Transcript Open slides - CTN Dissemination Library

CTN MIEDAR Studies
Baseline Comparison:
Methadone vs Psychosocial Participants
Maxine Stitzer, Ph.D.
AAAP December, 2003
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Background
Rationale & hypotheses
Findings
Conclusions
Drugs are Positive
Reinforcers
They Make People
Feel Good.
The Problem: Allure of
Immediate Drug Reinforcement
Drug Abusers Straddle the Fence
Methods are needed to:
Continued
Drug Use
Drug
Abstinence
- counteract ambivalence
- increase motivation for change
Motivational Incentives
Offer tangible incentives
for drug abstinence
Make abstinence a more
attractive option through
positive reinforcement of
behavior change
Incentive Therapies Promote Abstinence
Cocaine
(Higgins et al., 1994; Silverman et al., 1996; Petry & Martin, 2002)
Alcohol
(Petry et al., 2000)
Opioids
(Bickel et al., 1997; Silverman et al., 1996)
Marijuana
(Budney et al., 1991, Budney et al., 2000)
Nicotine (Tobacco smoking)
(Stitzer & Bigelow, 1984; Roll et al., 1996)
Problem: Cost
• Society can’t afford this
• Our program can’t afford this
Intermittent Reward Reduces Cost
Nancy Petry’s “Fishbowl”
• Drug-free patient draws from the “fishbowl”
• Only 50% of draws are “winners”
• Three types of prizes:
- small (toiletries; food)
- large (cordless phone; CD player)
- jumbo (TV; video)
CTN MIEDAR Protocol:
How Does It Work?
Eligible Patients
Stimulant Abusers
either cocaine or methamphetamine
Random Assignment
• Usual care
• Enhanced care
with incentives
Sample Collection
Twice Weekly
Abstinence Bowl
Good
Job
Small
Small
Large
Small
Good
Job
Good
Job
Good
Job
Good
Job
Good
Job
Good
Job
Small
Good
Job
Examples of
Incentive Prizes
SMALL
($1-$5 items)
LARGE
($20 items)
JUMBO
($80-$100 items)
Draws Escalate with
Stimulant-Free Test Results
5
4
3
2
1
Weeks Drug Free
# Draws
Bonus Draws for Marijuana
and/or Opiate Abstinence
2
2
2
2
Weeks Drug Free
2
# Draws
Total Earnings
• $400 in prizes could be earned on average
– If participant tested negative for all targeted
drugs over 12 consecutive weeks
Two MIEDAR Study Samples
• Psychosocial (8 clinics; N = 415)
– New admissions
– Self-reported stimulant use within past 2 weeks
(74%) or within 2 weeks of entering a controlled
environment (23%)
• Methadone (6 clinics; N = 388)
– In treatment 1-36 months
– Stimulant positive urine within past 2 weeks
Baseline Comparison:
Why Do IT?
• Unique opportunity to characterize stimulant
abusers entering different modalities
• Results may suggest differential service needs
Baseline Comparison: Methods
• Data derived from selected questions in study
intake interview
• Areas of interest:
– Demographics
– Psychosocial characteristics (employment,
education, etc)
– Health problems(medical & psychiatric)
– Drug use (stimulants, opiates, alcohol, cannabis)
Hypotheses
• Some patient characteristics may differ due to
differential referral patterns (e.g. criminal justice)
• Methadone patients will generally have more severe
psychosocial and drug use problems due to their
history of concurrent opiate and stimulant abuse
Basic Demographics
METH
(N = 388)
PSOC
(N = 415)
P value
Gender (% male)
56
45
<.01
Race (% Caucasian)
26
36
<.01
Age (mean years)
42
36
<.01
Subsequent analyses adjusted for gender, race & age
Psychosocial Characteristics
METH
PSOC
P value
Education (mean years)
Marital Status (% married)
12
14
12
24
0.42
<.01
Employed- past 3 years (%)
Employed- past 30 days (%)
50
32
68
35
<.01
0.74
Legal Status
METH PSOC
OR†
CJ referral (%)
6
33
0.1
Parole/Probation (%)
16
35
0.3
† OR is methadone vs drug-free
Health Problems
METH
PSOC
OR
Chronic med probs (%)
Lifetime hospital (%)
59
80
38
67
1.8
1.8
Psychiatric hospital (%)
Psychiatric outpatient (%)
29
37
29
35
Lifetime psych meds(%)
42
40
Drug Use: Stimulants
PSOC
OR
82
84
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76
26
7.8
METH
Dependence/Abuse
(% with diagnosis)
First Study Urine
(% positive)
Drug Use: Opiates
METH
PSOC
OR
Dependence/Abuse
(% with diagnosis)
80
9
48
First Study Urine
(% positive)
47
3
30
Drug Use: Alcohol
Dependence/Abuse
(% with diagnosis)
METH
PSOC
OR
17
42
0.3
1
1
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First Study BAL
(% positive)
Drug Use: Cannabis
Dependence/Abuse
(% with diagnosis)
First Study Urine
(% positive)
METH
PSOC
OR
8
21
0.5
12
11
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Drug Use: Other
ASI past 30 days; % with any use
SEDATIVES
NICOTINE
METH
PSOC
METH
PSOC
25
6
91
79
Data Summary
• Stimulant abusers entering methadone are:
– Older
– Less likely to have work history
– More likely to have medical problems
– More likely to be using opiates, stimulants &
sedatives
– Less likely to be alcohol or cannabis dependent
Data Summary
• Both groups have:
– Substantial unemployment
– Substantial psychiatric co-morbidity
– High rates of medical problems
– High rates of nicotine use
– Modest rates of cannabis use
Limitations
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Data apply only to stimulant abusers
Clinics may or may not be representative
Methadone have been in treatment longer
Methadone are pre-selected for opiate abuse
Conclusions: Service Needs
• Common service needs suggested:
– Employment; co-occurring medical & psychiatric
– Shift in emphasis from cannabis to nicotine
• Differential service needs suggested:
– Effective interventions for on-going polydrug
(opiate, stimulant and sedative) use in methadone
– Relapse prevention in outpatient psychosocial
Conclusions: CTN Potential
• CTN is a great place to collect data on large
samples of community treatment patients
• Access to special patient subgroups of
interest to service providers