A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery

This meta-analysis examined outcomes of smoking cessation interventions evaluated in 19 randomized controlled trials with individuals in current addictions treatment or recovery. Smoking and substance use outcomes at posttreatment and long-term follow-up (> or = 6 months) were summarized with random effects models. Intervention effects for smoking cessation were significant at posttreatment and comparable for participants in addictions treatment and recovery; however, intervention effects for smoking cessation were nonsignificant at long-term follow-up. Smoking cessation interventions provided during addictions treatment were associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs. Short-term smoking cessation effects look promising, but innovative strategies are needed for long-term cessation. Contrary to previous concerns, smoking cessation interventions during addictions treatment appeared to enhance rather than compromise long-term sobriety.     

Contingency management improves abstinence and quality of life in cocaine abusers

Contingency management (CM) treatments enhance drug abstinence. This study evaluated whether CM also improves quality of life and if these effects are mediated by abstinence. Across 3 independent trials, cocaine abusers in intensive outpatient treatment (n = 387) were randomly assigned to 12 weeks of standard treatment as usual or standard treatment with CM. The Quality Of Life Inventory (QOLI) was administered at baseline and at Months 1, 3, 6, and 9. Changes in QOLI scores over time differed significantly by treatment, with QOLI scores rising over time in CM participants and remaining stable in standard treatment participants. CM participants also achieved greater durations of abstinence, and duration of abstinence was correlated with posttreatment QOLI scores. During-treatment abstinence mediated the relationship between treatment condition and QOLI scores over time.     

The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12-month outcomes

This study of continuing care for substance dependent patients compared a telephone-based monitoring and brief counseling intervention (TEL) with 2 face-to-face interventions, relapse prevention (RP) and standard 12-step group counseling (STND). The participants were graduates of intensive outpatient programs who had current dependence on alcohol and/or cocaine. Self-report, collateral, and biological measures of alcohol and cocaine use were obtained over a 12-month follow-up. The treatment groups did not differ on abstinence-related outcomes in the complete sample (N = 359) or on cocaine use outcomes in participants with cocaine dependence (n = 268). However, in participants with alcohol dependence only (n = 91), TEL produced better alcohol use outcomes than STND on all measures examined and better outcomes than RP on some of the measures.     

A comparative outcome study of frequent,moderate, occasional,and nonattenders of alcoholics anonymous

The purpose of this project was to identify the outcomes associated with frequent, moderate, occasional, and nonparticipation in Alcoholics Anonymous by male alcohol dependents during the first month after treatment. Informants reported nonparticipants consumed far more alcohol during a 48 week followup than moderate or occasional participants. Moderate and occasional participants were rated as abstinent more often than nonparticipants. Nonparticipants were also reported jailed more often than participants. All other consumption and quality of life comparisons between the groups were nonsignificant. Occasional and moderate AA attendance appear to be associated with better outcomes than nonattendance, but frequent participation was not associated with additional improvement. © 1997 John Wiley & Sons, Inc.     

Treating alcohol problems with couple therapy

Couple therapy for treating alcohol use disorders (AUDs) results in less drinking and greater relationship stability and satisfaction in both men and women with AUDs. The theoretical tenets, treatment methods, and research evidence for Alcohol Behavioral Couple Therapy (ABCT) are summarized. The application of ABCT is illustrated through the treatment of a 42‐year‐old woman with an AUD and her 56‐year‐old husband. During 12 sessions over a 6‐month period, the woman attained abstinence from alcohol and learned cognitive and behavioral coping skills to deal with drinking antecedents. Her husband learned to support her abstinence by stopping drinking himself, helping her cope with drinking urges, and reinforcing her successes. The couple increased positive pleasurable activities that did not involve alcohol and improved their communication skills. Challenges in the treatment included her ambivalence about abstaining, their complicated work and travel schedules, and other life stressors.     

Continuing care for cocaine dependence: comprehensive 2-year outcomes.

This report presents 2-year outcome data from an outpatient continuing care study in which cocaine-dependent patients (N = 132) were randomly assigned to either standard group counseling (STND) or individualized relapse prevention (RP). Data on cocaine outcomes during the 6-month treatment phase of the study were presented in an earlier report (J. R. McKay, A. I. Alterman, J. S. Cacciola, M. R. Rutherford, & C. P. O'Brien, 1997). In the present report, a continuing care condition main effect was obtained on only 1 of 8 outcome variables examined. However, patients who endorsed a goal of absolute abstinence on entering continuing care had better cocaine use outcomes in RP than in STND, whereas the opposite was the case for those with less stringent abstinence goals. In addition, patients with current cocaine or alcohol dependence on entering continuing care who received RP had better cocaine use outcomes in Months 1-6 and better alcohol use outcomes in Months 13-24 than those in STND.     

A randomized controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men

This study tested the efficacy of behavioral treatments for alcohol use disorders (AUD) among men who have sex with men (MSM) and who are at risk for HIV transmission. HIV-negative MSM with current AUD (N = 198) were recruited, offered treatment focused on reducing drinking and HIV risk, and followed during treatment and 12 months posttreatment. Participants (n = 89) accepted treatment and were randomized to either 4 sessions of motivational interviewing (MI) or 12 sessions of combined MI and coping skills training (MI + CBT). Other participants (n = 109) declined treatment but were followed, forming a non-help-seeking group (NHS). MI yielded significantly better drinking outcomes during the 12-week treatment period than MI + CBT, but posttreatment outcomes were equivalent. NHS participants significantly reduced their drinking as well. Service delivery and treatment research implications are discussed.     

Changing network support for drinking: initial findings from the network support project

The aim of this study was to determine whether a socially focused treatment can effect change in the patient's social network from one that reinforces drinking to one that reinforces sobriety. Alcohol dependent men and women (N = 210) recruited from the community were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support + contingency management (NS + CM), or case management (CaseM; a control condition). Analysis of drinking rates for 186 participants at 15 months indicated a significant interaction effect of Treatment x Time, with both NS conditions yielding better outcomes than the CaseM condition. Analyses of social network variables at posttreatment indicated that the NS conditions did not reduce social support for drinking relative to the CaseM condition but did increase behavioral and attitudinal support for abstinence as well as Alcoholics Anonymous (AA) involvement. Both the NS variables and AA involvement variables were significantly correlated with drinking outcomes. These findings indicate that drinkers' social networks can be changed by a treatment that is specifically designed to do so, and that these changes contribute to improved drinking outcomes.     

Addressing heavy drinking in smoking cessation treatment: a randomized clinical trial

Heavy alcohol use frequently co-occurs with cigarette smoking and may impede smoking cessation. This clinical trial examined whether smoking cessation treatment that incorporates brief alcohol intervention can improve smoking cessation outcomes (7-day verified point prevalence abstinence) and reduce drinks consumed per week. Heavy drinkers seeking smoking cessation treatment were assigned by urn randomization to receive, along with 8 weeks of nicotine replacement therapy, either a 4-session standard smoking cessation treatment (ST, n = 119) or standard treatment of equal intensity that incorporated brief alcohol intervention (ST-BI, n = 117). Across follow-ups over 26 weeks, participants in ST-BI reported approximately 20% fewer drinks per week (p < .027) and greater smoking abstinence (adjusted odds ratio = 1.56; 95% confidence interval = 1.01, 2.43) than did those in ST; however, effects on smoking were primarily evident at 2 weeks after quit date and were essentially absent by 16 weeks. The effect of ST-BI on smoking outcome was most robust among moderately heavy drinkers compared with that on very heavy drinkers. Integrating brief alcohol intervention into smoking cessation treatment appears feasible, but further development is needed to yield lasting effects on smoking.     

Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients

Contingency management (CM) interventions frequently utilize vouchers as reinforcers, but a prize-based system is also efficacious. This study compared these approaches. Seventy-four cocaine-dependent methadone outpatients were randomly assigned to standard treatment (ST), ST plus a maximum of $585 in contingent vouchers, or ST plus an expected average maximum of $300 in contingent prizes for 12 weeks. CM participants achieved longer durations of abstinence (LDA) than ST participants, and CM conditions did not differ significantly in outcomes or amount of reinforcement earned. Although long-term abstinence did not differ by group, LDA during treatment was the best predictor of abstinence at 9 months. Thus, reinforcement with prizes was similar to voucher CM in promoting LDA, which is associated with posttreatment benefits.     

Behavioral couples therapy for female substance-abusing patients: effects on substance use and relationship adjustment

Married or cohabiting female drug-abusing patients (N = 75) were randomly assigned to either a behavioral couples therapy condition (BCT; n = 37), which consisted of group, individual, and behavioral couples therapy sessions, or to an equally intensive individual-based treatment condition (IBT; n = 38), which consisted of group and individual counseling. During most of the 1-year follow-up, compared with participants who received IBT, those who received BCT reported (a) fewer days of substance use, (b) longer periods of continuous abstinence, (c) lower levels of alcohol, drug, and family problems, and (d) higher relationship satisfaction. However, differences in relationship satisfaction and number of days of substance use dissipated over the course of the posttreatment follow-up period and were not significantly different by the end of 1 year.     

Alcoholics anonymous involvement and positive alcohol-related outcomes: cause,consequence, or just a correlate? A prospective 2-year study of 2,319 alcohol-dependent men

A positive corelation between Alcoholics Anonymous (AA) involvement and better alcohol-related outcomes has been identified in research studies, but whether this correlation reflects a causal relationship remains a subject of meaningful debate. The present study evaluated the question of whether AA affiliation appears causally related to positive alcohol-related outcomes in a sample of 2,319 male alcohol-dependent patients. An initial structural equation model indicated that 1-year posttreatment levels of AA affiliation predicted lower alcohol-related problems at 2-year follow-up, whereas level of alcohol-related problems at 1-year did not predict AA affiliation at 2-year follow-up. Additional models found that these effects were not attributable to motivation or psychopathology. The findings are consistent with the hypothesis that AA participation has a positive effect on alcohol-related outcomes.     

A comparison of three family therapy programs for treating family conflicts in adolescents with attention-deficit hyperactivity disorder.

Sixty-one 12- to 18-year-olds were randomized to 8-10 sessions of behavior management training (n = 20), problem-solving and communication training (n = 21), or structural family therapy (n = 20). Families were assessed at pre- and posttreatment and 3-month follow-up. All treatments resulted in significant reductions in negative communication, conflicts, and anger during conflicts and improved ratings of school adjustment, reduced internalizing and externalizing symptoms, and decreased maternal depressive symptoms. Most outcomes remained stable between posttreatment and follow-up, and some continued to improve over this time. Despite group improvements, analyses of clinically significant change and clinical recovery within Ss showed that only 5-30% reliably improved from treatment and only 5-20% recovered following treatment. The three treatments did not differ in these rates.     

Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities

Contingency management (CM) interventions usually reinforce submission of drug-negative specimens, but they can also reinforce adherence with goal-related activities. This study compared the efficacy of the 2 approaches. Substance-abusing outpatients (N = 131) were randomly assigned to 1 of 3 12-week treatments: standard treatment (ST), ST with CM for submitting negative urine toxicology screens, or ST with CM for completing goal-related activities. CM patients remained in treatment longer and achieved more abstinence than ST patients, but the CM condition that reinforced submission of negative samples resulted in better outcomes than the CM condition that reinforced goal-related activities. Abstinence at 6- and 9-month follow-ups did not differ by group, but longest duration of abstinence achieved during treatment was associated with abstinence posttreatment.     

A randomized trial of treatment options for alcohol-abusing workers

BACKGROUND. Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options. METHODS. We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period. RESULTS. All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment. CONCLUSIONS. Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.     

Posttreatment follow-up of Helicobacter pylori infection using a stool antigen immunoassay.

The Helicobacter pylori stool antigen enzyme immunoassay (HpSA) was evaluated during posttreatment follow-up of patients in a country with a very high prevalence of H. pylori infection. From among 273 dyspeptic individuals (18 to 55 years) initially recruited from a shantytown in Lima, Peru, 238 participants who met the inclusion criteria and were suspected to be H. pylori positive based on (14)C urea breath test (UBT) results underwent endoscopy. Participants with endoscopy-proven infections received standard eradication therapy and were monitored by UBT and HpSA at 1 month following treatment and at 3-month intervals for 9 months posttreatment. A second endoscopy was performed if UBT results showed evidence of treatment failure or H. pylori recurrence. Biopsy results were considered the "gold standard" in all analyses. Among patients who underwent endoscopy, HpSA had a pretreatment sensitivity of 93%. Two-hundred thirty patients completed the treatment regimen, of whom 201 (93%) were considered to have had successful treatment outcomes based on a negative follow-up UBT. Thirty-two patients with UBT-defined treatment failures or H. pylori recurrences at any point during the 9-month follow-up underwent a second endoscopy. In the posttreatment setting, HpSA had an overall sensitivity of 73% and a specificity of 67%. Agreement between UBT and HpSA diminished throughout the follow-up. Among 14 participants in whom HpSA remained positive at 1 month following treatment despite UBT evidence of treatment success, 12 (86%) became HpSA negative within 3 months posttreatment. Although this study confirmed the validity of the HpSA in the initial assessment of dyspeptic patients, the test demonstrated a reduced overall accuracy in the detection of treatment failures and H. pylori recurrences during 9 months of posttreatment follow-up. Furthermore, in some patients it may take up to 3 months after successful eradication for antigen shedding to diminish to levels within the negative HpSA range.     

Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: a study of process and outcome

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.     

Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients

Male and female managed care clients randomized to day hospital (n=154) or community residential treatment (n=139) were compared on substance use outcomes at 6 and 12 months. To address possible bias in naturalistic studies, outcomes were also examined for clients who self-selected day hospital (n=321) and for clients excluded from randomization and directed to residential treatment because of high environmental risk (n=82). American Society of Addiction Medicine criteria defined study and randomization eligibility. More than 50% of followed clients reported past-30-day abstinence at follow-ups (unadjusted rates, not significant between groups). Despite differing baseline severities, randomized, self-selecting, and directed clients displayed similar abstinence outcomes in multivariate longitudinal models. Index treatment days and 12-step attendance were associated with abstinence (p<.001). Other prognostic effects (including gender and ethnicity) were not significant predictors of differences in outcomes for clients in the treatment modalities. Although 12-step attendance continued to be important for the full 12 months, treatment beyond the index stay was not, suggesting an advantage for engaging clients in treatment initially and promoting 12-step attendance for at least a year.     

Cognitive-behavioral therapy for pathological gamblers

Few studies have evaluated efficacy of psychotherapies for pathological gambling. Pathological gamblers (N = 231) were randomly assigned to (a) referral to Gamblers Anonymous (GA), (b) GA referral plus a cognitive- behavioral (CB) workbook, or (c) GA referral plus 8 sessions of individual CB therapy. Gambling and related problems were assessed at baseline, 1 month later, posttreatment, and at 6- and 12-month follow-ups. CB treatment reduced gambling relative to GA referral alone during the treatment period and resulted in clinically significant improvements, with some effects maintained throughout follow-up ( ps = .05). Individual CB therapy improved some outcomes compared with the CB workbook. Attendance at GA and number of CB therapy sessions or workbook exercises completed were associated with gambling abstinence. These data suggest the efficacy of this CB therapy approach.     

Modular cognitive-behavioral therapy for affective symptoms in young individuals at ultra-high risk of first episode of psychosis: Randomized controlled trial

Objectives : Individuals at ultra-high risk of psychosis often present concurrent affective symptoms (depression/anxiety). This study investigated whether modular cognitive-behavioral therapy (CBT) targeting both ultra-high risk and affective symptoms (a) reduced/delayed risk of a first psychotic episode at posttreatment and 14-month follow-up compared with a supportive intervention, (b) was more effective than control condition in producing remission on depression/anxiety. Methods : Fifty-eight ultrahigh risk individuals were randomly assigned to CBT or control condition. CBT consisted of 30 sessions, including CBT for psychotic experiences and depression/anxiety. Results : In the CBT group, the cumulative number of participants who developed a first psychotic episode (n = 3, 10.34%) at follow-up was lower than in the control group (n = 8, 27.60%; logrank χ²₍₁₎ = 3.68, p = .05). In the CBT group, a higher number of participants achieved remission than in control condition on affective symptoms at posttreatment/follow-up. Conclusion : CBT can prevent psychosis risk and produce better outcomes on depression/anxiety than supportive intervention.