Methods to analyze treatment effects in the presence of missing data for a continuous heavy drinking outcome measure when participants drop out from treatment in alcohol clinical trials

Testing the combined effects of the PAX Good Behavior Game and MyTeachingPartner™ coaching for early career teachers: Impacts on teacher-student interaction quality and teachers' occupational health

Early career teachers experience exceptionally high rates of attrition from the profession, often due in part to elevated concerns about student behavior and poor occupational health. This study reports findings from a randomized controlled trial testing the combined effect of the PAX Good Behavior Game and MyTeachingPartner™ for 188 early career, early elementary teachers (Grades K-3). Of primary focus were observations of the quality of teachers' interactions with students and their self-reported occupational health over 2 consecutive school years. Results indicated that relative to comparison teachers, those in the intervention condition reported lower distress at follow-up (d = -0.23) and less decline in teacher affiliation across the 2-year period (d = 0.50). In addition, the intervention teachers who were highly distressed at baseline and who experienced high levels of disruptive behavior had higher quality interactions with students around emotional support (d = 0.27), classroom organization (d = 0.32), and instructional support (d = 0.69) at the end of 2 years than comparison teachers. This subgroup of intervention teachers also experienced more favorable changes over time in distress (d = -2.47) and teacher affiliation (d = 3.00) over the course of the study. Professional development focused on classroom management with coaching support may be particularly impactful for early career teachers experiencing higher levels of distress and in classrooms with higher rates of behavior problems.

Internalized Shame Among Justice-Involved Women in Substance Use Disorder Treatment: Measurement Invariance and Changes During Treatment

Shame is one of the leading barriers to successful recovery in substance use treatment settings. This secondary analysis study examined measurement invariance of the Internalized Shame Scale (ISS) and explored changes in shame during treatment. Participants (N=105) in the parent study were recruited from a nonprofit residential treatment center for justice-involved women and were randomized to receive mindfulness-based relapse prevention or relapse prevention treatment. A series of confirmatory factor analyses were used to assess measurement invariance in a one-factor measurement model of the ISS. Latent growth curve modeling was used to examine change in shame over time. Our findings support the assumption of measurement invariance across multiple time points and across treatment conditions, supporting comparisons of stigma scores across groups and over time. Although we observed significant reductions in shame from pre- to post-treatment, there were no differences across treatment conditions. Additional research is needed to determine how distinct treatment components relate to reductions in shame among individuals receiving treatment for a substance use disorder.

Reductions in World Health Organization Risk Drinking Level Are Associated With Reductions in Alcohol Use Disorder Diagnosis and Criteria: Evidence From an Alcohol Pharmacotherapy Trial

OBJECTIVES

This study aimed to evaluate the validity of World Health Organization (WHO) risk drinking level reductions as meaningful endpoints for clinical practice and research. This study examined whether such reductions were associated with a lower likelihood of a current alcohol use disorder (AUD) diagnosis and fewer AUD criteria.

METHODS

We conducted a secondary data analysis to address these objectives using data from a multisite randomized controlled trial of gabapentin enacarbil extended release in treating moderate to severe AUD among adults (N = 346). Participants received gabapentin enacarbil extended release or placebo for 6 months. The timeline follow-back was used to assess WHO risk drinking level reductions, and the Mini-International Neuropsychiatric Interview was used to assess Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) AUD diagnosis and criteria at baseline (past year) and end of treatment (past month).

RESULTS

Most participants (80.1%) achieved at least a 1-level reduction in the WHO risk drinking levels from baseline to end of treatment, and nearly half of participants (49.8%) achieved at least a 2-level reduction. At least a 1-level reduction or at least a 2-level reduction in WHO risk drinking level predicted lower odds of an active AUD diagnosis (1-level: odds ratio, 0.74 [95% confidence interval (CI), 0.66-0.84]; 2-level: odds ratio, 0.71 [95% CI, 0.64-0.79]) and fewer AUD criteria (1-level: B , -1.66 [95% CI, -2.35 to -0.98]; 2-level: B , -1.76 [95% CI, -2.31 to -1.21]) at end of treatment.

CONCLUSIONS

World Health Organization risk drinking level reductions correlate with Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) AUD diagnosis and criteria, providing further evidence for their use as endpoints in alcohol intervention trials, which has potential implications for broadening the base of AUD treatment.

Designing and testing treatments for alcohol use disorder

This chapter provides a succinct overview of several recommendations for the design and analysis of treatments for AUD with a specific focus on increasing rigor and generalizability of treatment studies in order to increase the reach of AUD treatment. We recommend that researchers always register their trials in a clinical trial registry and make the protocol accessible so that the trial can be replicated in future work, follow CONSORT reporting guidelines when reporting the results of the trial, carefully describe all inclusion and exclusion criteria as well as the randomization scheme, and always use an intent to treat design with attention to analysis of missing data. In addition, we recommend that researchers pay closer attention to recruitment and engagement strategies that increase enrollment and retention of historically marginalized and understudied populations, and we end with a plea for more consideration of implementation science approaches to increase the dissemination and implementation of AUD treatment in real-world settings.

Response to Letter to the Editors regarding 'A Meta-Regression of Trial Features Predicting the Effects of Alcohol Use Disorder Pharmacotherapies on Drinking Outcomes in Randomized Clinical Trials: A Secondary Data Analysis'

Short Summary: The Letter to the Editors regarding our article was reviewed. The take-home message is that substantively, the authors of the letter are referencing a paper that asks a different research question in a different set of studies. When we ask different questions, we are not surprised when we reach different answers.

Predicting implementation of the PAX Good Behavior Game + MyTeachingPartner interventions

Introduction

Effective classroom management is critical to creating a classroom environment in which social, emotional, and academic learning can take place. The present study investigated the association between early career, early elementary teachers' occupational health (job stress, burnout, and perceived teaching ability) and perceptions of program feasibility in relation to their implementation dosage and quality of two evidence-based classroom management programs implemented together: the PAX Good Behavior Game (GBG) and MyTeachingPartner (MTP) intervention.

Methods

Teachers provided information on their occupational health at the start of the school year and were then randomized to the PAX GBG + MTP condition or control condition. Teachers' perceptions of the feasibility of the program, implementation dosage, and implementation quality of the intervention were measured at the end of the school year for the 94 intervention teachers.

Results

Teachers participated in more MTP coaching cycles when they reported that the combined PAX GBG + MTP program was feasible. Although there were no main effects of occupational health on implementation, the associations between job stress and implementation quality were moderated by perceptions of feasibility.

Discussion

Findings highlight the complexity of factors influencing the implementation of evidence-based programs in school settings.

Sensitivity analyses for data missing at random versus missing not at random using latent growth modelling: a practical guide for randomised controlled trials

BACKGROUND

Missing data are ubiquitous in randomised controlled trials. Although sensitivity analyses for different missing data mechanisms (missing at random vs. missing not at random) are widely recommended, they are rarely conducted in practice. The aim of the present study was to demonstrate sensitivity analyses for different assumptions regarding the missing data mechanism for randomised controlled trials using latent growth modelling (LGM).

METHODS

Data from a randomised controlled brief alcohol intervention trial was used. The sample included 1646 adults (56% female; mean age = 31.0 years) from the general population who had received up to three individualized alcohol feedback letters or assessment-only. Follow-up interviews were conducted after 12 and 36 months via telephone. The main outcome for the analysis was change in alcohol use over time. A three-step LGM approach was used. First, evidence about the process that generated the missing data was accumulated by analysing the extent of missing values in both study conditions, missing data patterns, and baseline variables that predicted participation in the two follow-up assessments using logistic regression. Second, growth models were calculated to analyse intervention effects over time. These models assumed that data were missing at random and applied full-information maximum likelihood estimation. Third, the findings were safeguarded by incorporating model components to account for the possibility that data were missing not at random. For that purpose, Diggle-Kenward selection, Wu-Carroll shared parameter and pattern mixture models were implemented.

RESULTS

Although the true data generating process remained unknown, the evidence was unequivocal: both the intervention and control group reduced their alcohol use over time, but no significant group differences emerged. There was no clear evidence for intervention efficacy, neither in the growth models that assumed the missing data to be at random nor those that assumed the missing data to be not at random.

CONCLUSION

The illustrated approach allows the assessment of how sensitive conclusions about the efficacy of an intervention are to different assumptions regarding the missing data mechanism. For researchers familiar with LGM, it is a valuable statistical supplement to safeguard their findings against the possibility of nonignorable missingness.

TRIAL REGISTRATION

The PRINT trial was prospectively registered at the German Clinical Trials Register (DRKS00014274, date of registration: 12th March 2018).

A Meta-Regression of Trial Features Predicting the Effects of Alcohol Use Disorder Pharmacotherapies on Drinking Outcomes in Randomized Clinical Trials: A Secondary Data Analysis

AIMS

To test whether two critical design features, inclusion criteria of required pre-trial abstinence and pre-trial alcohol use disorder (AUD) diagnosis, predict the likelihood of detecting treatment effects in AUD pharmacotherapy trials.

METHODS

This secondary data analysis used data collected from a literature review to identify randomized controlled pharmacotherapy trials for AUD. Treatment outcomes were selected into abstinence and no heavy drinking. Target effect sizes were calculated for each outcome and a meta-regression was conducted to test the effects of required pre-trial abstinence, required pre-trial AUD diagnosis, and their interaction on effect sizes. A sub-analysis was conducted on trials, which included FDA-approved medications for AUD.

RESULTS

In total, 118 studies testing 19 medications representing 21,032 treated participants were included in the meta-regression analysis. There was no significant effect of either predictor on abstinence or no heavy drinking outcomes in the full analysis or in the sub-study of FDA-approved medications.

CONCLUSION

By examining these design features in a quantitative, rather than qualitative, fashion the present study advances the literature and shows that requiring AUD diagnosis or requiring pre-trial abstinence do not impact the likelihood of a significant medication effect in the trial.

Examining the added value of harm reduction strategies to emailed boosters to extend the effects of online interventions for college drinkers

Objective: Brief computer-delivered interventions (CDIs) reduce college student drinking and related problems but can be less efficacious and enduring than in-person interventions. The present study examined: (a) the utility of emailed personalized boosters after an evidence-based online CDI for alcohol (i.e., eCHECKUP TO GO), and (b) the added value of including protective behavioral strategies (PBS) in boosters containing personalized normative feedback (PNF) versus PNF alone. Method: 528 young adult (ages 18-24) college drinkers (71.6% female; 52.5% Black, 40.3% White) with a mean age of 19.9 years (SD = 1.65) were randomized to receive: CDI-only; CDI plus a PNF-only booster; or CDI plus a booster containing both PNF and PBS feedback. Booster emails were sent 2 weeks post-intervention. Online surveys completed pre-intervention and at 1 and 3 months assessed alcohol consumption, problems, descriptive normative perceptions, and PBS use. Results: The CDI led to significant reductions in alcohol consumption across all conditions, with no effect of boosters on drinking. Controlling for quantity, no reductions in problems were observed. Descriptive norms reduced significantly, with no condition differences. Only PBS use showed condition effects, such that the CDI-only and PNF-only booster groups reported reduced PBS use at 1 month, but the norms-plus-PBS booster group did not. Conclusions: The CDI was sufficient to change alcohol consumption and perceived norms without boosters, although the inclusion of boosters with PBS feedback may mitigate against PBS use reductions. Longer follow-ups may detect delayed booster benefits, or a larger dose through repeated exposure over time may be needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Cognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program

The U.S. Department of Veterans Affairs (VA) has been training clinicians in its cognitive behavioral therapy for chronic pain (CBT-CP) structured protocol since 2012. The aim of this project was to review patient outcomes to determine the effectiveness of the VA's CBT-CP treatment. From 2012-2018, 1,331 Veterans initiated individual CBT-CP treatment as part of the training program. Patient outcomes were assessed with measures of patient-reported pain intensity, pain catastrophizing, depression, pain interference, and quality of life (physical, psychological, social, and environmental). Mixed models of the effects of time indicated significant changes across pretreatment, midtreatment, and treatment conclusion on all outcomes. There was a large effect size (Cohen's d = 0.78) for pain catastrophizing, and there were medium to large effect sizes (d > 0.60) for worst pain intensity, pain interference, depression, and physical quality of life. Systematic training of therapists and implementation of the VA's CBT-CP protocol yielded significant patient improvements across multiple domains. This offers strong support for the VA's CBT-CP as an effective, safe treatment for Veterans with chronic pain and highlights it as a model to increase the availability of training in standardized, pain-focused, evidence-based, behavioral interventions. The findings suggest that the broad dissemination of such training, including in routine, nonpain specialty settings, would improve patient access to effective, nonpharmacological treatment options in both the public and private sectors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

ACTing towards better living during COVID-19: The effects of Acceptance and Commitment therapy for individuals affected by COVID-19

The widespread effects of COVID-19 have dramatically increased the prevalence of mental health difficulties, meaning it is vital to explore psychotherapy options. Acceptance and Commitment therapy (ACT) helps individuals engage in meaningful activities despite difficult and unchangeable circumstances. Recent literature suggests that psychological flexibility, the underlying process of ACT, may moderate COVID-related distress – making ACT a promising psychotherapy candidate. This study therefore aimed to explore the effects of an ACT-based, guided self-help intervention on wellbeing, psychological flexibility, COVID-related distress, and general psychological distress within the general population. 48 participants (recruited via social media) engaged in a three-week, non-concurrent baseline phase, then received six, weekly, digital modules and weekly webinars to address module queries. 20 participants completed all modules and provided post-intervention feedback via an online qualitative survey. Multilevel modelling analysis found significant improvements in: wellbeing; overall psychological flexibility (including subscales behavioural awareness and valued action); and general psychological distress (including depression, anxiety and stress). No significant changes were found for COVID-related distress. Findings were sustained at one- and two-months follow-up – suggesting lasting change. Qualitative findings provide further insights about the experience of the intervention: participants reported improved wellbeing, still experiencing COVID-related distress, but felt more able to cope with general psychological distress (such as anxiety). No change in COVID-related distress scores may be due to methodological and measurement issues. This study is one of the first to explore ACT as a psychotherapeutic intervention for COVID-related distress and adds to the growing body of literature highlighting psychological flexibility as a key process for mitigating COVID-related distress.

The estimand framework and its application in substance use disorder clinical trials: a case study

Relapse rates among individuals with substance use disorder (SUD) remain high and new treatment approaches are needed, which require evaluation in randomized controlled trials (RCTs). Measurement and interpretation challenges for SUD RCT data are often ignored or presented only in statistical analysis plans. Since different analytic approaches may result in different estimates and thus interpretations of the treatment effect, it is important to present this clearly throughout the trial. Inconsistencies between study analyses and objectives present further challenges for interpretation and cross-study comparisons. The recent International Council for Harmonization (ICH) addendum provides standardized language and a common framework for aligning trial objectives, design, conduct, and analysis. The framework focuses on estimands, which describe the treatment effect and link the trial objective with the scientific question and the analytic approach. The use of estimands offers SUD researchers and clinicians the opportunity to explicitly address events that affect measurement and interpretation at the outset of the trial. Furthermore, the use of standard terminology can lead to clearer interpretations of SUD trials and the treatments evaluated in SUD trials. Resources for understanding and applying estimands are needed to optimize the use of this new, helpful framework. This Perspective provides this resource for SUD researchers. Specifically, it highlights the relevance of estimands for SUD trials. Furthermore, it demonstrates how estimands can be used to develop clinically relevant analyses to address challenges in SUD trials. It also shows how a standardized framework can be employed to improve the interpretation and presentation of SUD study findings.

A longitudinal assessment of depression and anxiety in the Republic of Ireland before and during the COVID-19 pandemic

Few studies have examined changes in mental health before and after the outbreak of COVID-19. We examined changes in the prevalence of major depression and generalized anxiety disorder (GAD) between February 2019 and March-April 2020; if there were changes in major depression and GAD during six weeks of nationwide lockdown; and we identified factors that predicted major depression and GAD across the six-week lockdown period. Nationally representative samples of Irish adults were gathered using identical methods in February 2019 (N = 1020) and March-April 2020 (N = 1041). The latter was reassessed six weeks later. Significantly more people screened positive for depression in February 2019 (29.8% 95% CI = 27.0, 32.6) than in March-April 2020 (22.8% 95% CI = 20.2, 25.3), and there was no change in GAD. There were no significant changes in depression and GAD during the lockdown. Major depression was predicted by younger age, non-city dwelling, lower resilience, higher loneliness, and higher somatic problems. GAD was predicted by a broader set of variables including several COVID-19 specific variables. These findings indicate that the prevalence of major depression and GAD did not increase as a result of, or during the early phase of the COVID-19 pandemic in Ireland.

Clinician's Guide to Evaluating and Developing eHealth Interventions for Mental Health

Objective

This review aimed to examine key information regarding technology‐delivered interventions for patients with mental health and/or substance use disorders and to provide support for efforts by psychiatrists and other mental health professionals in recommending applications or helping to develop new technology‐delivered interventions.

Methods

The authors reviewed existing information about the appraisal, development, and evaluation of technology‐delivered interventions (eHealth interventions).

Results

High‐level guidance is available for clinicians who want to evaluate eHealth applications for their patients. Clinicians should be familiar with existing models of eHealth intervention development and with traditional as well as unique elements in the evaluation of efficacy for these approaches. However, existing intervention development models have not been empirically validated, and only one includes empirical optimization as an inherent part of its process.

Conclusions

Because of the proliferation of eHealth interventions, mental health professionals should bring to this area the same level of content knowledge, understanding of development and evaluation processes, and rigorous skepticism as they do for pharmacotherapy and therapist‐delivered behavioral interventions.

eHealth interventions are rapidly transforming mental health treatment.

Clinicians should apply the same rigor to evaluating eHealth interventions that they apply to pharmacological treatments or other behavioral therapies.

High‐level guidance and recommendations regarding ideal eHealth intervention development are available to aid in such evaluation, but empirical evidence in support of these guidelines is lacking.

Evaluating a longitudinal mediation model of perceived stress, depressive symptoms, and substance use treatment outcomes

The allostatic model of addiction suggests that negative affect, such as depressive symptoms, mediates the effect of stress on outcomes among individuals with substance use disorders. However, few longitudinal treatment studies have demonstrated this effect. We analyzed data from a 12-week randomized trial of galantamine and/or computerized cognitive-behavioral therapy (CBT4CBT) for individuals (N = 120) with cocaine use disorder in methadone treatment for opioid use disorder. We evaluated baseline perceived stress as a predictor of end-of-treatment (EOT) substance use outcomes, and EOT perceived stress as a predictor of month 6 posttreatment outcomes. We conducted mediation models with intervening depressive symptoms as a mediator. We also explored whether CBT4CBT moderated the effects of perceived stress. Baseline perceived stress did not predict EOT outcomes (i.e., total effect). However, in mediation models, we found indirect effects of baseline perceived stress on EOT cocaine and illicit opioid use, via midtreatment depressive symptoms. EOT perceived stress had significant total effects on month 6 cocaine and illicit opioid use, and an indirect effect on month 6 illicit opioid use (but not cocaine use), via month 3 depressive symptoms. Alternative models with depressive symptoms as the predictor and perceived stress as a mediator revealed no indirect effects. The addition of CBT4CBT to standard methadone treatment did not moderate total or indirect effects of perceived stress on substance use. Depressive symptoms may play a mediating role in the prospective indirect effect of perceived stress on substance use outcomes, particularly illicit opioid use. Further research is needed on therapies targeting stress. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Is physical exercise and dietary therapy a feasible alternative to cognitive behavior therapy in treatment of eating disorders? A randomized controlled trial of two group therapies

OBJECTIVE

To compare effects of physical exercise and dietary therapy (PED-t) to cognitive behavioral therapy (CBT) in treatment of bulimia nervosa (BN) and binge-eating disorder (BED).

METHOD

The active sample (18-40 years of age) consisted of 76 women in the PED-t condition and 73 in the CBT condition. Participants who chose not to initiate treatment immediately (n = 23) were put on a waiting list. Outcome measures were the eating disorder examination questionnaire (EDE-Q), Clinical Impairment Assessment (CIA), Satisfaction with Life Scale (SWLS), Beck Depression Inventory (BDI), and numbers in remission at posttreatment, and at 6-, 12-, and 24-months follow-up.

RESULTS

Both treatment conditions produced medium to strong significant improvements on all outcomes with long-term effect. The PED-t produced a faster improvement in EDE-Q and CIA, but these differences vanished at follow-ups. Only PED-t provided improvements in BDI, still with no between-group difference. Totally, 30-50% of participants responded favorable to treatments, with no statistical between-group difference.

DISCUSSION

Both treatments shared a focus on normalizing eating patterns, correcting basic self-regulatory processes and reducing idealized aesthetic evaluations of self-worth. The results point to the PED-t as an alternative to CBT for BN and BED, although results are limited due to compliance and dropout rates. Replications are needed by independent research groups as well as in more clinical settings.

Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning

OBJECTIVE

Abstinence outcomes are typically prioritized in the treatment of cocaine use disorder while ignoring patterns of low-frequency cocaine use. This study examined patterns of cocaine use frequency during treatment and evaluated how these patterns related to baseline characteristics and functioning outcomes 6 and 12 months after treatment.

METHOD

We used a pooled dataset (N = 720) from seven randomized clinical trials for cocaine use disorder. The Addiction Severity Index (ASI) was used to assess functioning. Repeated-measures latent class analysis was used to derive patterns of cocaine use.

RESULTS

Three patterns were identified: abstinence (10.6%), low-frequency use (approximately 1 day/week; 66.3%), and persistent frequent use (approximately 4 days/week; 23.1%). The low-frequency group was associated with male gender, younger age, and a criminal justice referral. The abstinent group had the highest alcohol problem severity score at baseline. At Month 6, the low-frequency group reported lower problem severity than the persistent frequent use group across multiple ASI areas, including the cocaine use as well as psychological, family, employment, and legal domains. At Month 12, the low-frequency group did not differ from the abstinent group in problem severity on any ASI domain and, relative to the persistent frequent use group, had lower cocaine use and employment problem severity.

CONCLUSIONS

These findings highlight the importance of adopting a harm reduction approach and recognizing the potential clinical benefits associated with nonabstinent outcomes.

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.

Broad Coping Repertoire Mediates the Effect of the Combined Behavioral Intervention on Alcohol Outcomes in the COMBINE Study: An Application of Latent Class Mediation

OBJECTIVE

Few studies have found support for coping as a mechanism of behavior change (MOBC) following coping skills training interventions for alcohol use disorder (AUD). One potential reason for null findings is heterogeneity in the patterns of coping skills acquired during treatment. This study sought to identify latent classes of coping and to test the latent class variable as a mediator of the effect of a combined behavioral intervention for AUD.

METHOD

Secondary analyses of data from the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) Study (N = 1,124; mean age = 44.4 years; 69.1% male; 23.2% non-White), a multisite study of medication and behavioral treatments for individuals with AUD. Latent class mediation models were estimated to test whether patterns of alcohol-specific coping mediated the effect of combined behavioral intervention with medication management, as compared with medication management only, on drinking outcomes 12 months following treatment.

RESULTS

Three classes were identified, which differed in repertoire broadness, or the degree in which a wide range of different skills were used. Coping repertoire class was a significant mediator of the effect of the combined behavioral intervention on drinking outcomes. Receiving the combined behavioral intervention, in addition to medication management, predicted a greater likelihood of expected classification in the broad coping repertoire class, which in turn was associated with significant improvements in drinking outcomes.

CONCLUSIONS

Using the novel methodological approach of latent class mediation, this study identified coping repertoire as a significant mediator of behavioral intervention efficacy for AUD. Future work examining heterogeneity in mediators and outcomes may help refine AUD treatment to be maximally effective.

Advancing Precision Medicine for Alcohol Use Disorder: Replication and Extension of Reward Drinking as a Predictor of Naltrexone Response

Background

Precision medicine aims to identify those patients who will benefit the most from specific treatments. Recent work found large effects of naltrexone among “reward drinkers,” defined as individuals who drink primarily for the rewarding effects of alcohol. This study sought to replicate and extend these recent findings by examining whether the desire to drink mediated the effect of naltrexone among reward drinkers.

Methods

We conducted a secondary analysis of a 12‐week randomized clinical trial of daily or targeted naltrexone among problem drinkers (n = 163), with a focus on 86 individuals (n = 45 naltrexone and n = 41 placebo) who received daily medication. Interactive voice response technology was used to collect daily reports of drinking and desire to drink. Factor mixture models were used to derive reward and relief phenotypes. Moderation analyses were used to evaluate naltrexone effects, with phenotype as a moderator variable. Multilevel mediation tested average desire to drink as a mediator.

Results

Results indicated 4 phenotypes: low reward/low relief; low reward/high relief; high reward/low relief; and high reward/high relief. There was an interaction between the high reward/low relief subgroup (n = 10) and daily naltrexone versus placebo on drinks per drinking day (DPDD; p = 0.03), percent heavy drinking days (p = 0.004), and daily drinking (p = 0.02). As compared to placebo, individuals in the high reward/low relief phenotype who received daily naltrexone had significantly fewer DPDD (Cohen's d = 2.05) and had a lower proportion of heavy drinking days (Cohen's d = 1.75). As hypothesized, reductions in average desire to drink mediated the effect of naltrexone on average daily drinking among the high reward/low relief drinkers (moderated mediation effect: p = 0.029).

Conclusions

This theory‐driven study replicates the empirical finding that naltrexone is particularly efficacious among high reward/low relief drinkers. Our study brings the field a step closer to the potential of using a precision medicine approach to treating alcohol use disorder.

Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning

OBJECTIVE

Abstinence outcomes are typically prioritized in the treatment of cocaine use disorder while ignoring patterns of low-frequency cocaine use. This study examined patterns of cocaine use frequency during treatment and evaluated how these patterns related to baseline characteristics and functioning outcomes 6 and 12 months after treatment.

METHOD

We used a pooled dataset (N = 720) from seven randomized clinical trials for cocaine use disorder. The Addiction Severity Index (ASI) was used to assess functioning. Repeated-measures latent class analysis was used to derive patterns of cocaine use.

RESULTS

Three patterns were identified: abstinence (10.6%), low-frequency use (approximately 1 day/week; 66.3%), and persistent frequent use (approximately 4 days/week; 23.1%). The low-frequency group was associated with male gender, younger age, and a criminal justice referral. The abstinent group had the highest alcohol problem severity score at baseline. At Month 6, the low-frequency group reported lower problem severity than the persistent frequent use group across multiple ASI areas, including the cocaine use as well as psychological, family, employment, and legal domains. At Month 12, the low-frequency group did not differ from the abstinent group in problem severity on any ASI domain and, relative to the persistent frequent use group, had lower cocaine use and employment problem severity.

CONCLUSIONS

These findings highlight the importance of adopting a harm reduction approach and recognizing the potential clinical benefits associated with nonabstinent outcomes.

Outcome Assessment in Trials of Pharmacological Treatments for Alcohol Use Disorders: Fair and Strict Testing

Outcome assessment in the pharmacological treatment of alcohol use disorders (AUDs) faces specific challenges resulting from low adherence to treatment, high rates of dropout, and the susceptibility of patient self-reports to bias. This review discusses methodological issues in planning, conducting, and interpreting clinical trials on AUD treatment against the background of the principle of 'strictness and fairness' of testing. Threats to fairness include factors that limit the implementation of an intervention, such as low compliance and early treatment termination. In turn, fairness of testing is increased by factors that support the degree to which an intervention is implemented, such as the use of adequate pretreatments and the matching of psychosocial and pharmacological treatment strategies. Furthermore, selecting outcomes on the basis of an intervention's mechanism of action and including continuous outcomes as sensitive measures of drinking change further increases fairness by increasing the likelihood that the data will adequately reflect the effects of the intervention. On the other hand, strictness of testing is increased by all measures that limit the influence of confounders that could potentially lead to an overestimation of effects. The use of a side effect-mimicking placebo to prevent an unmasking of blinding and the repeated assessment of alcohol biomarkers to validate drinking self-reports might be valid strategies to further increase the strictness of testing by limiting risks of bias in trials of AUD treatment.

Maintenance of World Health Organization Risk Drinking Level Reductions and Posttreatment Functioning Following a Large Alcohol Use Disorder Clinical Trial

Background

Reductions in the World Health Organization (WHO) risk drinking levels have been proposed as an alternative primary outcome for alcohol clinical trials. Yet, little is known about whether reductions in WHO risk drinking levels can be maintained over time. The current study examined whether reductions in WHO risk drinking levels were maintained for up to 1 year following treatment, and whether reductions over time were associated with improvements in functioning.

Methods

Secondary data analysis of individuals with alcohol dependence (n = 1,226) enrolled in the COMBINE study, a multisite, randomized, placebo‐controlled clinical trial. Logistic regression was used to examine the maintenance of end‐of‐treatment WHO risk level reductions and WHO risk level reductions at the 1‐year follow‐up. Repeated‐measures mixed models were used to examine the association between WHO risk level reductions and functional outcomes over time.

Results

Achieving at least a 1‐ or 2‐level reduction in risk by the end of treatment was significantly associated with WHO risk level reductions at the 1‐year follow‐up assessment (p < 0.001). Among individuals who achieved at least a 1‐level reduction by the end of treatment, 85.5% reported at least a 1‐level reduction at the 1‐year follow‐up. Among individuals who achieved at least a 2‐level reduction by the end of treatment, 77.8% reported at least a 2‐level reduction at the 1‐year follow‐up. WHO risk level reductions were associated with significantly lower alcohol consumption, better physical health (p < 0.01), and fewer alcohol‐related consequences (p < 0.001) up to 1 year following treatment.

Conclusions

One‐ and 2‐level reductions in WHO risk levels during alcohol treatment were maintained after treatment and associated with better functioning over time. These findings support the use of the WHO risk level reductions as an outcome measure that reflects clinically significant improvement in how individuals seeking treatment for alcohol use disorder feel and function.

Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial

We sought to test the efficacy of extended-release naltrexone (XR-NTX) on HIV-related and drinking outcomes. From April 2011-February 2015, we conducted a 4-site randomized double-blind placebo controlled clinical trial involving 51 HIV-positive patients with heavy drinking and < 95% antiretroviral (ART) adherence. All participants received counseling. The primary outcome was proportion with ≥ 95% ART adherence. Secondary outcomes included HIV biomarkers, VACS Index score, and past 30-day heavy drinking days. Based on receipt of ≥ 5 injections, 23 participants were retained at 24 weeks. We did not detect an effect of XR-NTX on ART adherence (p = 0.38); undetectable HIV viral load (p = 0.26); CD4 cell count (p = 0.75) or VACS Index score (p = 0.70). XR-NTX was associated with fewer heavy drinking days (p = 0.03). While XR-NTX decreases heavy drinking days, we did not detect improvements in ART adherence or HIV outcomes. Strategies to improve retention in alcohol treatment and HIV-related outcomes among heavy drinking HIV-positive patients are needed.

Drinking Risk Level Reductions Associated with Improvements in Physical Health and Quality of Life Among Individuals with Alcohol Use Disorder

BACKGROUND

Abstinence and no heavy drinking days are currently the only Food and Drug Administration-approved end points in clinical trials for alcohol use disorder (AUD). Many individuals who fail to meet these criteria may substantially reduce their drinking during treatment, and most individuals with AUD prefer drinking reduction goals. One- and two-level reductions in World Health Organization (WHO) drinking risk levels have been proposed as alternative end points that reflect reduced drinking and are associated with reductions in drinking consequences, improvements in mental health, and reduced risk of developing alcohol dependence. The current study examined the association between WHO drinking risk level reductions and improvements in physical health and quality of life in a sample of individuals with alcohol dependence.

METHODS

Secondary data analysis of individuals with alcohol dependence (n = 1,142) enrolled in the longitudinal, prospective COMBINE study, a multi site randomized placebo-controlled clinical trial, examining the association between reductions in WHO drinking risk levels and change in blood pressure, liver enzyme levels, and self-reported quality of life following treatment for alcohol dependence.

RESULTS

One- and two-level reductions in WHO drinking risk level during treatment were associated with significant reductions in systolic blood pressure (p < 0.001), improvements in liver enzyme levels (all p < 0.01), and significantly better quality of life (p < 0.001).

CONCLUSIONS

One- and two-level reductions in WHO drinking risk levels predicted significant improvements in markers of physical health and quality of life, suggesting that the WHO drinking risk level reduction could be a meaningful surrogate marker of improvements in how a person "feels and functions" following treatment for alcohol dependence. The WHO drinking risk levels could be useful in medical practice for identifying drinking reduction targets that correspond with clinically significant improvements in health and quality of life.

Treating loss-to-follow-up as a missing data problem: a case study using a longitudinal cohort of HIV-infected patients in Haiti

Background

HIV programs are often assessed by the proportion of patients who are alive and retained in care; however some patients are categorized as lost to follow-up (LTF) and have unknown vital status. LTF is not an outcome but a mixed category of patients who have undocumented death, transfer and disengagement from care. Estimating vital status (dead versus alive) among this category is critical for survival analyses and program evaluation.

Methods

We used three methods to estimate survival in the cohort and to ascertain factors associated with death among the first cohort of HIV positive patients to receive antiretroviral therapy in Haiti: complete case (CC) (drops missing), Inverse Probability Weights (IPW) (uses tracking data) and Multiple Imputation with Chained Equations (MICE) (imputes missing data). Logistic regression was used to calculate odds ratios and 95% confidence intervals for adjusted models for death at 10 years. The logistic regression models controlled for sex, age, severe poverty (living on <$1 USD per day), Port-au-Prince residence and baseline clinical characteristics of weight, CD4, WHO stage and tuberculosis diagnosis.

Results

Age, severe poverty, baseline weight and WHO stage were statistically significant predictors of AIDS related mortality across all models. Gender was only statistically significant in the MICE model but had at least a 10% difference in odds ratios across all models.

Conclusion

Each of these methods had different assumptions and differed in the number of observations included due to how missing values were addressed. We found MICE to be most robust in predicting survival status as it allowed us to impute missing data so that we had the maximum number of observations to perform regression analyses. MICE also provides a complementary alternative for estimating survival among patients with unassigned vital status. Additionally, the results were easier to interpret, less likely to be biased and provided an alternative to a problem that is often commented upon in the extant literature.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6115-0) contains supplementary material, which is available to authorized users.

Treatment for Alcohol Dependence in Primary Care Compared to Outpatient Specialist Treatment-A Randomized Controlled Trial

Aim

To investigate if treatment for alcohol dependence in primary care is as effective as specialist addiction care.

Method

Randomized controlled non-inferiority trial, between groups parallel design, not blinded. The non-inferiority limit was set to 50 grams of alcohol per week. About 288 adults fulfilling ICD-10 criteria for alcohol dependence were randomized to treatment in primary care (men n = 82, women n = 62) or specialist care (men n = 77, women n = 67). General practitioners at 12 primary care centers received 1-day training in a treatment manual for alcohol dependence. Primary outcome was change in weekly alcohol consumption at 6-months follow-up compared with baseline, as measured with timeline follow back. Secondary outcomes were heavy drinking days, severity of dependence, consequences of drinking, psychological health, quality of life, satisfaction with treatment and biomarkers.

Results

Intention-to-treat analysis (n = 228) was statistically inconclusive, and could not confirm non-inferiority for the primary outcome, since the high end of the confidence interval exceeded 50 grams (estimated mean weekly alcohol consumption was 30 grams higher in primary care compared with specialist care; 95% confidence interval -10.20; 69.72). However, treatment in specialist care was not significantly superior to primary care (P = 0.146). Subanalysis suggests that specialist care was superior to primary care only for patients with high severity of dependence.

Conclusions

Treatment for alcohol dependence in primary care is a promising approach, especially for individuals with low to moderate dependence. This may be a way to broaden the base of treatment for alcohol dependence, reducing the current treatment gap.

Study characteristics influence the efficacy of substance abuse treatments: A meta-analysis of medications for alcohol use disorder

BACKGROUND

Understanding study characteristics' influence on treatment efficacy could improve methodologies and interpretation of findings. We examine study characteristics as predictors of outcomes in clinical trials of medications for alcohol problems.

METHODS

We obtained data on 23 trials of naltrexone and 22 trials of acamprosate from Cochrane reviews. We extracted data for 14 study characteristics and 3 dependent variables (odds ratio; percent abstinent in placebo; medication conditions). We used general linear models to determine which study characteristics explained the variability among outcomes after controlling for medication characteristics.

RESULTS

Study characteristics accounted for 45% of the variance in odds ratio when trials of different medications were combined, 19% among acamprosate, and 48% among naltrexone trials above and beyond medication characteristics. When medications were combined, greater odds ratios were predicted by having more dropouts in the placebo than medication conditions, an earlier publication year, and not receiving industry funding. Whether this was due to effects on placebo or medication conditions was unclear. Among acamprosate trials, smaller sample sizes predicted greater odds ratios, which appeared to be due to more abstinence in medication conditions. Among naltrexone trials, greater odds ratios were predicted by having more dropouts in the placebo than medication conditions and a greater probability of randomizing participants to treatment. This appeared to be due to less abstinence in placebo conditions.

CONCLUSION

Study characteristics influence the assessment of treatment efficacy beyond medication characteristics in alcohol treatment trials. Future studies are needed to determine which study characteristics reliably influence efficacy to help investigators design and help clinicians interpret trials.

Opioid Misuse as a Predictor of Alcohol Treatment Outcomes in the COMBINE Study: Mediation by Medication Adherence

BACKGROUND

Alcohol is often consumed with opioids and alcohol misuse interferes with treatment for opioid use disorder (OUD). Drug misuse is associated with worse alcohol use disorder (AUD) treatment outcomes, yet no studies have investigated the role of opioid misuse in AUD treatment outcomes.

METHODS

We conducted secondary analyses of the medication conditions of the COMBINE study (n = 1,226), a randomized clinical trial of medications (acamprosate and/or naltrexone) and behavioral interventions (medication management and/or behavioral intervention) for alcohol dependence. We examined associations between baseline opioid misuse and the use of cannabis and other drugs with time to first drinking day, time to first heavy drinking day, and the frequency and intensity of drinking during treatment and 1 year following treatment, based on latent profile analysis. Opioid misuse was defined as use of illicit or prescription opioids without a prescription or not as directed in the previous 6 months, in the absence of OUD. Self-reported cannabis and other drug use were also examined. Seventy individuals (5.7%) met the opioid misuse definition and 542 (44.2%) reported use of cannabis or other drugs without opioid misuse. We also examined medication adherence as a potential mediator.

RESULTS

Baseline opioid misuse significantly predicted the time to first heavy drinking day (OR = 1.38 [95% CI: 1.13, 1.64], p = 0.001) and a higher probability of being in a heavier and more frequent drinking profile at the end of treatment (OR = 2.90 [95% CI: 1.43, 5.90], p = 0.003), and at 1 year following treatment (OR = 2.66 [95% CI: 1.26, 5.59], p = 0.01). Cannabis and other drug use also predicted outcomes. Medication adherence partially mediated the association between opioid misuse, cannabis use, other drug use, and treatment outcomes.

CONCLUSIONS

Opioid misuse and other drug use were associated with poorer AUD treatment outcomes, which was partially mediated by medication adherence. Clinicians and researchers should assess opioid misuse and other drug use in patients undergoing AUD treatment.

Efficacy, tolerability, and safety of low-dose and high-dose baclofen in the treatment of alcohol dependence: A systematic review and meta-analysis

A systematic review of the current literature on the efficacy of baclofen, particularly the effect of dosing, for the treatment of alcohol dependence (AD) is missing. We therefore conducted a systematic review and meta-analysis of currently available randomized placebo-controlled trials (RCTs). A systematic literature search for RCTs in AD patients comparing baclofen to placebo was performed in September 2017. The effect of baclofen treatment, and the moderating effects of baclofen dosing (low-dose (LDB) 30-60 mg versus high-dose (HDB) targeted as >60 mg/day), and the amount of alcohol consumption before inclusion were studied. Three treatment outcomes were assessed: time to lapse (TTL), percentage days abstinent (PDA), and percentage of patients abstinent at end point (PAE). 13 RCTs from 39 records were included. Baclofen was superior to placebo with significant increases in TTL (8 RCTs, 852 patients; SMD=0.42; 95% CI 0.19-0.64) and PAE (8 RCTs, 1244 patients; OR=1.93; 95% CI 1.17-3.17), and a non-significant increase in PDA (7 RCTs, 457 patients; SMD=0.21; 95% CI -0.24 to 0.66). Overall, studies with LDB showed better efficacy than studies with HDB. Furthermore, tolerability of HDB was low, but serious adverse events were rare. Meta-regression analysis showed that the effects of baclofen were stronger when daily alcohol consumption before inclusion was higher. Baclofen seems to be effective in the treatment of AD, especially among heavy drinkers. HDB is not necessarily more effective than LDB with low tolerability of HDB being an import limitation.

Baseline patterns of substance use disorder severity and depression and anxiety symptoms moderate the efficacy of mindfulness-based relapse prevention

OBJECTIVE

Few studies have evaluated moderators of mindfulness-based relapse prevention (MBRP) for substance use disorders (SUDs). We tested whether baseline patterns of scores for SUD symptom severity and depression and anxiety symptoms moderated the efficacy of MBRP.

METHOD

We used a latent class moderation approach with data from a randomized trial of MBRP compared to cognitive-behavioral relapse prevention and treatment as usual (TAU; Bowen et al., 2014; N = 286, 71.8% male, 48.4% non-White, mean age = 38.44 years, SD = 10.92) and a randomized trial comparing MBRP to TAU (Bowen et al., 2009; N = 168, 63.7% male, 44.6% non-White, mean age = 40.45, SD = .28). Indicators for the latent class models were measures of SUD severity (Severity of Dependence Scale and Short Inventory of Problems), depression symptoms (Beck Depression Inventory), and anxiety symptoms (Beck Anxiety Inventory).

RESULTS

In both trials, 3 latent classes provided the best fit: a high-high class characterized by high SUD severity and depression and anxiety symptoms, a high-low class characterized by high SUD severity and low depression and anxiety symptoms, and a low-low class characterized by low SUD severity and depression and anxiety symptoms. In both trials, we found significant latent Class × Treatment interaction effects: There were significant and large effects of MBRP on substance use outcomes in the high-high and high-low classes, but no MBRP effect in the low-low class.

CONCLUSION

MBRP may be an optimal treatment for preventing relapse among clients with severe levels of SUD symptoms and depression and anxiety symptoms, as well as clients with only severe SUD symptoms. (PsycINFO Database Record

Reward and relief dimensions of temptation to drink: construct validity and role in predicting differential benefit from acamprosate and naltrexone

Researchers have sought to distinguish between individuals whose alcohol use disorder (AUD) is maintained by drinking to relieve negative affect ('relief drinkers') and those whose AUD is maintained by the rewarding effects of alcohol ('reward drinkers'). As an opioid receptor antagonist, naltrexone may be particularly effective for reward drinkers. Acamprosate, which has been shown to down-regulate the glutamatergic system, may be particularly effective for relief drinkers. This study sought to replicate and extend prior work (PREDICT study; Glöckner-Rist et al. ) by examining dimensions of reward and relief temptation to drink and subtypes of individuals with distinct patterns of reward/relief temptation. We utilized data from two randomized clinical trials for AUD (Project MATCH, n = 1726 and COMBINE study, n = 1383). We also tested whether classes of reward/relief temptation would predict differential response to naltrexone and acamprosate in COMBINE. Results replicated prior work by identifying reward and relief temptation factors, which had excellent reliability and construct validity. Using factor mixture modeling, we identified five distinct classes of reward/relief temptation that replicated across studies. In COMBINE, we found a significant class-by-acamprosate interaction effect. Among those most likely classified in the high relief/moderate reward temptation class, individuals had better drinking outcomes if assigned to acamprosate versus placebo. We did not find a significant class-by-naltrexone interaction effect. Our study questions the orthogonal classification of drinkers into only two types (reward or relief drinkers) and adds to the body of research on moderators of acamprosate, which may inform clinical decision making in the treatment of AUD.

How Much Is Too Much? Patterns of Drinking During Alcohol Treatment and Associations With Post-Treatment Outcomes Across Three Alcohol Clinical Trials

OBJECTIVE

This secondary data analysis examined patterns of drinking during alcohol treatment and associated drinking outcomes during the first year following treatment. The goal was to provide clinicians with guidance on which patients may be most at risk for negative long-term outcomes based on drinking patterns during treatment.

METHOD

This study was an analysis of existing data (N = 3,851) from three randomized clinical trials for alcohol use disorder: the COMBINE Study (n = 1,383), Project MATCH (n = 1,726), and the United Kingdom Alcohol Treatment Trial (n = 742). Indicators of abstinence, non-heavy drinking, and heavy drinking (defined as 4/5 or more drinks per day for women/men) were examined during each week of treatment using repeated-measures latent class analysis. Associations between drinking patterns during treatment and drinking intensity, drinking consequences, and physical and mental health 12 months following intake were examined.

RESULTS

Seven drinking patterns were identified. Patients who engaged in persistent heavy drinking throughout treatment and those who returned to persistent heavy drinking during treatment had the worst long-term outcomes. Patients who engaged in some heavy drinking during treatment had better long-term outcomes than persistent heavy drinkers. Patients who reported low-risk drinking or abstinence had the best long-term outcomes. There were no differences in outcomes between low-risk drinkers and abstainers.

CONCLUSIONS

Abstinence, low-risk drinking, or even some heavy drinking during treatment are associated with the best long-term outcomes. Patients who are engaging in persistent heavy drinking are likely to have the worst outcomes and may require a higher level of care.

Aggregating and Analyzing Daily Drinking Data in Clinical Trials: A Comparison of Type I Errors, Power, and Bias

OBJECTIVE

Statistical analyses in alcohol clinical trials often use longitudinal daily drinking data (e.g., percentage of drinking days) to test treatment efficacy. Such data can be aggregated and analyzed in many ways. To assess how statistical analytic decisions may influence substantive results, the current report compares different aggregation methods (e.g., computing percentages of drinking days vs. using daily binary indicators of drinking) and statistical methods (i.e., least squares regression, linear mixed-effects models [LMM], generalized linear mixed models [GLMM], and generalized estimating equations [GEE]) for testing the effects of treatment on drinking outcomes in clinical trials.

METHOD

A simulation study repeatedly resampled daily drinking data from the treatment period of the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) Study at different sample sizes. Treatment effects in each data set were modeled using different aggregation and statistical methods.

RESULTS

Type I error rates were near the expected rate for most models but on occasion were mildly elevated when disaggregated daily drinking data were analyzed using GLMM or GEE with an exchangeable correlation structure. Most methods yielded similar statistical power, although power decreased when modeling disaggregated daily drinking with GLMM and had mixed increases and decreases when the longitudinal nature of data was ignored by using fully aggregated data with independent samples t tests.

CONCLUSIONS

When testing treatment main effects, relatively simpler statistical methods with fewer repeated measures may perform equally well or better than more complicated methods. Patterns of significance and treatment effect size estimates are likely comparable across most studies that use different aggregation and statistical methods, but differences between these methods may occasionally have an important impact on conclusions in clinical trials.

Working memory capacity and addiction treatment outcomes in adolescents

BACKGROUND

Brief addiction treatments including motivational interviewing (MI) have shown promise with adolescents, but the factors that influence treatment efficacy in this population remain unknown. One candidate is working memory, the ability to hold a fact or thought in mind. This is relevant, as in therapy, a client must maintain and manipulate ideas while working with a clinician. Working memory depends upon brain structures and functions that change markedly during neurodevelopment and that can be negatively impacted by substance use.

OBJECTIVES

In a secondary analysis of data from a clinical trial for adolescent substance use comparing alcohol/marijuana education and MI, we evaluated the relationship between working memory and three-month treatment-outcomes with the hypothesis that the relationship between intervention conditions and outcome would be moderated by working memory.

METHODS

With a diverse sample of adolescents currently using alcohol and/or marijuana (N = 153, 64.7% male, 70.6% Hispanic), we examined the relationship between baseline measures of working memory and alcohol and cannabis-related problem scores measured at the three-month follow-up.

RESULTS

The results showed that lower working memory scores were associated with poorer treatment response only for alcohol use, and only within the education group. No relationship was found between working memory and treatment outcomes in the MI group.

CONCLUSION

The results suggest that issues with working memory capacity may interfere with adolescents' ability to process and implement didactic alcohol and marijuana content in standard education interventions. These results also suggest that MI can be implemented equally effectively across the range of working memory functioning in youth.

Temporal Stability of Heavy Drinking Days and Drinking Reductions Among Heavy Drinkers in the COMBINE Study

BACKGROUND

Recently, the Food and Drug Administration (FDA) proposed to expand the options for primary end points in the development of medications for alcohol use disorder to include either abstinence from alcohol or a nonabstinent outcome: no heavy drinking days (with a heavy drinking day defined as more than 3 drinks per day for women and more than 4 drinks per day for men [>3/>4 cutoff]). The FDA also suggested that 6 months would be the most appropriate length for a clinical trial to demonstrate the stability of this nonabstinent drinking outcome. However, few alcohol clinical trials have examined the stability of nonheavy drinking during and after treatment.

METHODS

In a secondary analysis of the COMBINE study data (n = 1,383), we examined transitions in heavy drinking days during the course of treatment (months 1 through 4), during the transition out of treatment (months 4 through 7), and up to 12 months afterward (months 13 through 16) using latent variable mixture models.

RESULTS

Heavy drinking and nonheavy drinking were relatively stable in consecutive months (minimum agreement [kappa] = 0.64 for months 1 to 2). Most individuals were stable low-risk drinkers/abstainers or heavy drinkers by the end of treatment, as characterized by a 10% probability (or less) of transitioning out of either a no heavy drinking state or a heavy drinking state. More than two-thirds of the heavy drinkers who exceeded the heavy drinking threshold during treatment reported, on average, a 64% reduction in drinking frequency and a 38% reduction in drinking intensity from pretreatment drinking levels.

CONCLUSIONS

The results show stability of no heavy drinking as an outcome within the first 4 months of treatment and that the >3/>4 drink cutoff may mask substantial reductions in alcohol consumption among some patients. Future studies should explore the clinical utility of reduction end points.

Automatic avoidance tendencies for alcohol cues predict drinking after detoxification treatment in alcohol dependence

Alcohol dependence is characterized by conflict between approach and avoidance motivational orientations for alcohol that operate in automatic and controlled processes. This article describes the first study to investigate the predictive validity of these motivational orientations for relapse to drinking after discharge from alcohol detoxification treatment in alcohol-dependent patients. One hundred twenty alcohol-dependent patients who were nearing the end of inpatient detoxification treatment completed measures of self-reported (Approach and Avoidance of Alcohol Questionnaire; AAAQ) and automatic (modified Stimulus-Response Compatibility task) approach and avoidance motivational orientations for alcohol. Their drinking behavior was assessed via telephone follow-ups at 2, 4, and 6 months after discharge from treatment. Results indicated that, after controlling for the severity of alcohol dependence, strong automatic avoidance tendencies for alcohol cues were predictive of higher percentage of heavy drinking days (PHDD) at 4-month (β = 0.22, 95% CI [0.07, 0.43]) and 6-month (β = 0.22, 95% CI [0.01, 0.42]) follow-ups. We failed to replicate previous demonstrations of the predictive validity of approach subscales of the AAAQ for relapse to drinking, and there were no significant predictors of PHDD at 2-month follow-up. In conclusion, strong automatic avoidance tendencies predicted relapse to drinking after inpatient detoxification treatment, but automatic approach tendencies and self-reported approach and avoidance tendencies were not predictive in this study. Our results extend previous findings and help to resolve ambiguities with earlier studies that investigated the roles of automatic and controlled cognitive processes in recovery from alcohol dependence. (PsycINFO Database Record

Nalmefene for the management of alcohol dependence: review on its pharmacology, mechanism of action and meta-analysis on its clinical efficacy

Nalmefene, a mu- and delta-opioid receptor (MOR, DOR) antagonist and a partial kappa-opioid receptor (KOR) agonist, is approved in the European Union and other countries for the reduction of alcohol consumption in alcohol dependent patients with a high drinking risk level according to WHO ("target population"). This review presents an overview of nalmefene׳s pharmacology, its mechanisms of action and a meta-analysis on its efficacy in reducing alcohol consumption. The review was based on a systematic search of the literature. Random effects meta-analyses were performed on published and unpublished trials directed at drinking reduction using the changes in heavy drinking days (HDDs) and daily total alcohol consumption (TAC) from baseline to the primary endpoint. For each included study and each dose, Hedges' g was used as an unbiased estimator of the standardised mean differences between nalmefene and placebo. Preclinical data suggests that nalmefene counters alcohol-induced dysregulations of the MOR/endorphine and the KOR/dynorphin system. Evidence further suggests that reduced alcohol consumption is an effective treatment strategy that appeals to patients not ready for abstinence. Finally, meta-analyses confirmed the efficacy of 20mg nalmefene for reducing HDDs in the ITT population (Hedge׳s g=-0.20; 95% CI -0.30 to -0.09) and the target population (Hedge׳s g=-0.33; 95% CI -0.48 to -0.18). Similar results were seen for TAC. Several meta-analyses, including this new meta-analysis, support nalmefene׳s efficacy in reducing alcohol consumption. In conclusion, because it does not require abstinence, this treatment has the potential to motivate more patients for treatment and thus helps to address a major public health concern.

Continuous Abstinence During Early Alcohol Treatment is Significantly Associated with Positive Treatment Outcomes, Independent of Duration of Abstinence

AIMS

Neither the predictive value of early continuous abstinence in alcohol use disorder (AUD) or the point at which this effect may emerge has been evaluated. This analysis of the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) clinical trial evaluated whether abstinence early in treatment was a predictor of longer term abstinence.

METHODS

Participants who stated a goal of total abstinence (N = 954) were dichotomized into Early Abstainer vs. Nonabstainers and were compared on a variety of drinking outcome measures that are frequently used in clinical trial evaluations of alcohol treatment strategies, as a function of duration of early continuous abstinence.

RESULTS

Significant differences existed for every outcome. Early Abstinence was significantly associated with fewer drinks per drinking day, number of drinking and number of heavy drinking days, and longer time to first drinking and first heavy drinking day. Effects were evident within the first week. The magnitude of all effects increased as the duration of early abstinence (1-4 weeks) increased, though the size of increase varied across the outcomes.

CONCLUSIONS

These data provide evidence that drinking at the beginning of alcohol treatment is significantly and robustly associated with drinking throughout and at the end of a clinical trial treatment for AUD. Early drinking may be a useful early index to identify whether patients are responding positively to a treatment strategy, and provides a useful method for tailoring treatment to patients that is consistent with a personalized medicine approach.

Evaluation in alcohol use disorders - insights from the nalmefene experience

Nalmefene was the first treatment approved by the European Medicines Agency for reducing alcohol consumption in adult patients with alcohol dependence. It is often presented as a paradigm shift in therapeutics, but major issues limit the interpretation of the evidence supporting its use. The randomised trials submitted provided no evidence of harm reduction, the differences on consumption outcomes were of questionable clinical relevance, the target population was defined a posteriori and the drug was compared to a placebo although naltrexone was already used off-label. No post-approval randomised study is currently designed to clearly address these issues. In addition, nalmefene trials have been uncritically cited, even in guidelines. This experience reveals weaknesses in drug evaluations in alcohol dependence, which call for changes. We propose to dispense with alcohol consumption as a surrogate outcome, to consider comparative effectiveness issues, and to recommend randomised post-approval studies in case of controversial approval.

Discovery, Development, and Adoption of Medications to Treat Alcohol Use Disorder: Goals for the Phases of Medications Development

For more than 25 years, advances have been made in developing medications to treat alcohol use disorder (AUD), highlighted by the U.S. Food and Drug Administration's approval of naltrexone (oral and long-acting) and acamprosate. Despite this progress, more work remains to be done in this area because these medications, although effective for some people, do not work for everyone. A high priority for the National Institute on Alcohol Abuse and Alcohol is to put into place a solid infrastructure to aid in the development of medications that are more effective than those currently available and with few side effects. Medication development, especially for a disorder as complex as AUD, is challenging and involves multiple phases, including discovery of "druggable" targets, preclinical studies, human clinical trials, and the adoption and implementation of the new medication into mainstream medicine. A successful medications development program requires clearly established goals for each phase to ensure that a candidate compound is not trapped in one particular phase, a condition known as "the valley of death." In this article, the phases of medication development are described as they apply to AUD, and specific goals of each phase are identified for the next decade. In addition, several important crosscutting themes are outlined for each phase, all of which are essential for advancing medications development. These include identifying and validating screening models and druggable targets, making use of precision medicine, and establishing partnerships among key stakeholders. Our goal in writing this article is to provide a guide on medications development that will aid the alcohol research community in planning, testing, and developing medications for AUD.

Missing Data in Alcohol Clinical Trials with Binary Outcomes

BACKGROUND

Missing data are common in alcohol clinical trials for both continuous and binary end points. Approaches to handle missing data have been explored for continuous outcomes, yet no studies have compared missing data approaches for binary outcomes (e.g., abstinence, no heavy drinking days). This study compares approaches to modeling binary outcomes with missing data in the COMBINE study.

METHODS

We included participants in the COMBINE study who had complete drinking data during treatment and who were assigned to active medication or placebo conditions (N = 1,146). Using simulation methods, missing data were introduced under common scenarios with varying sample sizes and amounts of missing data. Logistic regression was used to estimate the effect of naltrexone (vs. placebo) in predicting any drinking and any heavy drinking outcomes at the end of treatment using 4 analytic approaches: complete case analysis (CCA), last observation carried forward (LOCF), the worst case scenario (WCS) of missing equals any drinking or heavy drinking, and multiple imputation (MI). In separate analyses, these approaches were compared when drinking data were manually deleted for those participants who discontinued treatment but continued to provide drinking data.

RESULTS

WCS produced the greatest amount of bias in treatment effect estimates. MI usually yielded less biased estimates than WCS and CCA in the simulated data and performed considerably better than LOCF when estimating treatment effects among individuals who discontinued treatment.

CONCLUSIONS

Missing data can introduce bias in treatment effect estimates in alcohol clinical trials. Researchers should utilize modern missing data methods, including MI, and avoid WCS and CCA when analyzing binary alcohol clinical trial outcomes.

Measures of outcome for stimulant trials: ACTTION recommendations and research agenda

BACKGROUND

The development and approval of an efficacious pharmacotherapy for stimulant use disorders has been limited by the lack of a meaningful indicator of treatment success, other than sustained abstinence.

METHODS

In March, 2015, a meeting sponsored by Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) was convened to discuss the current state of the evidence regarding meaningful outcome measures in clinical trials for stimulant use disorders. Attendees included members of academia, funding and regulatory agencies, pharmaceutical companies, and healthcare organizations. The goal was to establish a research agenda for the development of a meaningful outcome measure that may be used as an endpoint in clinical trials for stimulant use disorders.

RESULTS AND CONCLUSIONS

Based on guidelines for the selection of clinical trial endpoints, the lessons learned from prior addiction clinical trials, and the process that led to identification of a meaningful indicator of treatment success for alcohol use disorders, several recommendations for future research were generated. These include a focus on the validation of patient reported outcome measures of functioning, the exploration of patterns of stimulant abstinence that may be associated with physical and/or psychosocial benefits, the role of urine testing for validating self-reported measures of stimulant abstinence, and the operational definitions for reduction-based measures in terms of frequency rather than quantity of stimulant use. These recommendations may be useful for secondary analyses of clinical trial data, and in the design of future clinical trials that may help establish a meaningful indicator of treatment success.

Risks and Benefits of Nalmefene in the Treatment of Adult Alcohol Dependence: A Systematic Literature Review and Meta-Analysis of Published and Unpublished Double-Blind Randomized Controlled Trials

BACKGROUND

Nalmefene is a recent option in alcohol dependence treatment. Its approval was controversial. We conducted a systematic review and meta-analysis of the aggregated data (registered as PROSPERO 2014:CRD42014014853) to compare the harm/benefit of nalmefene versus placebo or active comparator in this indication.

METHODS AND FINDINGS

Three reviewers searched for published and unpublished studies in Medline, the Cochrane Library, Embase, ClinicalTrials.gov, Current Controlled Trials, and bibliographies and by mailing pharmaceutical companies, the European Medicines Agency (EMA), and the US Food and Drug Administration. Double-blind randomized clinical trials evaluating nalmefene to treat adult alcohol dependence, irrespective of the comparator, were included if they reported (1) health outcomes (mortality, accidents/injuries, quality of life, somatic complications), (2) alcohol consumption outcomes, (3) biological outcomes, or (4) treatment safety outcomes, at 6 mo and/or 1 y. Three authors independently screened the titles and abstracts of the trials identified. Relevant trials were evaluated in full text. The reviewers independently assessed the included trials for methodological quality using the Cochrane Collaboration tool for assessing risk of bias. On the basis of the I2 index or the Cochrane's Q test, fixed or random effect models were used to estimate risk ratios (RRs), mean differences (MDs), or standardized mean differences (SMDs) with 95% CIs. In sensitivity analyses, outcomes for participants who were lost to follow-up were included using baseline observation carried forward (BOCF); for binary measures, patients lost to follow-up were considered equal to failures (i.e., non-assessed patients were recorded as not having responded in both groups). Five randomized controlled trials (RCTs) versus placebo, with a total of 2,567 randomized participants, were included in the main analysis. None of these studies was performed in the specific population defined by the EMA approval of nalmefene, i.e., adults with alcohol dependence who consume more than 60 g of alcohol per day (for men) or more than 40 g per day (for women). No RCT compared nalmefene with another medication. Mortality at 6 mo (RR = 0.39, 95% CI [0.08; 2.01]) and 1 y (RR = 0.98, 95% CI [0.04; 23.95]) and quality of life at 6 mo (SF-36 physical component summary score: MD = 0.85, 95% CI [-0.32; 2.01]; SF-36 mental component summary score: MD = 1.01, 95% CI [-1.33; 3.34]) were not different across groups. Other health outcomes were not reported. Differences were encountered for alcohol consumption outcomes such as monthly number of heavy drinking days at 6 mo (MD = -1.65, 95% CI [-2.41; -0.89]) and at 1 y (MD = -1.60, 95% CI [-2.85; -0.35]) and total alcohol consumption at 6 mo (SMD = -0.20, 95% CI [-0.30; -0.10]). An attrition bias could not be excluded, with more withdrawals for nalmefene than for placebo, including more withdrawals for safety reasons at both 6 mo (RR = 3.65, 95% CI [2.02; 6.63]) and 1 y (RR = 7.01, 95% CI [1.72; 28.63]). Sensitivity analyses showed no differences for alcohol consumption outcomes between nalmefene and placebo, but the weight of these results should not be overestimated, as the BOCF approach to managing withdrawals was used.

CONCLUSIONS

The value of nalmefene for treatment of alcohol addiction is not established. At best, nalmefene has limited efficacy in reducing alcohol consumption.

Recommendations for the Design and Analysis of Treatment Trials for Alcohol Use Disorders

BACKGROUND

Over the past 60 years, the view that "alcoholism" is a disease for which the only acceptable goal of treatment is abstinence has given way to the recognition that alcohol use disorders (AUDs) occur on a continuum of severity, for which a variety of treatment options are appropriate. However, because the available treatments for AUDs are not effective for everyone, more research is needed to develop novel and more efficacious treatments to address the range of AUD severity in diverse populations. Here we offer recommendations for the design and analysis of alcohol treatment trials, with a specific focus on the careful conduct of randomized clinical trials of medications and nonpharmacological interventions for AUDs.

METHODS

This paper provides a narrative review of the quality of published clinical trials and recommendations for the optimal design and analysis of treatment trials for AUDs.

RESULTS

Despite considerable improvements in the design of alcohol clinical trials over the past 2 decades, many studies of AUD treatments have used faulty design features and statistical methods that are known to produce biased estimates of treatment efficacy.

CONCLUSIONS

The published statistical and methodological literatures provide clear guidance on methods to improve clinical trial design and analysis. Consistent use of state-of-the-art design features and analytic approaches will enhance the internal and external validity of treatment trials for AUDs across the spectrum of severity. The ultimate result of this attention to methodological rigor is that better treatment options will be identified for patients with an AUD.

Guidelines for the Reporting of Treatment Trials for Alcohol Use Disorders

BACKGROUND

The primary goals in conducting clinical trials of treatments for alcohol use disorders (AUDs) are to identify efficacious treatments and determine which treatments are most efficacious for which patients. Accurate reporting of study design features and results is imperative to enable readers of research reports to evaluate to what extent a study has achieved these goals. Guidance on quality of clinical trial reporting has evolved substantially over the past 2 decades, primarily through the publication and widespread adoption of the Consolidated Standards of Reporting Trials statement. However, there is room to improve the adoption of those standards in reporting the design and findings of treatment trials for AUD.

METHODS

This paper provides a narrative review of guidance on reporting quality in AUD treatment trials.

RESULTS

Despite improvements in the reporting of results of treatment trials for AUD over the past 2 decades, many published reports provide insufficient information on design or methods.

CONCLUSIONS

The reporting of alcohol treatment trial design, analysis, and results requires improvement in 4 primary areas: (i) trial registration, (ii) procedures for recruitment and retention, (iii) procedures for randomization and intervention design considerations, and (iv) statistical methods used to assess treatment efficacy. Improvements in these areas and the adoption of reporting standards by authors, reviewers, and editors are critical to an accurate assessment of the reliability and validity of treatment effects. Continued developments in this area are needed to move AUD treatment research forward via systematic reviews and meta-analyses that maximize the utility of completed studies.