 12.98)]. There was no effect of PPs on the retention in treatment.

CONCLUSION

Prescription psychostimulants, particularly prescription amphetamines given in robust doses, have a clinically significant beneficial effect to promote abstinence in the treatment of individuals with PSUD, specifically the population with cocaine use disorder.

Clinical validation of reduction in cocaine frequency level as an endpoint in clinical trials for cocaine use disorder

BACKGROUND

Despite calls for non-abstinence endpoints in randomized clinical trials (RCTs) for cocaine use disorder, there is a lack of data validating non-abstinence endpoints. We conducted a clinical validation of reduction in cocaine frequency level as a non-abstinence endpoint in RCTs for cocaine use disorder (CUD).

METHODS

We utilized a pooled dataset (n = 716; 63.6 % male, 51.4 % non-Hispanic white) from seven RCTs for CUD. We specified three cocaine frequency levels at baseline and end of treatment (EOT): abstinence, low frequency (1-4 days/month), and high frequency (5+ days/month). Multiple regression analyses were conducted.

RESULTS

Among the sample, 38.3 % had at least a one-level reduction from baseline to EOT, whereas 61.7 % did not change/increased frequency level. At least a one-level reduction in cocaine frequency level from baseline to EOT versus no change/increase was significantly associated with better functioning up to one year following treatment on measures of cocaine use, as well as psychological, employment, legal, and other drug use problem severity domains of the Addiction Severity Index (ASI). We also conducted analyses only among those at the high frequency level at baseline and found those who reduced to low frequency use at EOT had similar outcomes at follow-up as those who reduced to abstinence.

CONCLUSIONS

At least a one-level reduction in cocaine frequency level from pretreatment to EOT can be a clinically meaningful endpoint given its relation to sustained clinical benefit up to one-year following treatment. These data parallel recent findings regarding reduction in drinking risk level among individuals with alcohol use disorder.

Change in employment status and cocaine use treatment outcomes: A secondary analysis across six clinical trials

BACKGROUND

Unemployment is a chronic problem among treatment seeking substance users and is associated with poor treatment response. Most studies that have examined the relationship between employment and treatment outcomes for substance use disorders have done so by considering employment at only one specific point in time (e.g., upon entering treatment). There is a lack of research on how change in employment status over time is associated with substance use treatment outcomes. The aim of this study was to evaluate both static employment status and change in employment status over time as predictors of cocaine use treatment outcomes.

METHODS

We utilized data pooled from six randomized clinical trials evaluating treatment for cocaine use disorders (n = 553). Multiple general linear mixed models were conducted to determine the association of baseline, end-of-treatment, and change in employment status (from baseline to end-of-treatment) with treatment outcomes.

RESULTS

Treatment outcomes did not differ by baseline employment status but were significantly better for those employed versus unemployed at the end-of-treatment. In regard to change in employment status over time, those who were unemployed at baseline and acquired employment by end-of-treatment had significantly better treatment outcomes during active treatment and follow-up, as compared to those who were unemployed at baseline and remained unemployed by end-of-treatment.

CONCLUSION

Our findings suggest that end-of-treatment employment status may be an important marker of good outcome among those unemployed at treatment entry and support the incorporation of interventions designed to promote employment by substance use disorders treatment programs.

Sociodemographic and clinical outcome differences among individuals seeking treatment for cocaine use disorders. The intersection of gender and race

BACKGROUND

Most published treatment trials for cocaine use disorders (CUD) have been conducted with samples composed predominantly of White men and underrepresent women and racial/ethnic minorities. Because of the high prevalence of men and White individuals in CUD treatment trials, results from studies that have compared treatment outcomes by gender and race or ethnicity separately may not be representative of women or racial/ethnic minorities.

METHODS

With a sample pooled from seven randomized clinical trials of treatment for CUD (n = 629), baseline characteristics and treatment outcome responses were compared with 4 subgroups of individuals created based on the intersection of gender and race (White men, Black men, White women and Black women).

RESULTS

At baseline, sociodemographic status, pattern, frequency and severity of cocaine use, psychiatric comorbidities, employment and legal problems significantly differed across groups. Treatment outcome indicators collected during treatment and through follow-up, consistently indicated poorer outcomes among the sample of White women, but were similar for the other groups.

CONCLUSIONS

Men and women with CUD from both racial groups enter treatment with different psychosocial issues (e.g., history of violence/trauma, financial problems, co-occurring psychiatric disorders) and substance use problems (e.g. types of substances) that may impact treatment outcomes and indicate a need for culturally-informed care to deliver more effective treatment for CUD. Poorer overall outcomes among White women may reflect the need for a more focused treatment approach for this group; and highlight the importance of evaluating gender and race in treatment trials to better address health disparities.

Contingency management is effective in promoting abstinence and retention in treatment among crack cocaine users with a previous history of poor treatment response: a crossover trial

BACKGROUND

Crack use has become a severe health problem in Brazil. Contingency management has shown robust evidence of efficacy in the treatment of cocaine use disorder (CUD) in high-income countries; however, it is still unclear how this intervention can impact treatment in low-income countries.

OBJECTIVE

To evaluate the efficacy of contingency management in the treatment of CUD among individuals with a previous history of poor treatment response in Brazil.

METHODS

Six months after the end of treatment, 32 participants previously allocated to the usual care condition (UCC) were invited to receive an additional 12 weeks of treatment in a contingency management condition (CMC), and 16 accepted the invitation. We compared data obtained from only the 16 participants (14 male) exposed to both treatment conditions.

RESULTS

Participants attended more treatment sessions and were retained in treatment for a longer period during the CMC than during the UCC (p < .01 for both). The proportion of negative cocaine samples submitted, the mean longest duration of cocaine abstinence, and the odds of being abstinent from cocaine during the 12 weeks of treatment were significantly higher during treatment in the CMC when compared to the UCC (p < .05).

CONCLUSIONS

This study provides further evidence that contingency management is effective in promoting abstinence and retention in treatment among individuals with CUD with a history of poor treatment response. Our findings argue for the incorporation of CM among public treatment services for CUD in Brazil.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov as NCT01815645 on March 21, 2013.