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Mind & Brain, the Journal of Psychiatry

buprenorphine group reduced their injection risk behavior over time significantly more than men receiving buprenor- phine treatment. For all injectors who continued to inject drugs, there was no decrease in injection risk behavior from baseline to posttreatment. Furthermore, women who con- tinued to inject during treatment engaged in more injection risk behavior compared to men. The authors conclude that buprenorphine treatment is superior to detoxification for reducing injection risk behavior but that risk reduction counseling is necessary to extend the benefits of the treatment.

Study of Adolescents

Subramaniam and colleagues45 report on 94 adolescents between 14 and 18 years of age with a current opioid use disorder (OUD), compared to 74 adolescents with current cannabis or alcohol use but who did not have OUD (non- OUD). The participants were recruited from a large residen- tial treatment center in Baltimore, Maryland. Participants were referred from other residential or outpatient treatment facilities and the participants were matched on age, gender, and whether they were being treated in residential or outpatient treatment prior to their admission. The results of this study showed that a lower proportion of adolescents with OUD were enrolled in school but had higher rates of multiple substance use disorders (three or more), and had somewhat more depressive symptoms compared to the non-OUD group. While it was not surprising to find that OUD participants had higher rates of injecting behaviors, this clearly places youth with OUD at greater risk for HIV/HCV infection.

Study of Infectious Diseases

The CTN-0012 surveyed administrators and direct care providers from the CTP that participate in the CTN on services and policies related to treatment and reporting of the human immunodeficiency virus (HIV), hepatitis C (HCV), and sexually transmitted diseases (STD). Brown and colleagues46 report the results of their study that most CTP programs provide risk assessment, education, and/or counseling ser- vices, but a much smaller percentage offer medical services such as physical examinations, biological testing, treatment, and clinical monitoring. Administrators of the surveyed CTP programs report that lack of funding and government regulatory barriers often keep them from offering medical services that could be beneficial for reducing risk and progression of IV drug-related infection. Programs more often offer services related to HIV than services related to HCV and STD services and programs that offer outpatient pharmacotherapy are more likely to provide medical services for HIV, HCV, and STD. The investigators suggest that a relationship can be seen between this finding and findings from other clinics where opiate addicts are treated with methadone since such clinics report reduced rates of infec- tion-related drug use behaviors, HIV transmission, and HIV disease progression.

M&B 2011; 2:(1). July 2011 62 CONCLUSIONS

The next 10 years of the CTN can be most fruitful by focusing on two objectives. First, it is important to develop research efforts to expand on what the previously conducted studies have shown. Outcomes of CTN trials conducted thus far have shown that, in the real world, TAU is a good treatment due to the difficulty implementing evidence-based psychotherapies at optimal levels in the experimental arm of randomized trials. Still, evidence-based treatments are often somewhat better than TAU, even if it is in only a small way. Just a few of the examples include: (a) MI works better for treatment of alcoholism compared to TAU,47,48 (b) patients retain improvements longer into follow-up when treated with MET versus TAU,47 (c) patients treated with one session ofMI were more likely to be retained in treatment longer than patients treated with TAU,48 and (d) patients who received a follow-up telephone call after discharge to encourage atten- dance at outpatient treatment is somewhat better than TAU.49 It is likely that treatment sites such as clinician training and patient severity factors are moderating these outcomes. More can be done to improve the effectiveness of MI and other EBPs when such factors are better controlled.

Second, it is important to explore how what we now know

can be used to design more efficient clinical trials. Consistent with other recent reviews50,51 it is clear that sample sizes must increase in order to detect differences and overcome the significant impact of other covariates such as site variability. As McLellan50 points out, differences such as site and sample variability are part of real world research. Such variables in large scale studies cannot be adequately controlled with absent adequate statistical power.

One implication from the CTN findings is that combina-

tions of interventions work better than stand-alone therapies. One CTN study that combined technologies, medication, and manualized smoking cessation treatment reported excellent outcomes, finding that patients who received the experimen- tal intervention had better quit rates and smoked fewer cigarettes than patients treated with TAU.52 At least one of the current CTN studies (0046), ‘‘Stimulant Treatment for Smoking Cessation’’ (S-CAST) is also using this strategy as it combines pharmacotherapy, motivational incentives, and manualized psychotherapy to investigate stimulant use and smoking cessation among patients addicted to stimulants. Thoughtful, creative combinations of therapies that are specific for the addiction under investigation are needed as new studies are planned. Combining interventions for testing against TAU provide the best opportunities for increasing effect sizes and a more complete view of how treatments can be incorporated into treatment plans that use all potentially effective interventions against a particular addiction.

The work of the CTN has shown convincingly that the effect

of interventions in ‘‘real world’’ clinical trials is dependent on the nature of the technology being used, the length of the trial, and the outcomes being tested. For example, technology varies because comparing the effects of medications is

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