Randomized multi-site trial of the Job Seekers' Workshop in patients with substance use disorders.

BACKGROUND: Unemployment is associated with negative outcomes both during and after drug abuse treatment. Interventions designed to increase rates of employment may also improve drug abuse treatment outcomes. The purpose of this multi-site clinical trial was to evaluate the Job Seekers' Workshop (JSW), a three session, manualized program designed to train patients in the skills needed to find and secure a job. METHOD: Study participants were recruited through the NIDA Clinical Trials Network (CTN) from six psychosocial counseling (n=327) and five methadone maintenance (n=301) drug treatment programs. Participants were randomly assigned to either standard care (program-specific services plus brochure with local employment resources) (SC) or standard care plus JSW. Three 4-h small group JSW sessions were offered weekly by trained JSW facilitators with ongoing fidelity monitoring. RESULTS: JSW and SC participants had similar 12- and 24-week results for the primary outcome measure (i.e., obtaining a new taxed job or enrollment in a training program). Specifically, one-fifth of participants at 12weeks (20.1-24.3%) and nearly one-third at 24 weeks (31.4-31.9%) had positive outcomes, with "obtaining a new taxed job" accounting for the majority of cases. CONCLUSION: JSW group participants did not have higher rates of employment/training than SC controls. Rates of job acquisition were modest for both groups, suggesting more intensive interventions may be needed. Alternate targets (e.g., enhancing patient motivation, training in job-specific skills) warrant further study as well.

Randomized controlled trial of osmotic-release methylphenidate with cognitive-behavioral therapy in adolescents with attention-deficit/hyperactivity disorder and substance use disorders.

OBJECTIVE: To evaluate the efficacy and safety of osmotic-release methylphenidate (OROS-MPH) compared with placebo for attention-deficit/hyperactivity disorder (ADHD), and the impact on substance treatment outcomes in adolescents concurrently receiving cognitive-behavioral therapy (CBT) for substance use disorders (SUD). METHOD: This was a 16-week, randomized, controlled, multi-site trial of OROS-MPH + CBT versus placebo + CBT in 303 adolescents (aged 13 through 18 years) meeting DSM-IV diagnostic criteria for ADHD and SUD. Primary outcome measures included the following: for ADHD, clinician-administered ADHD Rating Scale (ADHD-RS), adolescent informant; for substance use, adolescent-reported days of use in the past 28 days. Secondary outcome measures included parent ADHD-RS and weekly urine drug screens (UDS). RESULTS: There were no group differences on reduction in ADHD-RS scores (OROS-MPH: -19.2, 95% confidence interval [CI], -17.1 to -21.2; placebo, -21.2, 95% CI, -19.1 to -23.2) or reduction in days of substance use (OROS-MPH: -5.7 days, 95% CI, 4.0-7.4; placebo: -5.2 days, 95% CI, 3.5-7.0). Some secondary outcomes favored OROS-MPH, including lower parent ADHD-RS scores at 8 (mean difference = 4.4, 95% CI, 0.8-7.9) and 16 weeks (mean difference =6.9; 95% CI, 2.9-10.9) and more negative UDS in OROS-MPH (mean = 3.8) compared with placebo (mean = 2.8; p = .04). CONCLUSIONS: OROS-MPH did not show greater efficacy than placebo for ADHD or on reduction in substance use in adolescents concurrently receiving individual CBT for co-occurring SUD. However, OROS-MPH was relatively well tolerated and was associated with modestly greater clinical improvement on some secondary ADHD and substance outcome measures. Clinical Trial Registration Information-Attention Deficit Hyperactivity Disorder (ADHD) in Adolescents with Substance Use Disorders (SUD); http://www.clinicaltrials.gov; NCT00264797.

Implementing an adapted version of the job seekers' workshop in a residential program for patients with substance use disorders.

OBJECTIVES: To evaluate the feasibility and effectiveness of adapting the Job Seekers' Workshop (JSW) to a residential setting within a Massachusetts-based substance use disorder treatment agency. METHODS: Implementation of the adapted JSW consisted of a continual sequence of three weekly sessions that focused on job interview rehearsals, practice completing job applications, and identification of job leads. Data were compiled on the employment rates of the 188 patients discharged from the residential treatment program during July - December 2006 (baseline participants, n = 95) and January - June 2007 (JSW intervention participants, n = 93). The effectiveness of the adapted JSW was evaluated through a comparison of baseline and intervention participants' employment rates at discharge from residential treatment. RESULTS: Analyses indicated a trend towards a significant increase in employment at discharge for the intervention period (40.9%) compared to baseline (29.5%), χ(2)(1, N = 188) = 2.675, p = .051. CONCLUSIONS: Further evaluation of the JSW in residential settings is necessary, but this preliminary research suggests that the intervention could begin to address the need for vocational services in residential treatment for substance use disorders.

A "community-friendly" version of integrated group therapy for patients with bipolar disorder and substance dependence: a randomized controlled trial.

BACKGROUND: Integrated group therapy, a new treatment for patients with bipolar disorder and substance use disorder, has previously been found to be efficacious in reducing substance use, but its length (20 sessions) and need for highly trained therapists may limit its adoption in substance use disorder community treatment programs. This paper compares a briefer (12 session) version of integrated group therapy, led by substance use disorder counselors without previous cognitive-behavioral training or bipolar disorder experience, to group drug counseling. METHODS: Sixty-one patients with bipolar disorder and substance dependence, taking mood stabilizers, were randomized to 12 sessions of integrated group therapy (n=31) or group drug counseling (n=30). RESULTS: Analyses of primary outcomes showed trends favoring integrated group therapy, with greater reduction in substance use during follow-up and a greater decline in risk of mood episodes during treatment. Secondary analyses favored integrated group therapy, with a significantly greater likelihood of achieving total abstinence, a significantly shorter time to the first abstinent month, and a significantly greater likelihood of achieving a "good clinical outcome" (a composite measure encompassing both substance use and mood simultaneously). CONCLUSIONS: A shortened version of integrated group therapy can be delivered successfully by substance use disorder counselors, with better overall outcomes than those achieved with group drug counseling.

Depression precipitated by alcohol use in patients with co-occurring bipolar and substance use disorders.

OBJECTIVE: Bipolar disorder and substance use disorder frequently co-occur. However, little is known about the near-term effects of substance use on bipolar disorder. Thus, the present study tests whether alcohol use precipitates depression among patients with co-occurring bipolar disorder and substance use disorder. METHOD: This study uses data collected as part of 2 clinical trials (the first study was conducted from March 1999 through March 2004 and the second study was conducted from August 2003 through May 2007) of a manualized group therapy for patients with co-occurring bipolar disorder and substance dependence. One hundred fifteen participants were assessed at baseline and each month through month 8. Baseline diagnoses were made using the Structured Clinical Interview for DSM-IV, and monthly substance use and mood data were collected using the Longitudinal Interval Follow-Up Evaluation and the Addiction Severity Index. Generalized estimating equation methodology was used to analyze these longitudinal data. RESULTS: Our primary hypotheses were supported: days of alcohol use and an increase in days of alcohol use each significantly predicted the presence of a depressive episode in the subsequent month when controlling for current depression and current drug use. CONCLUSION: These data suggest that alcohol use in patients with bipolar disorder and substance dependence increases the risk of a depressive episode in the near term. TRIAL REGISTRATION: This study draws on data generated during 2 clinical trials. One was exempt from trial registration; clinicaltrials.gov Identifier for other trial: NCT00227838.

Personality, problem solving, and adolescent substance use.

The major aim of this study was to examine the role of social problem solving in the relationship between personality and substance use in adolescents. Although a number of studies have identified a relationship between personality and substance use, the precise mechanism by which this occurs is not clear. We hypothesized that problem-solving skills could be one such mechanism. More specifically, we sought to determine whether problem solving mediates, moderates, or both mediates and moderates the relationship between different personality traits and substance use. Three hundred and seven adolescents were administered the Substance Use Profile Scale, the Social Problem-Solving Inventory-Revised, and the Personality Experiences Inventory to assess personality, social problem-solving ability, and substance use, respectively. Results showed that the dimension of rational problem solving (i.e., effective problem-solving skills) significantly mediated the relationship between hopelessness and lifetime alcohol and marijuana use. The theoretical and clinical implications of these results were discussed.

Methods of recruiting adolescents with psychiatric and substance use disorders for a clinical trial.

BACKGROUND: The present article reports on recruiting strategies in a 16-week, multi-site trial of osmotic-release methylphenidate combined with cognitive-behavioral therapy in adolescents with co-occurring attention deficit hyperactivity disorder and substance use disorder. METHODS: A multifaceted recruiting strategy was employed that targeted multiple referral sources, used incentives, involved numerous staff members, emphasized the therapeutic alliance during prescreening, and utilized data to modify strategies based on results. Overall, 303 adolescents were randomized from 1,333 total referrals across 11 participating sites. RESULTS: Overall, existing treatment program sources, including treatment program staff, social services, the juvenile justice system, and mental health clinics provided a majority of referrals for pre-screening and randomization. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: These results support the feasibility of recruiting dually-diagnosed adolescents utilizing a multifaceted approach involving the entire study team.

Focus on alcohol & drug abuse: ensuring validity in urine drug testing.

Methods for urine drug testing have been available for several decades. These procedures are useful in assessing and identifying substance use in treatment programs, research programs, law enforcement, the workplace, and schools. Despite widespread adoption of such techniques, limited knowledge exists regarding their valid use and interpretation among many who frequently perform these tests. This column discusses how obtaining a valid test result is a complex process because results are affected by several factors, including the substance of interest, test methodology, pharmacokinetics, chain-of-custody procedures, and intentional tampering.

Is this urine really negative? A systematic review of tampering methods in urine drug screening and testing.

Adulterants and urine substitutes that are designed to defeat drug tests are readily available and can be easily researched or purchased over the Internet. Utilizing Google, PsychInfo, and Medline, we searched the Internet and psychiatric and medical literature to identify a comprehensive list of products, compounds, and methods of urine tampering, as well as data on their efficacy. These products, compounds, and methods are described, and literature on their effectiveness in masking drug use is reviewed. Additionally, we identify and review methods for detecting tampering of urine screens and tests. It is recommended that clinicians and researchers involved in urine drug screening and testing consider the possibility of tampering when designing treatment programs and research protocols and employ methods to detect its occurrence when appropriate.

Group therapy for substance use disorders: what do we know?

Although group therapy is the most prevalent treatment modality for substance use disorders, an up-to-date review of treatment outcome literature does not exist. A search of the literature yielded 24 treatment outcome studies comparing group therapy to other treatment conditions. These studies fell into one of six research design categories: (1) group therapy versus no group therapy; (2) group therapy versus individual therapy; (3) group therapy plus individual therapy versus group therapy alone; (4) group therapy plus individual therapy versus individual therapy alone; (5) group therapy versus another group therapy with different content or theoretical orientation; and (6) more group therapy versus less group therapy. In general, treatment outcome studies did not demonstrate differences between group and individual modalities, and no single type of group therapy reliably demonstrated greater efficacy than others. Unique methodological and logistical hurdles encountered in research on group therapy for substance use disorders, as well as considerations for future research, are also discussed.