Use of a sequential multiple assignment randomized trial to test contingency management and an integrated behavioral economic and mindfulness intervention for buprenorphine-naloxone medication adherence for opioid use disorder.

BACKGROUND: Buprenorphine-naloxone is a medication shown to improve outcomes for individuals seeking treatment for opioid use disorder (OUD); however, outcomes are limited by low medication adherence rates. This is especially true during the early stages of treatment. METHODS: The present study proposes to utilize a sequential multiple assignment randomized trial design to compare two psychological interventions targeting buprenorphine-naloxone adherence: (1) contingency management (CM) and (2) brief motivational interviewing plus substance-free activities session plus mindfulness (BSM). Participants will be N = 280 adults who present to a university-based addictions clinic seeking treatment for OUD. Participants will be randomized to condition to receive 4 sessions of their assigned intervention (CM or BSM). Participants who are adherent, defined as attending physician appointments and having buprenorphine present in urine toxicology, will enter maintenance intervention for an additional 6 months. Those who are not adherent will be re-randomized to receive either the other intervention or both interventions. Follow-up will occur at 8 months post-randomization. CONCLUSIONS: This novel design will examine the benefit of sequential treatment decisions following non-adherence. The primary outcome of this study is buprenorphine-naloxone medication adherence, as assessed by physician visit attendance and presence of buprenorphine in urine. Results will elicit the relative efficacy of CM and BSM compared to one another and whether keeping the initial treatment approach when adding the alternative approach for initially non-adherent individuals is beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04080180.

Sexually Transmitted Infections and Contraceptive Use in Adolescents.

INTRODUCTION: Although a number of contraception methods exist, long-acting reversible contraceptives have been recommended for female adolescents owing to their low failure rates. However, concern exists that the increasing use of long-acting reversible contraceptive among female adolescents may have unintended consequences of decreasing condom use for the prevention of sexually transmitted infections. Despite this concern, few studies have directly explored the relationship between the use of long-acting reversible contraceptive versus other forms of contraception and diagnosis of sexually transmitted infections in female adolescents. This study compares the rates of sexually transmitted infection diagnosis following various forms of contraceptive use. METHODS: This study was an archival data analysis of single state Medicaid claims retrieved for female adolescents, aged 14-19 years, who received a contraceptive prescription and had 1 year of follow-up data available (n=62,550) between 2011 and 2015. Incidence of sexually transmitted infections was the outcome of interest. Data analysis was conducted in 2018. RESULTS: Compared with the contraceptive pill, hormonal implant (a form of long-acting reversible contraceptives) was associated with significantly lower risk of sexually transmitted infections (hazard ratio=0.81; 95% CI=0.70, 0.93; p=0.004), and hormonal injection was associated with higher risk of sexually transmitted infections (hazard ratio=1.08; 95% CI=1.00, 1.16; p=0.040). CONCLUSIONS: This analysis provides strong evidence that the risk for the acquisition of sexually transmitted infections is no higher for long-acting reversible contraceptives than for other forms of contraception. These results support the use of long-acting reversible contraceptive in female adolescents, as proposed and reaffirmed by the American College of Obstetricians and Gynecologists and American Academy of Pediatrics.

Addiction Medicine Training Fellowships in North America: A Recent Assessment of Progress and Needs.

OBJECTIVES: Although unhealthy substance use and addiction contribute to 1 in 4 deaths and are estimated to cost the US more than $740 billion annually, fewer than 12 hours of physician education over the 7 years of medical school and primary residency training specifically address alcohol and other drug-related issues. Addiction Medicine was formally recognized as a medical subspecialty in 2016 to address the need for physicians trained in prevention, treatment, and management of substance use. This study examines the characteristics of the Addiction Medicine fellowships in operation during this critical period in the subspecialty's development to identify needs and potential. METHODS: This study is a cross-sectional survey of Addiction Medicine Fellowship Directors from 46 fellowships accredited as of 2017 (43 in the United States and 3 in Canada). The response rate was 100%. RESULTS: Directors estimated significant growth in available fellowship slots between 2016 to 2017 and 2017 to 2018 (F = 49.584, P < .001). The majority of Directors reported that demand for their graduates was high (79.5%). Fellow training in screening, brief intervention, and referral to treatment spanned many substances and age groups, although fewer programs focused on nicotine and on adolescent populations. Notably, most directors reported that graduates completed waiver training to prescribe buprenorphine-naloxone (77.5%) and gained clinical experience in an opioid treatment setting (89.1%). Funding was the #1 need among 56.8% of Directors. CONCLUSIONS: Despite significant growth in Addiction Medicine fellowships over the past 6 years, meeting future workforce demands for Addiction Medicine specialists depends on access to funding to support fellowships.

Smoking Cessation for Smokers Not Ready to Quit: Meta-analysis and Cost-effectiveness Analysis.

CONTEXT: To provide a systematic review and cost-effectiveness analysis on smoking interventions targeting smokers not ready to quit, a population that makes up approximately 32% of current smokers. EVIDENCE ACQUISITION: Twenty-two studies on pharmacological, behavioral, and combination smoking-cessation interventions targeting smokers not ready to quit (defined as those who reported they were not ready to quit at the time of the study) published between 2000 and 2017 were analyzed. The effectiveness (measured by the number needed to treat) and cost effectiveness (measured by costs per quit) of interventions were calculated. All data collection and analyses were performed in 2017. EVIDENCE SYNTHESIS: Smoking interventions targeting smokers not ready to quit can be as effective as similar interventions for smokers ready to quit; however, costs of intervening on this group may be higher for some intervention types. The most cost-effective interventions identified for this group were those using varenicline and those using behavioral interventions. CONCLUSIONS: Updating clinical recommendations to provide cessation interventions for this group is recommended. Further research on development of cost-effective treatments and effective strategies for recruitment and outreach for this group are needed. Additional studies may allow for more nuanced comparisons of treatment types among this group.

Planning a Change Easily (PACE): A randomized controlled trial for smokers who are not ready to quit.

Smoking cessation programs are efficacious and have been validated to assist the 10% to 30% of smokers who are ready to quit in the next 30 days. While the majority of smokers want to quit smoking in the future, only 69% are planning to quit within the next year. Planning a Change Easily (PACE) is a nation-wide, telephone-based comparative effectiveness, randomized controlled trial for smokers not ready to quit (SNRTQ). This project, as well as its intervention components, outcomes, and hypotheses are discussed. This study will compare the effectiveness of four intervention conditions that could potentially help SNRTQ to quit smoking: Brief Advice, Motivational Interviewing, Rate Reduction, and Motivational Interviewing plus Rate Reduction combined. Rate Reduction conditions will include the provision of nicotine replacement therapy in the form of gum. Approximately 840 participants will be recruited and randomized to the four intervention conditions. The main outcomes for this study include self-report prolonged and point prevalence abstinence with biochemical verification of cessation. Secondary outcomes include quit attempts, cost-per-quit, and cost-effectiveness analyses. Informed by evidenced-based interventions, strong clinical guidelines, and economic analysis, PACE has the potential for significant public health impact. Results could readily be disseminated and translated to tobacco quitlines, which are present in all 50 states and are offered free to the public.

Economic Analyses of an Alcohol Misconduct Prevention Program in a Military Setting.

OBJECTIVE: The economic burden associated with alcohol misuse, in particular early attrition or discharge associated with alcohol-related incidents (ARIs), is significant in military settings. We assessed the potential economic benefit of a brief alcohol intervention program, the Alcohol Misconduct Prevention Program (AMPP), initially implemented at Joint Base San Antonio-Lackland Technical Training site for the U.S. Air Force (USAF) from October 1, 2010, to December 31, 2012. METHODS: We conducted cost-effectiveness and cost-benefit analyses of the AMPP from the perspective of the USAF. Program effectiveness was measured as the number of ARIs avoided after the AMPP implementation, and program benefit was measured as the potential cost savings related to reductions in ARIs. One-way sensitivity analyses were conducted to examine the robustness of base case results. RESULTS: The AMPP resulted in the avoidance of 59 ARIs which cost $9,869 for every ARI avoided. For every dollar invested in the AMPP, the USAF saved $4.09 in a conservative model without health effects, and saved $6.17 taking into account the potential health benefits. Our findings of favorable cost benefit were robust across sensitivity analyses. CONCLUSIONS: Investing in the AMPP at other military bases is likely to produce substantial economic benefit.