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The appalachian tri-state node experiences

very straightforward based on our comparatively greater knowledge of the physical workings of the human body and the expected outcomes in these trials. Conversely, it is unlikely that findings based on comparisons of interventions designed to effect psychological and behavioral outcomes will be as clear cut as those testing medications since we know and can control so much less about the operation of the mind.

One area of addiction research that profoundly affects outcomes is that of patient severity or psychiatric comorbid- ity. Carroll and colleagues53 noted the difficulty of detecting effects in effectiveness trials due to patient heterogeneity and severity but this is not to say that such variables can be neglected. These effects are evident in the Hartzler and colleagues41 study finding that opioid addicts with AUD had a greater degree of psychiatric severity including hallucinations, anxiety, and suicidal ideation and were more likely to report violent behaviors. Similarly, Sonne and colleagues32 findings that severity of depression is associated with more severe outcomes and difficulty stopping use of cigarettes relates to this. Finally, in this regard, the studies by Hien and colleagues27,29,30 were well designed in determining that severity of PTSD symptoms was responsible for severity of drug use and not the other way around. The methodology for future CTN treatment studies must include attention to diagnosis and treatment of nonsubstance related disorders, eg, medication for depression.

Variability in outcomes can also be seen, for example, in

CTN studies that have thus far found that certain treatments vary in effectiveness depending on the type of addiction for which they are used. The most important example is that of MI, which works well for alcohol addiction but not as well for other drugs of abuse. Yet, effective implementation of MI is significantly affected by program characteristics and quality of training. Guydish and colleagues37 findings on adoption of motivational interviewing (MI) indicates that more must be done to understand the obstacles to dissemination or accepting of evidence-based treatments and future CTN studies should address this issue.

On the positive side, Pinto and colleagues36 study of substance abuse treatment providers indicates that acceptance of evidence-based practices can be increased by focusing on promoting an environment of support for professional growth. It is clear that, combined with a supportive environ- ment, conducting ‘‘community-based participatory research’’ is an effective way for disseminating evidence-based prac- tices.

McCarty and colleagues39 descriptive findings are instruc-

tive in this regard as they found that the medical model of addiction, to which most evidence-based therapies relate, is on the rise in most CTPs in the CTN. Implementing methods for expediting this process among CTPs that do not currently ascribe to it will be critical to overcoming obstacles to adoption of evidence-based practices. Campbell and collea- gues38 recent study relates to this in finding that having a 63

higher staff-to-patient ratio, higher levels of training of staff, communities that have more outpatient clinics, and those that are closer to the inpatient program from which the patient was referred increased the likelihood of the patient following through with treatment. Daley and colleagues18 demonstrated the validity of these findings by conducting one MI session with addicted patients in a hospital nearby the outpatient unit to which they were being referred. This session occurred just prior to their discharge from inpatient treatment and focused on developing a rapport with the patient and removing obstacles to the patient’s attending a first follow-up out- patient session. The follow-up rate for patients who received this session was 67% compared to 33% for patients who did not receive the session.

Finally, on the issue of therapist training and fidelity, more

must be done to ensure that CTP therapists have access to continued supervision and consultation on the conduct of evidence-based practices. Martino and colleagues54 found that therapists are more likely to develop advanced MI skills during the post-workshop period when they are practicing MI while they are receiving supervision and feedback from competent supervisors. Furthermore, as Tai and colleagues24 point out, the CTN has emphasized treating CTP as partners with the RRTC in order to prevent CTPs from becoming recruitment machines and to promote early adoption of evidence-based practices that are developed in CTN clinical trials. These concepts can be combined to encourage individual CTP therapists to continue training informally by promoting ongoing consultation groups. At the suggestion of one CTP therapist in the Appalachian Tri-State Node, the first author, who is a MINT Trainer (TMK), has used the seminars he conducts as platforms for encouraging the formation of local, ongoing MI consultation groups that meet monthly. The MI promotes an egalitarian stance between patient and therapist and the suggested groups are based on all members offering to discuss their opinions and provide consultation to each other, rather than supervision that is available to the CTP therapists by the MINT trainers. In this way everyone owns the group process and outcomes and everyone shares equally in its success.

Cost-effectiveness will become paramount as the CTN

continues in an era of shrinking budgets. The studies that have been done on motivational incentives are enlightening. They show that motivational incentives can be cost effective and that even small incremental payouts can yield very high improvement rates.3335,55 Olmstead and colleagues35 discuss how the cost of motivational incentives should be considered against the cost of crime and other societal resources. Similarly, one possible study of the value of contingency management could consist of a group that receives con- tingency management and a group matched on age, gender, and comorbidity comparing cost of health care resources such as inpatient detoxification and residential treatment over 6 months of treatment.

In summary, the CTN is a highly valuable resource in developing and implementing the most effective treatments

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

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