background rationale & hypotheses findings conclusions

CTN MIEDAR Studies Baseline Comparison:

Methadone vs Psychosocial Participants

Maxine Stitzer, Ph.D.AAAP December, 2003

• Background • Rationale & hypotheses • Findings• Conclusions

Drugs are Drugs are Positive Positive Reinforcers Reinforcers

They Make People They Make People Feel Good.Feel Good.

The Problem: Allure of Immediate Drug Reinforcement

Drug Abusers Straddle the FenceDrug Abusers Straddle the Fence

Continued Drug Use

DrugAbstinence

Methods are needed to:Methods are needed to:

- - counteract ambivalencecounteract ambivalence- increase motivation for change- increase motivation for change

Motivational IncentivesMotivational Incentives

Offer tangible incentivesOffer tangible incentivesfor drug abstinencefor drug abstinence

Make abstinence a more Make abstinence a more attractive option through attractive option through positive reinforcement of positive reinforcement of behavior changebehavior change

Incentive Therapies Promote AbstinenceCocaine (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 CostNancy 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: CTN MIEDAR Protocol: How Does It Work?How Does It Work?

Eligible PatientsEligible Patients

Stimulant AbusersStimulant Abuserseither cocaine or methamphetamineeither cocaine or methamphetamine

Random Assignment

• Usual care

• Enhanced care with incentives

Sample CollectionSample CollectionTwice WeeklyTwice Weekly

Abstinence BowlAbstinence Bowl

Good Job

Good Job

Good Job

Small Small

Small

Large

Large

Jumbo

Good Job

Good Job

Good Job

Good Job

Good Job

Small

Good Job

Small

Examples ofExamples ofIncentive PrizesIncentive Prizes

SMALLSMALL ($1-$5 items)($1-$5 items)

LARGELARGE($20 items)($20 items)

JUMBOJUMBO($80-$100 items)($80-$100 items)

Draws Escalate with Draws Escalate with Stimulant-Free Test ResultsStimulant-Free Test Results

Weeks Drug Free

# Draws

12

45

3

Bonus Draws for Marijuana Bonus Draws for Marijuana and/or Opiate Abstinenceand/or Opiate Abstinence

Weeks Drug Free

# Draws2 2 2 2 2

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

<.013642Age (mean years)

<.013626Race (% Caucasian)

<.014556Gender (% male)

P valuePSOC(N = 415)

METH (N = 388)

Subsequent analyses adjusted for gender, race & age

Psychosocial Characteristics

METH PSOC P value

Education (mean years)Marital Status (% married)

1214

1224

0.42<.01

Employed- past 3 years (%)Employed- past 30 days (%)

5032

6835

<.010.74

Legal Status

0.3

0.1

OR†

3516Parole/Probation (%)

336CJ referral (%)

PSOCMETH

† OR is methadone vs drug-free

Health ProblemsMETH PSOC OR

Chronic med probs (%) 59 38 1.8Lifetime hospital (%) 80 67 1.8

Psychiatric hospital (%) 29 29Psychiatric outpatient (%) 37 35

Lifetime psych meds(%) 42 40

Drug Use: Stimulants

METH PSOC

Dependence/Abuse (% with diagnosis) 82 84 ___

First Study Urine 76 26 7.8 (% positive)

OR

Drug Use: Opiates

Dependence/Abuse (% with diagnosis) 80 9 48

METH PSOC OR

First Study Urine (% positive) 47 3 30

Drug Use: Alcohol

METH PSOC OR

Dependence/Abuse (% with diagnosis) 17 42 0.3

First Study BAL (% positive) 1 1 __

Drug Use: Cannabis

METH PSOC OR

Dependence/Abuse (% with diagnosis) 8 21 0.5

First Study Urine (% positive) 12 11 __

Drug Use: Other

SEDATIVES

METH PSOC

25 6

ASI past 30 days; % with any use

NICOTINE

METH PSOC

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

• 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