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Bugarski-Kirola D, Abbs B, Odetalla R, Liu IY, Darwish M, DeKarske D. Adherence to Background Antipsychotic and Pimavanserin in Patients with Schizophrenia: Post Hoc Analyses from the ENHANCE and ADVANCE Studies. Patient Prefer Adherence 2024; 18:207-216. [PMID: 38264323 PMCID: PMC10804867 DOI: 10.2147/ppa.s436041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/11/2024] [Indexed: 01/25/2024] Open
Abstract
Background In patients with schizophrenia, study design to optimize adherence and objective measurement of adherence is critical for interpreting results. Two randomized, double-blind studies evaluating adjunctive pimavanserin in patients with schizophrenia who received stable antipsychotic treatment included measures to encourage and assess treatment adherence. Objective This post hoc analysis evaluated adherence levels achieved in the Phase III ENHANCE study (NCT02970292) and the Phase II ADVANCE study (NCT02970305). Methods Blood levels of participants receiving adjunctive treatment with pimavanserin or placebo added to their ongoing antipsychotic medication were tested and evaluated regularly throughout both studies. For both the background antipsychotic and pimavanserin, treatment adherence was defined as a blood sample test result above the lower limit of quantification. Results Overall, 392 of 633 screened patients and 403 of 608 screened patients were in the safety populations in ENHANCE and ADVANCE, respectively. In ENHANCE, at weeks 1, 3, and 6/early termination (ET), the adherence rates remained ≥ 95.1% for the background antipsychotic in both pimavanserin and placebo treatment groups and ≥ 96.8% for pimavanserin. In ADVANCE, high adherence rates (≥90.6%) with the background antipsychotic (for both treatment groups) and pimavanserin (≥95.0%) were observed at weeks 2, 8, 14, and 26/ET. Conclusion Rigorous screening was performed to exclude patients not adherent to their background antipsychotic before enrollment and to pimavanserin during study visits by using regular blood sampling. Mandatory caregiver participation further supported adherence to study treatment and procedures. These efforts may have contributed to the high levels of adherence to both background antipsychotic and pimavanserin reported in ENHANCE and ADVANCE.
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Affiliation(s)
- Dragana Bugarski-Kirola
- Acadia Pharmaceuticals GmbH, Basel, Switzerland
- Acadia Pharmaceuticals Inc, Princeton, NJ, USA
| | | | | | - I-Yuan Liu
- Acadia Pharmaceuticals Inc, Princeton, NJ, USA
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Schwenker R, Dietrich CE, Hirpa S, Nothacker M, Smedslund G, Frese T, Unverzagt S. Motivational interviewing for substance use reduction. Cochrane Database Syst Rev 2023; 12:CD008063. [PMID: 38084817 PMCID: PMC10714668 DOI: 10.1002/14651858.cd008063.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues. OBJECTIVES To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment. SEARCH METHODS We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022. SELECTION CRITERIA We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up). MAIN RESULTS We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision. AUTHORS' CONCLUSIONS Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.
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Affiliation(s)
- Rosemarie Schwenker
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Carla Emilia Dietrich
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Selamawit Hirpa
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies in Germany, Berlin, c/o Philipps University Marburg, Berlin & Marburg, Germany
| | | | - Thomas Frese
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Susanne Unverzagt
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
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Ciraldo K, Seraydarian M, Gasper J, DeFries T, Martin M. Extended-release naltrexone for people with alcohol use disorder on therapeutic anticoagulation: A case series. J Clin Pharm Ther 2022; 47:2393-2396. [PMID: 36511083 DOI: 10.1111/jcpt.13800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/28/2022] [Accepted: 10/12/2022] [Indexed: 12/15/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Individuals with medication adherence challenges or a preference for long-acting medications may benefit from extended-release naltrexone (XR-NTX) for treatment of alcohol use disorder (AUD). Individuals on therapeutic anticoagulation were excluded from XR-NTX studies and its safety in this population has not been reported. CASE SUMMARY We conducted structured retrospective chart review of six individuals who received XR-NTX for AUD while on therapeutic anticoagulation between November 2019 and Deccember 2020. We found no documented complications among six individuals who received up to 11 doses of XR-NTX while on therapeutic anticoagulation. WHAT IS NEW AND CONCLUSION XR-NTX may be safely tolerated by patients on therapeutic anticoagulation. We need larger studies evaluating XR-NTX administration in patients on therapeutic anticoagulation and those with coagulopathies, including individuals with alcohol-related liver disease, to better quantify risks and benefits for shared decision-making.
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Affiliation(s)
- Katrina Ciraldo
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Miami, Miami, Florida, USA.,Department of Family Medicine and Community Health, University of Miami, Miami, Florida, USA
| | | | - James Gasper
- Department of Family and Community Medicine, San Francisco General Hospital, San Francisco, California, USA
| | - Triveni DeFries
- San Francisco General Hospital, San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Marlene Martin
- San Francisco General Hospital, San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Adherence to Prescribed Acamprosate in Alcohol Dependence and 1-Year Morbidities and Mortality: Utilizing a Data Linkage Methodology. J Clin Med 2021; 10:jcm10102102. [PMID: 34068243 PMCID: PMC8153116 DOI: 10.3390/jcm10102102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 01/22/2023] Open
Abstract
Objectives: We tested the hypothesis that poor adherence is associated with a greater risk of alcohol-caused mortality and morbidities within the first year of discontinuing this medication. Materials and Methods: A retrospective cohort study of 3319 individuals who received acamprosate in the East of Scotland in a 10-year period was conducted using a health informatics approach with record linkage of dispensing data, hospital utilization (SMR) and General Register Office of Scotland (GROS) data. The primary outcome was adherence between one to six months after initiating acamprosate medication. The secondary outcome was all-cause morbidities and mortality. Results: Of the total 3319 individuals identified, a good adherence index of >80% was found in 59% of those prescribed acamprosate after three months and 6% after six months. There were significant linear trends of poorer adherence with increased risk of alcohol-caused mortality (Hazard Ratio, HR 1.2), medical morbidities especially neoplasm (HR 4.1) and poisoning (HR 1.4), and psychiatric morbidities especially stress (HR 35.1), psychotic (HR 5.6) and neurotic disorders, and directly alcohol induced conditions (7.4 HR) after adjustment for other factors within a one-year period of initiation of acamprosate treatment. Discussion and Conclusions: Further exploratory studies using this digitalized approach should be encouraged in order to capture role of compliance to acamprosate and other types of medication that are known to reduce relapse into alcohol dependence and its direct relationship to mortality and morbidities in this population.
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Design and conduct of confirmatory chronic pain clinical trials. Pain Rep 2020; 6:e845. [PMID: 33511323 PMCID: PMC7837951 DOI: 10.1097/pr9.0000000000000854] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/07/2020] [Accepted: 08/19/2020] [Indexed: 12/30/2022] Open
Abstract
The purpose of this article is to provide readers with a basis for understanding the emerging science of clinical trials and to provide a set of practical, evidence-based suggestions for designing and executing confirmatory clinical trials in a manner that minimizes measurement error. The most important step in creating a mindset of quality clinical research is to abandon the antiquated concept that clinical trials are a method for capturing data from clinical practice and shifting to a concept of the clinical trial as a measurement system, consisting of an interconnected set of processes, each of which must be in calibration for the trial to generate an accurate and reliable estimate of the efficacy (and safety) of a given treatment. The status quo of inaccurate, unreliable, and protracted clinical trials is unacceptable and unsustainable. This article gathers aspects of study design and conduct under a single broad umbrella of techniques available to improve the accuracy and reliability of confirmatory clinical trials across traditional domain boundaries.
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Muvvala SB, O'Malley SS, Rosenheck R. Multiple Psychiatric Morbidity and Continued Use of Naltrexone for Alcohol Use Disorder. Am J Addict 2020; 30:55-64. [PMID: 32805083 DOI: 10.1111/ajad.13089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/28/2020] [Accepted: 07/28/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite substantial evidence of the efficacy of naltrexone in treating alcohol use disorder (AUD), naltrexone is used infrequently and often for short durations. Understanding factors related to the initiation and continued use of naltrexone could identify targets for improving its use in clinical practice. METHODS We used the Fiscal year 2012 national data from the Veterans Health Administration to identify the proportion of veterans diagnosed with AUD who initiated and then continued to receive naltrexone for AUD over a 6-month period (N = 67,788). We further examined correlates of any use and continued use, and patterns of use in inpatient and outpatient mental health services and psychotropic prescription fills. Comparisons were made using bivariate analyses and multinomial logistic regression. RESULTS Among the veterans diagnosed with AUD, 2.02% initiated treatment with naltrexone. Naltrexone initiation was associated with recent homelessness, concurrent psychiatric disorders, receipt of psychiatric outpatient services, psychotropic prescription fills, residential treatment, and psychiatric and medical-surgical hospitalization. Of the 1,366 patients initiating naltrexone, 43.2% (590) received 2 to 5 prescriptions and 16.3% (223) received more than 5 prescriptions for naltrexone. Use of naltrexone beyond one prescription was associated with homelessness, major depressive disorder, schizophrenia, psychotropic medication use, and psychiatric hospitalization. CONCLUSION Veterans with AUD who used and continued naltrexone were primarily those with multimorbidity and extensive involvement in psychiatric treatment. SCIENTIFIC SIGNIFICANCE Prior studies examined the correlates of initiation of naltrexone but retention in treatment has received less attention. This study identified the frequency and important patient and service correlates of continued use of naltrexone. (Am J Addict 2021;30:55-64).
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Affiliation(s)
| | | | - Robert Rosenheck
- Yale University School of Medicine, New Haven, Connecticut.,VISN1 VA New England Mental Illness Research, Education and Clinical Center.,VA Connecticut Health Care System, West Haven, Connecticut
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Dermody SS, Wardell JD, Stoner SA, Hendershot CS. Predictors of Daily Adherence to Naltrexone for Alcohol Use Disorder Treatment During a Mobile Health Intervention. Ann Behav Med 2019; 52:787-797. [PMID: 30124761 DOI: 10.1093/abm/kax053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Adherence to medications for treating alcohol use disorder (AUD) is poor. To identify predictors of daily naltrexone adherence over time, a secondary data analysis was conducted of a trial evaluating a mobile health intervention to improve adherence. Methods Participants seeking treatment for AUD (n = 58; Mage = 38 years; 71% male) were prescribed naltrexone for 8 weeks. Adherence was tracked using the Medication Event Monitoring System (MEMS). In response to daily text messages, participants reported the previous day's alcohol use, craving, and naltrexone side effects. Using multilevel structural equation modeling (MSEM), we examined baseline dispositional factors and within-person, time-varying factors as predictors of daily adherence. Results Naltrexone adherence decreased over time. Adherence was higher on days when individuals completed daily mobile assessments relative to days when they did not (odds ratio [OR] = 2.53, 95% confidence interval [CI] 1.61 to 3.98), irrespective of intervention condition. Days when individuals drank more than their typical amount were related to lower next-day adherence (OR = 0.93, 95% CI 0.88 to 0.99). A similar pattern was supported for craving (OR = 0.88, 95% CI 0.79 to 0.98). Weekend days were associated with lower adherence than weekdays (OR = 0.71, 95% CI 0.58 to 0.86); this effect was partly mediated by heavier daily drinking (indirect effect = -0.02, 95% CI -0.04 to -0.003) and stronger-than-usual craving (indirect effect = -0.01, 95% CI -0.02 to 0.00) on weekend days. Conclusions The results further demonstrate the need to improve adherence to AUD pharmacotherapy. The present findings also support developing interventions that target daily-level risk factors for nonadherence. Mobile health interventions may be one means of developing tailored and adaptive adherence interventions.
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Affiliation(s)
- Sarah S Dermody
- School of Psychological Science, Oregon State University, Corvallis, USA.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jeffery D Wardell
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Susan A Stoner
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Oldfield BJ, McGinnis KA, Edelman EJ, Williams EC, Gordon AJ, Akgün K, Crystal S, Fiellin LE, Gaither JR, Goulet JL, Korthuis PT, Marshall BDL, Justice AC, Bryant K, Fiellin DA, Kraemer KL. Predictors of initiation of and retention on medications for alcohol use disorder among people living with and without HIV. J Subst Abuse Treat 2019; 109:14-22. [PMID: 31856946 DOI: 10.1016/j.jsat.2019.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status. METHODS From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status. RESULTS Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51-0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61-0.99; for uninfected: AOR 0.70, 95% CI 0.61-0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49-0.1.00; for uninfected: AOR 0.63, 95% CI 0.48-0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention. CONCLUSIONS For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH).
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Affiliation(s)
- Benjamin J Oldfield
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America.
| | - Kathleen A McGinnis
- Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - E Jennifer Edelman
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Emily C Williams
- School of Public Health, University of Washington, Seattle, WA, United States of America; Health Services Research and Development, VA Puget Sound Healthcare Services, Seattle, WA, United States of America
| | - Adam J Gordon
- Department of Medicine, University of Utah, Salt Lake City, UT, United States of America; Department of Medicine, Salt Lake City VA Health Care System, Salt Lake City, UT, United States of America
| | - Kathleen Akgün
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Stephen Crystal
- School of Social Work, Rutgers University, New Brunswick, NJ, United States of America
| | - Lynn E Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America
| | - Joseph L Goulet
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - P Todd Korthuis
- Department of Medicine, Oregon Health Sciences University, Portland, OR, United States of America
| | - Brandon D L Marshall
- School of Public Health, Brown University, Providence, RI, United States of America
| | - Amy C Justice
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States of America
| | - David A Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Kevin L Kraemer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
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Blum K, Han D, Modestino EJ, Saunders S, Roy AK, Jacobs W, Inaba DS, Baron D, Oscar-Berman M, Hauser M, Badgaiyan RD, Smith DE, Femino J, Gold MS. A Systematic, Intensive Statistical Investigation of Data from the Comprehensive Analysis of Reported Drugs (CARD) for Compliance and Illicit Opioid Abstinence in Substance Addiction Treatment with Buprenorphine/naloxone. Subst Use Misuse 2018; 53:220-229. [PMID: 29257919 DOI: 10.1080/10826084.2017.1400064] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Buprenorphine and naloxone (bup/nal), a combination partial mu receptor agonist and low-dose delta mu antagonist, is presently recommended and used to treat opioid-use disorder. However, a literature review revealed a paucity of research involving data from urine drug tests that looked at compliance and abstinence in one sample. METHOD Statistical analysis of data from the Comprehensive Analysis of Reported Drugs (CARD) was used to assess compliance and abstinence during treatment in a large cohort of bup/nal patients attending chemical-dependency programs from eastern USA in 2010 and 2011. RESULTS Part 1: Bup/nal was present in 93.4% of first (n = 1,282; p <.0001) and 92.4% of last (n = 1,268; p <.0001) urine samples. Concomitantly, unreported illicit drugs were present in 47.7% (n = 655, p =.0261) of samples. Patients who were compliant to the bup/nal prescription were more likely than noncompliant patients to be abstinent during treatment (p =.0012; odds ratio = 1.69 with 95% confidence interval (1.210, 2.354). Part 2: An analysis of all samples collected in 2011 revealed a significant improvement in both compliance (p < 2.2 × 10-16) and abstinence (p < 2.2 × 10-16) during treatment. Conclusion/Importance: While significant use of illicit opioids during treatment with bup/nal is present, improvements in abstinence and high compliance during maintenance-assisted therapy programs may ameliorate fears of diversion in comprehensive programs. Expanded clinical datasets, the treatment modality, location, and year of sampling are important covariates, for further studies. The potential for long-term antireward effects from bup/nal use requires consideration in future investigations.
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Affiliation(s)
- Kenneth Blum
- a Department of Psychiatry & McKnight Brain Institute , University of Florida College of Medicine , Gainesville , Florida , USA.,b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA.,c Departments of Psychiatry & Behavioral Sciences , Keck School of Medicine of USC , Los Angeles , California , USA.,d Department of Psychology , Eötvös Loránd University, Institute of Psychology , Budapest , Hungary.,e Human Integrated Services Unit , University of Vermont Centre for Clinical & Translational Science, College of Medicine , Burlington , Vermont , USA.,f Division of Neuroscience Research & Addiction Therapy , Shores Treatment & Recovery Center , Port Saint Lucie , Florida , USA.,g Geneus Health , San Antonio , Texas , USA
| | - David Han
- h Department of Management Science and Statistics , University of Texas at San Antonio , Texas , USA
| | - Edward J Modestino
- i Department of Psychology , Curry College , Milton , Massachusetts , USA
| | - Scott Saunders
- b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA
| | - A Kennison Roy
- j Behavioral Medical Corporation , Metairie , Louisiana , USA
| | - W Jacobs
- k Division of Addiction Medicine , Medical College of Georgia , Augusta , Georgia , USA
| | - Darryl S Inaba
- l Division of Alcohol & Drug Studies , University of Utah , Salt Lake City , Utah , USA
| | - David Baron
- c Departments of Psychiatry & Behavioral Sciences , Keck School of Medicine of USC , Los Angeles , California , USA
| | - Marlene Oscar-Berman
- n Department of Psychiatry, Neurology, Anatomy & Neurobiology , Boston University School of Medicine, & VA Boston Healthcare System , Boston , Massachusetts , USA
| | - Mary Hauser
- b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA
| | - Rajendra D Badgaiyan
- m Department of Psychiatry , Icahn School of Medicine , New York , New York , USA
| | - David E Smith
- p Department of Pharmacology , University of San Francisco , San Francisco , California , USA
| | - John Femino
- b Division of Addiction Services , Dominion Diagnostics, LLC , North Kingstown , Rhode Island , USA
| | - Mark S Gold
- o Department of Psychiatry , Washington University School of Medicine , St. Louis , Missouri , USA
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10
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Zweben A, Piepmeier ME, Fucito L, O'Malley SS. The clinical utility of the Medication Adherence Questionnaire (MAQ) in an alcohol pharmacotherapy trial. J Subst Abuse Treat 2017; 77:72-78. [PMID: 28476276 PMCID: PMC5480370 DOI: 10.1016/j.jsat.2017.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/10/2017] [Accepted: 04/03/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Medication nonadherence is a ubiquitous problem in pharmacology treatment for alcohol use disorders. Unintentional and purposeful nonadherence as measured by the Medication Adherence Questionnaire (MAQ) has been shown to predict problems with medication adherence; however, feedback from the MAQ has never been incorporated into a behavioral intervention to facilitate medication adherence. We assessed the integration of the MAQ into medical management (MM), a counseling approach frequently employed in conjunction with alcohol pharmacotherapy, to determine whether prior patterns of nonadherence could be addressed effectively to promote medication adherence. METHODS We conducted a post-hoc analysis of data from 131 alcohol dependent smokers who participated in a double blind, placebo controlled study of varenicline for the treatment of alcohol dependence. At baseline, participants completed a single administration of the MAQ, which asks 2 questions about unintentional nonadherence (e.g., forgetting) and 2 questions about purposeful nonadherence (e.g., stopping because feeling good or feeling bad). Based on these responses, participants were divided into 1 of 3 three categories. Adherent (n=60), Unintentional or Purposeful Nonadherent (n=50) and Unintentional and Purposeful Nonadherent (n=21). Over the course of the 16-week treatment period, patients were expected to participate in 12 medical management (MM) sessions; a brief psychosocial treatment. Feedback based on the MAQ responses was integrated into the MM sessions to facilitate medication and treatment adherence. RESULTS The 3 adherence groups were compared on baseline characteristics, medication adherence, treatment attendance and end-of-treatment patient ratings of treatment helpfulness. Baseline demographics and characteristics were not significantly different among the three categories. We found no statistically significant differences among the three groups with respect to pill adherence, treatment attendance, and treatment satisfaction ratings. CONCLUSIONS The findings suggest that the incorporation of MAQ feedback into the MM approach could be effective in mitigating risks associated with prior patterns of nonadherence suggesting that further testing of the integrated behavioral approach is warranted.
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Affiliation(s)
- A Zweben
- Columbia University School of Social Work, New York, NY, United States.
| | - M E Piepmeier
- Columbia University School of Social Work, New York, NY, United States
| | - L Fucito
- Yale University School of Medicine, Department of Psychiatry, New Haven, CT, United States
| | - S S O'Malley
- Yale University School of Medicine, Department of Psychiatry, New Haven, CT, United States
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11
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Ramanujam VMS, Nayeem F, Anderson KE, Kuo YF, Chen NW, Ju H, Lu LJW. Riboflavin as an independent and accurate biomarker for adherence in a randomized double-blind and placebo-controlled clinical trial. Biomarkers 2016; 22:508-516. [PMID: 27918196 DOI: 10.1080/1354750x.2016.1269201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medication adherence is critical for success of clinical trials. OBJECTIVE To assess oral riboflavin is an adherence marker. METHODS Riboflavin was incorporated into active treatment and placebo pills for a clinical trial lasting for 2 years. RESULTS The accuracy (area under the receiver operating curve) of urinary riboflavin was 0.91 as a binary classifier of adherence, and was similar or better than for two active study ingredients daidzein (0.92) and genistein (0.87) (all p < 0.0001). Decreased adherence over time was similar in the two study groups. CONCLUSION Riboflavin is an accurate and useful biomarker for study pill ingestion.
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Affiliation(s)
- V-M S Ramanujam
- a Department of Preventive Medicine and Community Health , The University of Texas Medical Branch , Galveston , TX , USA
| | - Fatima Nayeem
- a Department of Preventive Medicine and Community Health , The University of Texas Medical Branch , Galveston , TX , USA
| | - Karl E Anderson
- a Department of Preventive Medicine and Community Health , The University of Texas Medical Branch , Galveston , TX , USA
| | - Yong-Fang Kuo
- a Department of Preventive Medicine and Community Health , The University of Texas Medical Branch , Galveston , TX , USA
| | - Nai-Wei Chen
- a Department of Preventive Medicine and Community Health , The University of Texas Medical Branch , Galveston , TX , USA
| | - Hyunsu Ju
- a Department of Preventive Medicine and Community Health , The University of Texas Medical Branch , Galveston , TX , USA
| | - Lee-Jane W Lu
- a Department of Preventive Medicine and Community Health , The University of Texas Medical Branch , Galveston , TX , USA
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12
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El Alili M, Vrijens B, Demonceau J, Evers SM, Hiligsmann M. A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence. Br J Clin Pharmacol 2016; 82:268-79. [PMID: 27005306 DOI: 10.1111/bcp.12942] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 03/16/2016] [Accepted: 03/17/2016] [Indexed: 12/31/2022] Open
Abstract
Different methods are available for measuring medication adherence. In this paper, we conducted a scoping review to identify and summarize evidence of all studies comparing the Medication Event Monitoring System (MEMS) with alternative methods for measuring medication adherence. A literature search was performed using the open database www.iAdherence.org that includes all original studies reporting findings from the MEMS. Papers comparing methods for measuring adherence to solid oral formulations were included. Data was extracted using a standardized extraction table. A total of 117 articles fulfilled the inclusion criteria, including 251 comparisons. Most frequent comparisons were against self-report (n = 119) and pill count (n = 59). Similar outcome measures were used in 210 comparisons (84%), among which 78 used dichotomous variables (adherent or not) and 132 used continuous measures (adherence expressed as percentage). Furthermore, 32% of all comparisons did not estimate adherence over the same coverage period and 44% of all comparisons did not use a statistical method or used a suboptimal one. Only eighty-seven (35%) comparisons had similar coverage periods, similar outcome measures and optimal statistical methods. Compared to MEMS, median adherence was grossly overestimated by 17% using self-report, by 8% using pill count and by 6% using rating. In conclusion, among all comparisons of MEMS versus alternative methods for measuring adherence, only a few used adequate comparisons in terms of outcome measures, coverage periods and statistical method. Researchers should therefore use stronger methodological frameworks when comparing measurement methods and be aware that non-electronic measures could lead to overestimation of medication adherence.
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Affiliation(s)
- Mohamed El Alili
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Bernard Vrijens
- WestRock Healthcare, Visé, Belgium.,Department of Public Health, University of Liège, Liège, Belgium
| | | | - Silvia M Evers
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Trimbos Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Mickael Hiligsmann
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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13
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Shiovitz TM, Bain EE, McCann DJ, Skolnick P, Laughren T, Hanina A, Burch D. Mitigating the Effects of Nonadherence in Clinical Trials. J Clin Pharmacol 2016; 56:1151-64. [PMID: 26634893 PMCID: PMC5066799 DOI: 10.1002/jcph.689] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 11/27/2015] [Indexed: 11/26/2022]
Abstract
Accounting for subject nonadherence and eliminating inappropriate subjects in clinical trials are critical elements of a successful study. Nonadherence can increase variance, lower study power, and reduce the magnitude of treatment effects. Inappropriate subjects (including those who do not have the illness under study, fail to report exclusionary conditions, falsely report medication adherence, or participate in concurrent trials) confound safety and efficacy signals. This paper, a product of the International Society for CNS Clinical Trial Methodology (ISCTM) Working Group on Nonadherence in Clinical Trials, explores and models nonadherence in clinical trials and puts forth specific recommendations to identify and mitigate its negative effects. These include statistical analyses of nonadherence data, novel protocol design, and the use of biomarkers, subject registries, and/or medication adherence technologies.
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Affiliation(s)
- Thomas M Shiovitz
- California Neuroscience Research Medical Group, Sherman Oaks, CA, USA.,CTSdatabase, LLC, Beverly Hills, CA, USA
| | - Earle E Bain
- Global Pharmaceutical Research and Development, AbbVie, Inc, North Chicago, IL, USA
| | - David J McCann
- Division of Therapeutics and Medical Consequences, NIDA, NIH, Bethesda, MD, USA
| | - Phil Skolnick
- Division of Therapeutics and Medical Consequences, NIDA, NIH, Bethesda, MD, USA
| | - Thomas Laughren
- Director of Regulatory Affairs, Massachusetts General Hospital Clinical Trial Network and Institute, Boston, MA, USA
| | | | - Daniel Burch
- Pharmaceutical Product Development, LLC, Wilmington, NC, USA
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14
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Witkiewitz K, Finney JW, Harris AH, Kivlahan DR, Kranzler HR. Recommendations for the Design and Analysis of Treatment Trials for Alcohol Use Disorders. Alcohol Clin Exp Res 2015; 39:1557-70. [PMID: 26250333 PMCID: PMC4558228 DOI: 10.1111/acer.12800] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/30/2015] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology and Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico
| | - John W. Finney
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
| | - Alex H.S Harris
- VA Substance Use Disorder Quality Enhancement Research Initiative, VA Palo Alto Health Care System, Menlo Park, CA
| | - Daniel R. Kivlahan
- Veterans Health Administration, Washington, DC and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Henry R. Kranzler
- Center for Studies of Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine and VISN4 MIRECC, Philadelphia VAMC, Philadelphia, PA
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15
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Witkiewitz K, Finney JW, Harris AHS, Kivlahan DR, Kranzler HR. Guidelines for the Reporting of Treatment Trials for Alcohol Use Disorders. Alcohol Clin Exp Res 2015; 39:1571-81. [PMID: 26259958 DOI: 10.1111/acer.12797] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/27/2015] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico.,Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, Albuquerque, New Mexico
| | - John W Finney
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,VA Substance Use Disorder Quality Enhancement Research Initiative, VA Palo Alto Health Care System, Menlo Park, California
| | - Daniel R Kivlahan
- Veterans Health Administration, Washington, District of Columbia.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Henry R Kranzler
- Center for Studies of Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,VISN4 MIRECC, Philadelphia VAMC, Philadelphia, Pennsylvania
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16
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McRae-Clark AL, Baker NL, Sonne SC, DeVane CL, Wagner A, Norton J. Concordance of Direct and Indirect Measures of Medication Adherence in A Treatment Trial for Cannabis Dependence. J Subst Abuse Treat 2015; 57:70-4. [PMID: 26028133 DOI: 10.1016/j.jsat.2015.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/29/2015] [Accepted: 05/03/2015] [Indexed: 10/23/2022]
Abstract
The current study compared adherence rates as measured by two indirect measurement methods (pill count and daily medication diary) to two direct measurement methods (urine riboflavin and serum 6-OH-buspirone level measurement) among participants (n = 109) in a medication treatment trial for cannabis dependence. Pill count and diary data showed high levels of percent agreement and strong kappa coefficients throughout the study. Riboflavin levels indicated lower level of percent in adherence during the study as compared to both pill count and self-report. In the subset of participants with 6-OH-buspirone levels (n = 58), the kappa coefficient also showed low to moderate agreement between the pill count and medication diaries with 6-OH-buspirone levels. In contrast to pill count and medication diaries, adherence as measured by riboflavin and 6-OH-buspirone significantly decreased over time. The findings from this study support previous work demonstrating that pill count and patient self-report of medication taking likely overestimate rates of medication adherence, and may become less reliable as the duration of a clinical trial increases.
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Affiliation(s)
- Aimee L McRae-Clark
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29425.
| | - Nathaniel L Baker
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425
| | - Susan C Sonne
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29425
| | - C Lindsay DeVane
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29425
| | - Amanda Wagner
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29425
| | - Jessica Norton
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29425
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17
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Stoner SA, Arenella PB, Hendershot CS. Randomized controlled trial of a mobile phone intervention for improving adherence to naltrexone for alcohol use disorders. PLoS One 2015; 10:e0124613. [PMID: 25909320 PMCID: PMC4409303 DOI: 10.1371/journal.pone.0124613] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 02/28/2015] [Indexed: 11/18/2022] Open
Abstract
Background Naltrexone is a front-line treatment for alcohol use disorders, but its efficacy is limited by poor medication adherence. This randomized controlled trial evaluated whether a mobile health intervention could improve naltrexone adherence. Methods Treatment-seeking participants with an alcohol use disorder (N = 76) were randomized to intervention and control conditions. All participants received naltrexone (50 mg/day) with a medication event monitoring system (MEMS) and a prepaid smartphone, and received a daily text message querying medication side effects, alcohol use, and craving. Those in the intervention arm received additional medication reminders and adherence assessment via text message. Results The primary outcome, proportion of participants with adequate adherence (defined as ≥80% of prescribed doses taken through Week 8), did not differ between groups in intent-to-treat analyses (p = .34). Mean adherence at study midpoint (Week 4) was 83% in the intervention condition and 77% in the control condition (p = .35). Survival analysis found that the intervention group sustained adequate adherence significantly longer (M = 19 days [95% CI = 0.0–44.0]) than those in the control group (M = 3 days [95% CI = 0.0–8.1]) during the first month of treatment (p = .04). Medication adherence did not predict drinking outcomes. Conclusions These results suggest that in the context of daily monitoring and assessment via cell phone, additional text message reminders do not further improve medication adherence. Although this initial trial does not provide support for the efficacy of text messaging to improve adherence to pharmacotherapy for alcohol use disorders, additional trials with larger samples and alternate designs are warranted. Trial Registration ClinicalTrials.gov: NCT01349985
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Affiliation(s)
- Susan A. Stoner
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Pamela B. Arenella
- Department of Psychiatry, University of New Mexico, Albuquerque, New Mexico, United States of America
| | - Christian S. Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
- The Mind Research Network and Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, United States of America
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18
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Development of an Instrument to Characterize Methodological and Collaborative Factors that May Influence Community-Based Clinician Post-Trial Adoption of Clinical Research Interventions. Int J Ment Health Addict 2014. [DOI: 10.1007/s11469-014-9474-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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19
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Hulse GK. Improving clinical outcomes for naltrexone as a management of problem alcohol use. Br J Clin Pharmacol 2013; 76:632-41. [PMID: 22946873 PMCID: PMC3853523 DOI: 10.1111/j.1365-2125.2012.04452.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/30/2012] [Indexed: 12/13/2022] Open
Abstract
Despite being a relatively effective and safe treatment, the clinical management of alcohol abuse/dependence by oral naltrexone can be compromised due to the patient's non-compliance with daily use of this medication. Over the past decade an increasing body of research has suggested that the use of sustained release depot naltrexone preparations can overcome this issue and deliver improved clinical outcomes. However, at the same time, research findings from diverse areas of pharmacogenetics, neurobiology and behavioural psychology have also been converging to identify variables including genetic markers, patient psychosocial characteristics and drug use history differences, or clusters of these variables that play a major role in mediating the response of alcohol abuse/dependent persons to treatment by naltrexone. While this article does not attempt to review all available data pertaining to an individual alcohol dependent patient's response to treatment by naltrexone, it does identify relevant research areas and highlights the importance of data arising from them. The characterization of clinical markers, to identify those patients who are most likely to benefit from naltrexone and to tailor a more individual naltrexone treatment, will ultimately provide significant benefit to both patients and clinicians by optimizing treatment outcome.
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Affiliation(s)
- Gary K Hulse
- Addiction Medicine, School of Psychiatry & Clinical Neurosciences (M521), The University of Western Australia, Crawley, WA, Australia
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20
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Thomas CP, Garnick DW, Horgan CM, Miller K, Harris AHS, Rosen MM. Establishing the feasibility of measuring performance in use of addiction pharmacotherapy. J Subst Abuse Treat 2013; 45:11-8. [PMID: 23490233 PMCID: PMC3954716 DOI: 10.1016/j.jsat.2013.01.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 11/17/2012] [Accepted: 01/22/2013] [Indexed: 11/19/2022]
Abstract
This paper presents the rationale and feasibility of standardized performance measures for use of pharmacotherapy in the treatment of substance use disorders (SUD), an evidence-based practice and critical component of treatment that is often underused. These measures have been developed and specified by the Washington Circle, to measure treatment of alcohol and opioid dependence with FDA-approved prescription medications for use in office-based general health and addiction specialty care. Measures were pilot tested in private health plans, the Veterans Health Administration (VHA), and Medicaid. Testing revealed that use of standardized measures using administrative data for overall use and initiation of SUD pharmacotherapy is feasible and practical. Prevalence of diagnoses and use of pharmacotherapy vary widely across health systems. Pharmacotherapy is generally used in a limited portion of those for whom it might be indicated. An important methodological point is that results are sensitive to specifications, so that standardization is critical to measuring performance across systems.
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Affiliation(s)
- Cindy Parks Thomas
- Schneider Institutes for Health Policy, Brandeis University, Waltham, MA 02454, USA.
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21
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Stoner SA, Hendershot CS. A randomized trial evaluating an mHealth system to monitor and enhance adherence to pharmacotherapy for alcohol use disorders. Addict Sci Clin Pract 2012. [PMID: 23186301 PMCID: PMC3507635 DOI: 10.1186/1940-0640-7-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nonadherence to prescribed medication regimens is a substantial barrier to the pharmacological management of alcohol use disorders. The availability of low-cost, sustainable interventions that maximize medication adherence would likely lead to improved treatment outcomes. Mobile health (mHealth) technologies are increasingly being adopted as a method of delivering behavioral health interventions and represent a promising tool for adherence interventions. We are evaluating a cell-phone-based intervention called AGATE that seeks to enhance adherence with regular text-messaging. METHODS/DESIGN A randomized controlled effectiveness trial in the context of an eight-week open label naltrexone efficacy trial delivered in a naturalistic clinical setting. Treatment-seeking heavy drinkers (N = 105) are currently being recruited and randomly assigned to the AGATE intervention or a control condition. Daily measures of alcohol use and medication side effects are being recorded via cell phone in both conditions. Additionally, participants randomized to the AGATE condition receive medication reminders via SMS text message according to a schedule that adjusts according to their level of adherence. DISCUSSION Results from this trial will provide initial information about the feasibility and efficacy of mHealth interventions for improving adherence to alcohol pharmacotherapies. TRIAL REGISTRATION NCT01349985.
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22
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Czobor P, Skolnick P. The secrets of a successful clinical trial: compliance, compliance, and compliance. Mol Interv 2011; 11:107-10. [PMID: 21540470 DOI: 10.1124/mi.11.2.8] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Pál Czobor
- Semmelweis University, Department of Psychiatry and Psychotherapy, Budapest, Hungary.
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23
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Abraham AJ, Knudsen HK, Roman PM. A longitudinal examination of alcohol pharmacotherapy adoption in substance use disorder treatment programs: patterns of sustainability and discontinuation. J Stud Alcohol Drugs 2011; 72:669-77. [PMID: 21683049 PMCID: PMC3125890 DOI: 10.15288/jsad.2011.72.669] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The objectives of this study were to (a) identify the patterns of disulfiram (Antabuse) and tablet naltrexone (Revia) adoption over a 48-month period in a nationally representative sample of privately funded programs that deliver substance use disorder treatment; (b) examine predictors of sustainability, later adoption, discontinuation, and nonadoption of disulfiram and tablet naltrexone; and (c) measure reasons for medication discontinuation. METHOD Two waves of data were collected via face-to-face structured interviews with 223 program administrators. RESULTS These data demonstrated that adoption of medications for alcohol use disorders (AUDs) was a dynamic process. Although nonadoption was the most common pattern, approximately 20% of programs sustained use of the AUD medications and 30% experienced organizational change in adoption over the study period. Bivariate multinomial logistic regression models revealed that organizational characteristics were associated with sustainability including location in a hospital setting, program size, accreditation, revenues from private insurance, referrals from the criminal justice system, number of medical staff, and use of selective serotonin reuptake inhibitors at baseline. Two patterns of discontinuation were found: Programs either discontinued use of all substance use disorder medications or replaced disulfiram/tablet naltrexone with a newer AUD medication. CONCLUSIONS These findings suggest that adoption of AUD medications may be positively affected by pressure from accreditation bodies, partnering with primary care physicians, medication-specific training for medical staff, greater availability of resources to cover the costs associated with prescribing AUD medications, and amending criminal justice contracts to include support for AUD medication use.
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Affiliation(s)
- Amanda J. Abraham
- Correspondence may be sent to Amanda J. Abraham at the above address or via email at: . Amanda J. Abraham and Paul M. Roman are also with the Department of Sociology, University of Georgia, Athens, GA. Hannah K. Knudsen is with the Department of Behavioral Science and Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY
| | - Hannah K. Knudsen
- Correspondence may be sent to Amanda J. Abraham at the above address or via email at: . Amanda J. Abraham and Paul M. Roman are also with the Department of Sociology, University of Georgia, Athens, GA. Hannah K. Knudsen is with the Department of Behavioral Science and Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY
| | - Paul M. Roman
- Correspondence may be sent to Amanda J. Abraham at the above address or via email at: . Amanda J. Abraham and Paul M. Roman are also with the Department of Sociology, University of Georgia, Athens, GA. Hannah K. Knudsen is with the Department of Behavioral Science and Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY
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24
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Abraham AJ, Rieckmann T, McNulty T, Kovas AE, Roman PM. Counselor attitudes toward the use of naltrexone in substance abuse treatment: a multi-level modeling approach. Addict Behav 2011; 36:576-583. [PMID: 21382667 DOI: 10.1016/j.addbeh.2011.01.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Accepted: 01/20/2011] [Indexed: 11/17/2022]
Abstract
Alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs). Despite evidence of clinical effectiveness, adoption of medications for the treatment of AUDs is suboptimal. Low rates of AUD medication adoption have been explained by characteristics of both treatment organizations and individual counselor's attitudes and behaviors. However, few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program, 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.
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Affiliation(s)
- Amanda J Abraham
- Institute for Behavioral Research, Center for Research on Behavioral Health and Human Services Delivery, University of Georgia, 112 Barrow Hall, Athens, GA 30602, USA; Department of Sociology, University of Georgia, Athens, GA 30602, USA.
| | - Traci Rieckmann
- Department of Public Health and Preventative Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Thomas McNulty
- Department of Sociology, University of Georgia, Athens, GA 30602, USA
| | - Anne E Kovas
- Department of Public Health and Preventative Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Paul M Roman
- Institute for Behavioral Research, Center for Research on Behavioral Health and Human Services Delivery, University of Georgia, 112 Barrow Hall, Athens, GA 30602, USA; Department of Sociology, University of Georgia, Athens, GA 30602, USA
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Foa EB, Williams MT. Methodology of a randomized double-blind clinical trial for comorbid posttraumatic stress disorder and alcohol dependence. ACTA ACUST UNITED AC 2010; 3:131-147. [PMID: 22942892 DOI: 10.1080/17523281003738661] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION: Alcohol dependence (AD) and posttraumatic stress disorder (PTSD) are each associated with profound disruptions in psychological, social, and physical functioning, and these disruptions are compounded in individuals with both disorders. Comorbidity between the two disorders is high, with the risk for AD increasing substantially among individuals with PTSD and, conversely, PTSD is highly prevalent among people experiencing AD. AIMS: Given the increased impairment associated with this comorbidity, it is imperative to develop effective treatments for individuals who experience both disorders. METHODS: This paper describes the methodology of a study that examines the efficacy of prolonged exposure therapy alone, naltrexone alone, and their combination compared to pill placebo in reducing the severity of PTSD and alcohol use in individuals with comorbid AD and PTSD. DISCUSSION: Issues related to design, assessment, treatment choice, and challenges posed by the study population are discussed.
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Affiliation(s)
- Edna B Foa
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, USA
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Gueorguieva R, Wu R, Donovan D, Rounsaville BJ, Couper D, Krystal JH, O’Malley SS. Naltrexone and combined behavioral intervention effects on trajectories of drinking in the COMBINE study. Drug Alcohol Depend 2010; 107:221-9. [PMID: 19969427 PMCID: PMC2821955 DOI: 10.1016/j.drugalcdep.2009.10.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 10/28/2009] [Accepted: 10/28/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE COMBINE is the largest study of pharmacotherapy for alcoholism in the United States to date, designed to answer questions about the benefits of combining behavioral and pharmacological interventions. Trajectory-based analyses of daily drinking data allowed identification of distinct drinking trajectories in smaller studies and demonstrated significant naltrexone effects even when primary analyses on summary drinking measures were unsuccessful. The objective of this study was to replicate and refine trajectory estimation and to assess effects of naltrexone, acamprosate and therapy on the probabilities of following particular trajectories in COMBINE. It was hypothesized that different treatments may affect different trajectories of drinking. METHODS We conducted exploratory analyses of daily indicators of any drinking and heavy drinking using a trajectory-based approach and assessed trajectory membership probabilities and odds ratios for treatment effects. RESULTS We replicated the trajectories ("abstainer", "sporadic drinker", "consistent drinker") established previously in smaller studies. However, greater numbers of trajectories better described the heterogeneity of drinking over time. Naltrexone reduced the chance to follow a "nearly daily" trajectory and Combined Behavioral Intervention (CBI) reduced the chance to be in an "increasing to nearly daily" trajectory of any drinking. The combination of naltrexone and CBI increased the probability of membership in a trajectory in which the frequency of any drinking declined over time. Trajectory membership was associated with different patterns of treatment compliance. CONCLUSION The trajectory-analyses identified specific patterns of drinking that were differentially influenced by each treatment and provided support for hypotheses about the mechanisms by which these treatments work.
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Affiliation(s)
- Ralitza Gueorguieva
- Yale University School of Public Health and School of Medicine, New Haven, CT 06520, USA.
| | - Ran Wu
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Dennis Donovan
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA 98105, USA
| | - Bruce J. Rounsaville
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
| | - David Couper
- Department of Biostatistics, The University of North Carolina at Chapel Hill, NC 27514, USA
| | - John H. Krystal
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA,VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Stephanie S. O’Malley
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
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Heffner JL, Tran GQ, Johnson CS, Barrett SW, Blom TJ, Thompson RD, Anthenelli RM. Combining motivational interviewing with compliance enhancement therapy (MI-CET): development and preliminary evaluation of a new, manual-guided psychosocial adjunct to alcohol-dependence pharmacotherapy. J Stud Alcohol Drugs 2010; 71:61-70. [PMID: 20105415 PMCID: PMC2815064 DOI: 10.15288/jsad.2010.71.61] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 06/26/2009] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Psychosocial interventions that are practical, transportable, and effective in promoting treatment adherence and efficacy are greatly needed in both research and clinical settings involving alcohol-dependence pharmacotherapy. In this article, we describe the development and preliminary evaluation of an integrative treatment blending motivational interviewing and compliance enhancement therapy (MI-CET) as a means of enhancing adherence and retention in an ongoing clinical trial. METHOD Medication adherence, session attendance, and study completion rates were examined for 121 treatment-seeking, alcohol-dependent adults participating in a randomized clinical trial of citalopram (n = 81) versus placebo (n = 40). All participants received the manual-guided MI-CET intervention as an adjunct to pharmacotherapy. Preliminary adherence and retention data for this trial were compared with data from prior studies involving treatment for alcohol dependence with a selective serotonin reuptake inhibitor. RESULTS High rates of medication adherence (79% of citalopram and 91% of placebo completers took > or = 80% of doses), session attendance (average of 90% for citalopram and 93% for placebo groups), and study completion (81% for citalopram and 88% for placebo groups) were obtained in the present study using MI-CET. These rates were at least comparable to or were, in some cases, 20%-30% higher than rates obtained in the comparison trials. CONCLUSIONS These results suggest that MI-CET is feasible as a psychosocial adjunct to alcohol-dependence pharmacotherapy. Given its strengths as a clinical and research intervention (e.g., practicality, transportability), further evaluation of its efficacy is warranted.
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Affiliation(s)
- Jaimee L. Heffner
- Tri-State Tobacco and Alcohol Research Center, Department of Psychiatry, University of Cincinnati College of Medicine, UC Reading Campus, 2120 E. Galbraith Road, Building A, Cincinnati, Ohio 45237
| | | | | | - Suzan Winders Barrett
- Tri-State Tobacco and Alcohol Research Center, Department of Psychiatry, University of Cincinnati College of Medicine, UC Reading Campus, 2120 E. Galbraith Road, Building A, Cincinnati, Ohio 45237
| | | | | | - Robert M. Anthenelli
- Tri-State Tobacco and Alcohol Research Center, Department of Psychiatry, University of Cincinnati College of Medicine, UC Reading Campus, 2120 E. Galbraith Road, Building A, Cincinnati, Ohio 45237
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Acamprosate and naltrexone treatment effects on ethanol and sucrose seeking and intake in ethanol-dependent and nondependent rats. Psychopharmacology (Berl) 2009; 204:335-48. [PMID: 19153715 PMCID: PMC2864152 DOI: 10.1007/s00213-009-1465-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 01/05/2009] [Indexed: 10/21/2022]
Abstract
RATIONALE Two pharmacotherapies are approved for treating alcohol craving (acamprosate and naltrexone), but both have shown mixed findings in animals and humans. OBJECTIVES The present experiments utilized a "reinforcer blocking" approach (i.e., rats were able to consume ethanol during treatment) to better understand the efficacy of these treatments for ethanol seeking and drinking using ethanol-dependent and nondependent rats. MATERIALS AND METHODS In "nondependent" experiments, drugs (acamprosate 50, 100, and 200 mg/kg; naltrexone 0.1, 0.3, and 1.0 mg/kg) were administered over 3-week periods prior to operant sessions with a low response requirement to gain access to reinforcers for 20 min. For "dependent" experiments, rats were made dependent in vapor/inhalation chambers. RESULTS Acamprosate and naltrexone had similar effects on intake in nondependent and dependent rats; neither drug was selective for ethanol over sucrose drinking. In nondependent animals, naltrexone was more efficacious at more doses than acamprosate, and acamprosate's effects were limited to a dose that also had adverse effects on body weight. Both pharmacotherapies showed more selectivity when examining reinforcer seeking. In nondependent rats, acamprosate and naltrexone had response-attenuating effects in ethanol, but not sucrose, groups. In dependent animals, acamprosate had selective effects limited to a decrease in sucrose seeking. Naltrexone, however, selectively decreased ethanol-seeking in nondependent rats. CONCLUSIONS The naltrexone-induced decreases in seeking suggested a change in incentive motivation which was selective for ethanol in nondependent rats. The "nondependent" paradigm may model early stages of "problem drinking" in humans, and the findings suggest that naltrexone could be a good intervention for this level of alcohol abuse and relapse prevention.
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Pettinati HM, Gastfriend DR, Dong Q, Kranzler HR, O'Malley SS. Effect of extended-release naltrexone (XR-NTX) on quality of life in alcohol-dependent patients. Alcohol Clin Exp Res 2008; 33:350-6. [PMID: 19053979 DOI: 10.1111/j.1530-0277.2008.00843.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX) is a once-a-month injectable formulation for the treatment of alcohol dependence previously shown to reduce drinking and heavy drinking relative to placebo (Garbutt et al., 2005). A 24-week, randomized, double-blind, placebo-controlled study established the efficacy and safety of XR-NTX in this patient population. In this report, the effect of XR-NTX on quality of life (QOL) was examined. METHODS Alcohol-dependent patients were randomly assigned to receive XR-NTX 380 mg (N = 205), XR-NTX 190 mg (N = 210), or placebo (N = 209), combined with a standardized psychosocial intervention. QOL was assessed using the Medical Outcomes Study 36-item short-form health survey, administered at baseline and at 4-week intervals during 24 weeks of treatment. RESULTS Compared with U.S. population norms, patients showed initial impairment in the health-related QOL domains of mental health, social functioning, and problems with work or other daily activities due to emotional problems. Adherence to all 6 injections was 65% for XR-NTX 190 mg, 63% for XR-NTX 380 mg, and 64% for placebo. Generalized estimating equations analyses using an intention-to-treat sample revealed that XR-NTX 380 mg was associated with significantly greater improvements from baseline in mental health (p = 0.0496), social functioning (p = 0.010), general health (p = 0.048), and physical functioning (p = 0.028), compared with placebo. Linear regression analyses revealed that reductions from baseline in drinking (percentage of drinking days and percentage of heavy drinking days in the last 30 days) were significantly (p < 0.05) correlated with improvements in quality of life. CONCLUSION Extended-release naltrexone 380 mg in combination with psychosocial intervention was associated with improvements in QOL, specifically in the domains of mental health, social functioning, general health, and physical functioning.
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Affiliation(s)
- Helen M Pettinati
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Kranzler HR, Stephenson JJ, Montejano L, Wang S, Gastfriend DR. Persistence with oral naltrexone for alcohol treatment: implications for health-care utilization. Addiction 2008; 103:1801-8. [PMID: 19032530 PMCID: PMC2652482 DOI: 10.1111/j.1360-0443.2008.02345.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Concerns have been raised about patients' failure to persist in alcohol treatment. We examined prescriptions for oral naltrexone in a large, nationally distributed treatment population to identify characteristics and health-care utilization patterns associated with persistence. DESIGN Data from the 2000-2004 MarketScan Commercial Claims and Encounters Database were used to identify patients with alcohol-related claims who were prescribed naltrexone. MEASUREMENTS Analysis identified patient characteristics that predicted persistence with naltrexone (defined as having filled prescriptions for >or=80% of the 6-month treatment period) and its association to health-care utilization. FINDINGS Of 1138 patients, 162 (14.2%) were persistent in obtaining naltrexone. Non-persistent patients were significantly younger, more likely to be hourly employees and to live in an area with a lower median income, and less likely to be newly diagnosed with an alcohol-related disorder. Non-persistence in obtaining naltrexone was associated with significantly more intensive treatments, including inpatient detoxification, emergency room visits and hospitalizations. CONCLUSIONS Over a 6-month period, 85.8% of patients who filled an initial prescription for naltrexone did not persist in obtaining the medication. Non-persistence was associated with significantly greater use of costly health-care services. Because the study was correlational, it is not possible to conclude that persistence reduced health-care costs, as patients with a better prognosis may have been more persistent. Research is needed to determine whether interventions that enhance persistence with naltrexone therapy improve treatment outcomes and reduce health-care costs.
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Affiliation(s)
- Henry R. Kranzler
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT 06030,To whom correspondence should be addressed at: Department of Psychiatry, University of Connecticut Health Center, Farmington, CT 06030-2103; telephone: 860-679-4151; fax: 860-679-1316;
| | | | | | - Shaohung Wang
- Outcomes Research, Thomson Healthcare, Ann Arbor, MI 48108
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Zweben A, Pettinati HM, Weiss RD, Youngblood M, Cox CE, Mattson ME, Gorroochurn P, Ciraulo D. Relationship between medication adherence and treatment outcomes: the COMBINE study. Alcohol Clin Exp Res 2008; 32:1661-9. [PMID: 18616687 DOI: 10.1111/j.1530-0277.2008.00743.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Within the alcoholism field, there is mounting evidence supporting an important relationship between medication adherence and drinking outcomes. Little is known however, about the complex relationships between medication and treatment variables and drinking outcomes. The present paper reports on the differential impact of medication adherence and treatment factors on drinking outcomes. Data derived from the COMBINE Study was used to investigate the interrelationships between medication adherence, combination treatments and drinking outcomes. METHODS Twelve hundred and twenty-six patients were randomized to 1 of 8 different combination treatments involving 2 medications--naltrexone and acamprosate and placebo, and 2 behavioral treatments--medical management (MM) and combined behavioral intervention (CBI). Two primary drinking outcomes were percent days abstinent (PDA) and time to first heavy drinking day. Medication adherence was defined as a proportion that reflects the number of pills taken by the maximum number of pills expected to be taken over the course of the trial. A generalized linear mixed model was used to estimate the effects of adherence on PDA while proportional hazards model was used to examine similar co-variate effects on time to first heavy drinking day. RESULTS Concerning time to first heavy drinking day, a significant three-way interaction was found between medication adherence, CBI and naltrexone (p = 0.0160). Within the MM only plus placebo group (no CBI), significant differences were found in "recovery" (i.e., no heavy drinking days) rates between adherers and nonadherers (40% vs. 10%, p < 0.0001). Such differences became nonsignificant (p = 0.12) when CBI was introduced into the relationship. CBI did not add any such advantage to naltrexone-treated patients. CONCLUSIONS CBI might serve a protective function for nonadherers in the placebo group; the median relapse time was reduced when these nonadherers were exposed to the alcohol specialty intervention. CBI offered little additional benefit to nonadherers in the naltrexone group. Among nonadherers in the naltrexone group, relapse rates appear to be more a function of inadequate exposure to the active medication and less influenced by CBI.
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Affiliation(s)
- Allen Zweben
- Columbia University School of Social Work, New York, New York, USA.
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Baros AM, Latham PK, Anton RF. Naltrexone and cognitive behavioral therapy for the treatment of alcohol dependence: do sex differences exist? Alcohol Clin Exp Res 2008; 32:771-6. [PMID: 18336635 DOI: 10.1111/j.1530-0277.2008.00633.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sex differences in regards to pharmacotherapy for alcoholism is a topic of concern following publications suggesting naltrexone, one of the longest approved treatments of alcoholism, is not as effective in women as in men. This study was conducted by combining 2 randomized placebo controlled clinical trials utilizing similar methodologies and personnel in which the data was amalgamated to evaluate sex effects in a reasonable sized sample. METHODS A total of 211 alcoholics (57 female and 154 male) were randomized to the naltrexone/cognitive behavorial thearpy (CBT) or placebo/CBT arm of the 2 clinical trials analyzed. Baseline variables were examined for differences between sex and treatment groups via ANOVA for continuous variable or chi-squared test for categorical variables. All initial outcome analysis was conducted under an intent-to-treat analysis plan. Effect sizes for naltrexone over placebo were determined by Cohen's D (d). RESULTS The effect size of naltrexone over placebo for the following outcome variables was similar in men and women [% days abstinent (PDA) d = 0.36, % heavy drinking days (PHDD) d = 0.36, and total standard drinks (TSD) d = 0.36]. Only for men were the differences significant secondary to the larger sample size (PDA p = 0.03; PHDD p = 0.03; TSD p = 0.04). There were a few variables (GGT at week-12 change from baseline to week-12: men d = 0.36, p = 0.05; women d = 0.20, p = 0.45 and drinks per drinking day: men d = 0.36, p = 0.05; women d = 0.28, p = 0.34) where the naltrexone effect size for men was greater than women. In women, naltrexone tended to increase continuous abstinent days before a first drink (women d = 0.46, p = 0.09 and men d = 0.00, p = 0.44). CONCLUSIONS The effect size of naltrexone over placebo appeared similar in women and men in our hands suggesting the findings of sex differences in naltrexone response might have to do with sample size and/or endpoint drinking variables rather than any inherent pharmacological or biological differences in response.
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Affiliation(s)
- A M Baros
- Charleston Alcohol Research Center, MUSC, Charleston, South Carolina 29425, USA.
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