Adaptation of a motivational interviewing intervention to improve antidepressant adherence among Latinos.

Poor antidepressant adherence is a significant issue in depression treatment that adversely affects treatment outcomes. Although being a common problem, it tends to be more common among Latinos. To address this problem, the current study adapted a Motivational Interviewing (MI) intervention to improve adherence among Latinos with depression. The adaptation process included six focus groups that elicited participants' perspectives (N = 30), applying the intervention with test cases (N = 7) to fine-tune the intervention, and eliciting feedback on the intervention (N = 5). The findings generated from these adaptation phases are described, along with a case example. Examples of adaptations to the MI included reframing antidepressant adherence as a way to luchar (struggle) against problems, focusing on motivation for improving depression and not just medication, refining methods for imparting antidepressant information, and inclusion of personalized visual feedback on dose-taking. The findings provide a description of the antidepressant issues experienced by a group of Latinos, as well as considerations for applying MI with this population. The intervention remained grounded in MI principles, but was contextualized for this Latino group.

Predictors of outcome for short-term medically supervised opioid withdrawal during a randomized, multicenter trial of buprenorphine-naloxone and clonidine in the NIDA clinical trials network drug and alcohol dependence.

Few studies in community settings have evaluated predictors, mediators, and moderators of treatment success for medically supervised opioid withdrawal treatment. This report presents new findings about these factors from a study of 344 opioid-dependent men and women prospectively randomized to either buprenorphine-naloxone or clonidine in an open-label 13-day medically supervised withdrawal study. Subjects were either inpatient or outpatient in community treatment settings; however not randomized by treatment setting. Medication type (buprenorphine-naloxone versus clonidine) was the single best predictor of treatment retention and treatment success, regardless of treatment setting. Compared to the outpatient setting, the inpatient setting was associated with higher abstinence rates but similar retention rates when adjusting for medication type. Early opioid withdrawal severity mediated the relationship between medication type and treatment outcome with buprenorphine-naloxone being superior to clonidine at relieving early withdrawal symptoms. Inpatient subjects on clonidine with lower withdrawal scores at baseline did better than those with higher withdrawal scores; inpatient subjects receiving buprenorphine-naloxone did better with higher withdrawal scores at baseline than those with lower withdrawal scores. No relationship was found between treatment outcome and age, gender, race, education, employment, marital status, legal problems, baseline depression, or length/severity of drug use. Tobacco use was associated with worse opioid treatment outcomes. Severe baseline anxiety symptoms doubled treatment success. Medication type (buprenorphine-naloxone) was the most important predictor of positive outcome; however the paper also considers other clinical and policy implications of other results, including that inpatient setting predicted better outcomes and moderated medication outcomes.

Relationship between self-reported task persistence and history of quitting smoking, plans for quitting smoking, and current smoking status in adolescents.

The task persistence construct has previously been measured primarily behaviorally (e.g., with a mirror-tracing task, or breath holding), and only in adults. It has been shown to differentiate between adult smokers and non-smokers and to predict smoking cessation in adult smokers trying to quit. This theory-based analysis is the first to examine task persistence in adolescent smokers and to examine a two-item, internally consistent, self-report measure of task persistence. Results indicate that task persistence is greater among adolescent non-smokers as compared to adolescent current smokers, and those planning to quit smoking as compared to those with no plans to quit. Contrary to hypotheses, task persistence was not found to be related to prior successful attempts to quit smoking. Our results suggest that a brief, self-report measure of task persistence may be a methodologically sound, practical clinical tool for this population.

A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network.

AIMS: The clinical effectiveness of buprenorphine-naloxone (bup-nx) and clonidine for opioid detoxification in in-patient and out-patient community treatment programs was investigated in the first studies of the National Institute of Drug Abuse Clinical Trials Network. DESIGN: Diagnostic and Statistical Manual version IV (DSM IV)-diagnosed opioid-dependent individuals seeking short-term treatment were randomly assigned, in a 2 : 1 ratio favoring bup-nx, to a 13-day detoxification using bup-nx or clonidine. METHODS: A total of 113 in-patients (77 bup-nx, 36 clonidine) and 231 out-patients (157 bup-nx, 74 clonidine) participated. Supportive interventions included appropriate ancillary medications and standard counseling procedures guided by a self-help handbook. The criterion for treatment success was defined as the proportion of participants in each condition who were both retained in the study for the entire duration and provided an opioid-free urine sample on the last day of clinic attendance. Secondary outcome measures included use of ancillary medications, number of side effects reported and withdrawal and craving ratings. FINDINGS: A total of 59 of the 77 (77%) in-patients assigned to the bup-nx condition achieved the treatment success criterion compared to eight of the 36 (22%) assigned to clonidine, whereas 46 of the 157 (29%) out-patients assigned to the bup-nx condition achieved the treatment success criterion, compared to four of the 74 (5%) assigned to clonidine. CONCLUSION: The benefits of bup-nx for opioid detoxification are supported and illustrate important ways in which clinical research can be conducted in community treatment programs.

Applicability of the Fagerström Test for Nicotine Dependence in smokers with schizophrenia.

Up to 90% of individuals with schizophrenia smoke cigarettes, and many show signs of heavy dependence. Although the severity of nicotine dependence is often measured by the six-item Fagerstrom Test for Nicotine Dependence (FTND), this measure, in its current form, may not be as appropriate in this population--or in others who's smoking is regulated by others--as in the general population due to differences in smoking patterns, living arrangements, and daily routines. These factors may produce an underestimate of nicotine dependence, which may have clinical implications for successful medical detoxification if the FTND scores are used to guide the dosage of nicotine replacement medication. Data indicate poor internal consistency reliability (alpha=.4581) and a factor pattern lacking simple structure (i.e., two nonmeaningful factors/components with substantial cross loadings) when administered to smokers with schizophrenia. Specific examples of problematic items and how these may contribute to an underestimate of tobacco dependence severity are discussed, as well as ways to modify the FTND to be more appropriate for this population.

Motivational interviewing with personalized feedback: a brief intervention for motivating smokers with schizophrenia to seek treatment for tobacco dependence.

Individuals with schizophrenia have a much higher prevalence of tobacco smoking, a lower cessation rate, and a higher incidence of tobacco-related diseases than the general population. The initial challenge has been to motivate these individuals to quit smoking. This study tested whether motivational interviewing is effective in motivating smokers with schizophrenia or schizoaffective disorder to seek tobacco dependence treatment. Participants (N = 78) were randomly assigned to receive a 1-session motivational interviewing (MI) intervention, standard psychoeducational counseling, or advice only. As hypothesized, a greater proportion of participants receiving the MI intervention contacted a tobacco dependence treatment provider (32%, 11%, and 0%, respectively) and attended the 1st session of counseling (28%, 9%. and 0%) by the 1-month follow-up as compared with those receiving comparison interventions.

Bringing buprenorphine-naloxone detoxification to community treatment providers: the NIDA Clinical Trials Network field experience.

In October 2002, the U.S. Food and Drug Administration approved buprenorphine-naloxone (Suboxone) sublingual tablets as an opioid dependence treatment available for use outside traditionally licensed opioid treatment programs. The NIDA Center for Clinical Trials Network (CTN) sponsored two clinical trials assessing buprenorphine-naloxone for short-term opioid detoxification. These trials provided an unprecedented field test of its use in twelve diverse community-based treatment programs. Opioid-dependent men and women were randomized to a thirteen-day buprenorphine-naloxone taper regimen for short-term opioid detoxification. The 234 buprenorphine-naloxone patients averaged 37 years old and used mostly intravenous heroin. Direct and rapid induction onto buprenorphine-naloxone was safe and well tolerated. Most patients (83%) received 8 mg buprenorphine-2 mg naloxone on the first day and 90% successfully completed induction and reached a target dose of 16 mg buprenorphine-4 mg naloxone in three days. Medication compliance and treatment engagement was high. An average of 81% of available doses was ingested, and 68% of patients completed the detoxification. Most (80.3%) patients received some ancillary medications with an average of 2.3 withdrawal symptoms treated. The safety profile of buprenorphine-naloxone was excellent. Of eighteen serious adverse events reported, only one was possibly related to buprenorphine-naloxone. All providers successfully integrated buprenorphine-naloxone into their existing treatment milieus. Overall, data from the CTN field experience suggest that buprenorphine-naloxone is practical and safe for use in diverse community treatment settings, including those with minimal experience providing opioid-based pharmacotherapy and/or medical detoxification for opioid dependence.

Smoking status and substance abuse severity in a residential treatment sample.

Treatment seeking substance abusers were classified as current smokers or non-smokers to identify differences between groups on psychiatric and substance use severity variables. The Addiction Severity Index (fifth edition; ASI) was administered to 313 substance abusers seeking treatment in a private, residential addictions treatment program. Since current smokers were younger and less educated than non-smokers, these variables were entered as covariates in all analyses. As measured by the ASI, current smokers experienced a significantly greater number of days with drug problems in the last 30 days and were seen as being in significantly more need of drug treatment and alcohol treatment by ASI interviewers. These findings indicate that smoking status may be a marker for greater substance use severity, although the fact that participants were not randomly assigned to groups precludes making causal interpretations of these data. Areas of future research are suggested including examining the potential mediating role of third variables such as personality and temperament.

Medications in the treatment of addiction: workplace issues.

Despite resistance from some treatment providers, medications play an increasingly important role in the treatment of substance dependence disorders. Goals of pharmacotherapy are discussed in terms of a four-stage model of treatment: acute withdrawal, protracted withdrawal, abstinence, and maintenance. The greatest controversy centers on the use of medications during the abstinence and maintenance phases of recovery. Particularly controversial, despite considerable supporting scientific data, is the lon -term use of agonists such as methadone. Occupational physicians and other non-prescribing staff can play a crucial role by supporting the responsible use of medications, maintaining contact with other medical and psychosocial treatment providers, enlisting support for medication compliance in patients' personal and professional support systems, advocating for comprehensive and humane patient care, and being alert to signs of medication misuse.