Abstinence and moderate use goals in the treatment of marijuana dependence

AIMS: The purpose of this study was to examine the influence of personal goals (abstinence or moderation) on treatment outcomes for marijuana use. Hypotheses regarding self-efficacy for goal attainment were tested. DESIGN: Adult marijuana users seeking treatment were assigned randomly to three treatment conditions: (1) cognitive-behavioral relapse prevention support group; (2) individualized brief motivational enhancement; and (3) delayed treatment control group. Follow-up assessments were conducted at 4, 7, 13 and 16 months. SETTING: University research offices. PARTICIPANTS: Participants were 291 adult marijuana users. Measurements Marijuana use, personal treatment goals and self-efficacy for achieving one's goal were assessed across the 16-month follow-up. FINDINGS: Greater marijuana related problems and dependence symptoms were associated with an initial goal of abstinence. Participants were more likely to achieve outcomes consistent with their personal goals. Participants with abstinence goals reported greater self-efficacy for goal achievement than those with moderation goals after participating in the abstinence oriented treatment; self-efficacy for goal success predicted goal achievement for both moderate use and abstinence goals. CONCLUSIONS: Marijuana users approaching an abstinence-oriented treatment varied in the extent to which they were actively seeking abstinence as the outcome. Differences in goals were predictable from severity of problems related to use. Goal preference and self-efficacy for achieving goals predicted outcomes. Future research should incorporate personal goals into treatment and assess their effects on outcomes.     

The cost-effectiveness of four treatments for marijuana dependence

AIM: To analyze data from a randomized clinical trial to determine the cost-effectiveness of using contingency management (CM) and motivational/skills building therapy (motivational enhancement therapy/cognitive-behavioral therapy: MET/CBT) to treat young adults with marijuana dependence. PARTICIPANTS, DESIGN AND MEASUREMENTS: A total of 136 marijuana-dependent young adults, all referred by the criminal justice system, were randomized to one of four treatment conditions: MET/CBT with CM, MET/CBT without CM, drug counseling (DC) with CM and DC without CM. Patient outcome measures include the longest duration of confirmed marijuana abstinence (LDA) during treatment and the total number of marijuana-free urine specimens provided during treatment. Costs were collected retrospectively from the provider and include the costs of therapy, patient drug testing, and those associated with the incentives component (value of vouchers, time to administer the voucher system). SETTING: Out-patient substance abuse clinic in New Haven, Connecticut, USA. FINDINGS: Which treatment is the most cost-effective depends on the threshold values of an additional week of LDA or an additional marijuana-free urine specimen. For example, the most effective treatment, MET/CBT with CM, was also the most cost-effective treatment at the highest threshold values, while the least effective treatment, DC, was the most cost-effective at the lowest values. Because consensus threshold values for these patient outcomes do not exist, results are presented showing the ranges of values over which each treatment would be considered cost-effective compared to the others. Acceptability curves are presented to show the decision uncertainty associated with these ranges. The results are shown to be robust to (i) sensitivity analyses on several key cost parameters and (ii) patient outcomes measured during the 6-month follow-up period. CONCLUSIONS: This study uses incremental cost-effectiveness ratios and acceptability curves to shed light on the relative cost-effectiveness of four interventions for treating young adults with marijuana dependence. Given the relatively small and specialized nature of our study sample, and the fact that we examined a CM procedure with a single reinforcement schedule, additional studies are warranted to determine the reliability and generalizability of our results both to alternative marijuana-using populations and to CM procedures with alternative incentive parameters. Nevertheless, the relative durability of effects of MET/CBT compared to DC through the 6-month follow-up, and its cost-effectiveness over a comparatively wide range of threshold values, underscores the promise of this approach.     

Individualized assessment and treatment program for alcohol dependence: results of an initial study to train coping skills

Aims Cognitive–behavioral treatments (CBT) are among the most popular interventions offered for alcohol and other substance use disorders, but it is not clear how they achieve their effects. CBT is purported to exert its beneficial effects by altering coping skills, but data supporting coping changes as the mechanism of action are mixed. The purpose of this pilot study was to test a treatment in which coping skills were trained in a highly individualized way, allowing us to determine if such training would result in an effective treatment. Design Participants were assigned randomly to a comprehensive packaged CBT program (PCBT), or to an individualized assessment and treatment program (IATP). The IATP program employed experience sampling via cellphone to assess coping skills prior to treatment, and provided therapists with a detailed understanding of patients' coping strengths and deficits. Setting Out‐patient treatment. Participants A total of 110 alcohol‐dependent men and women. Measurements Participants in both conditions completed experience sampling of situations, drinking and coping efforts prior to, and following, 12 weeks of treatment. Time‐line follow‐back procedures were also used to record drinking at baseline and post‐treatment. Findings IATP yielded higher proportion of days abstinent (PDA) at post‐treatment (P < 0.05) than did PCBT, and equivalent heavy drinking days. IATP also elicited more momentary coping responses and less drinking in high‐risk situations, as recorded by experience sampling at post‐treatment. Post‐treatment coping response rates were associated with decreases in drinking. Conclusions The IATP approach was more successful than PCBT at training adaptive coping responses for use in situations presenting a high risk for drinking. The highly individualized IATP approach may prove to be an effective treatment strategy for alcohol‐dependent patients.     

Quality versus quantity: acquisition of coping skills following computerized cognitive–behavioral therapy for substance use disorders

Aims To evaluate the changes over time in quality and quantity of coping skills acquired following cognitive behavioral therapy (CBT), and examine potential mediating effects on substance use outcomes. Design A randomized controlled trial (RCT) evaluating the effectiveness of a computerized version of CBT (CBT4CBT) as an adjunct to standard out‐patient treatment over an 8‐week period. Setting Data were collected from individuals seeking treatment for substance dependence in an out‐patient community setting. Participants Fifty‐two substance abusing individuals (50% African American), with an average age of 42 years, and a majority reporting cocaine as their primary drug of choice. Measurements Participants' responses to behavioral role‐plays of situations associated with high risk for drug and alcohol use were audio‐taped and rated independently to assess their coping responses. Findings There were statistically significant increases in mean ratings of the quality of participants' coping responses for those assigned to CBT4CBT compared to treatment as usual, and these differences remained significant 3 months after treatment completion. Moreover, quality of coping responses mediated the effect of treatment on participants' duration of abstinence during the follow‐up period. Conclusions These findings suggest that assignment to the computerized CBT program improved participants' coping skills, as measured by independent ratings of a role‐playing task. It is also the first study to test and support quality of coping skills acquired as a mediator of the effect of CBT for substance use.     

Project MATCH secondary a priori hypotheses

Aims. (1) To assess the benefits of matching alcohol dependent clients to three treatments, based upon a priori hypotheses involving 11 client attributes; (2) to discuss the implications of these findings and of matching hypotheses previously reported from Project MATCH. Setting and participants. (1) Clients receiving outpatient therapy (N = 952; 72% male); (2) clients receiving aftercare therapy following inpatient or day hospital treatment (N = 774; 80% male). Intervention. Clients were randomly assigned to one of three 12-week, manual-guided, individual treatments: Cognitive Behavioral Coping Skills Therapy (CBT), Motivational Enhancement Therapy (MET) or Twelve-Step Facilitation Therapy (TSF). Design. Two parallel but independent randomized clinical trials were conducted, one with outpatients, one with aftercare clients. Participants were monitored over 15 months including a 1-year post-treatment period. Individual differences in response to treatment were modeled as a latent growth process and evaluated for 17 contrasts specified a priori. Outcome measures were percentage of days abstinent and drinks per drinking day. Findings. Two a priori contrasts demonstrated significant post-treatment attribute by treatment interactions: (1) outpatients high in anger and treated in MET had better post-treatment drinking than in CBT; (2) aftercare clients high in alcohol dependence had better post-treatment outcomes in TSF; low dependence clients did better in CBT. Other matching effects varied over time, while still other interactions were opposite that predicted. Conclusions. (1) Anger and dependence should be considered when assigning clients to these three treatments; (2) considered together with the results of the primary hypotheses, matching effects contrasting these psychotherapies are not robust. Possible explanations include: (a) among the client variables and treatments tested, matching may not be an important factor in determining client outcomes; (b) design issues limited the robustness of effects; and (c) a more fully specified theory of matching is necessary to account for the complexity of the results.     

Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less

Aims To evaluate reciprocal enhancement (combining treatments to offset their relative weaknesses) as a strategy to improve cannabis treatment outcomes. Contingency management (CM) with reinforcement for homework completion and session attendance was used as a strategy to enhance cognitive–behavioral therapy (CBT) via greater exposure to skills training; CBT was used as a strategy to enhance durability of CM with rewards for abstinence. Setting Community‐based out‐patient treatment program in New Haven, Connecticut, USA. Design Twelve‐week randomized clinical trial of four treatment conditions: CM for abstinence alone or combined with CBT, CBT alone or combined with CM with rewards for CBT session attendance and homework completion. Participants A total of 127 treatment‐seeking young adults (84.3% male, 81.1% minority, 93.7% referred by criminal justice system, average age 25.7 years). Measurements Weekly urine specimens testing positive for cannabis, days of cannabis use via the time‐line follow‐back method. Findings Within treatment, reinforcing homework and attendance did not significantly improve CBT outcomes, and the addition of CBT worsened outcomes when added to CM for abstinence (75.5 versus 57.1% cannabis‐free urine specimens, F = 2.25, P = 0.02). The CM for abstinence condition had the lowest percentage of cannabis‐negative urine specimens and the highest mean number of consecutive cannabis‐free urine specimens (3.3, F = 2.33, P = 0.02). Attrition was higher in the CBT alone condition, but random effect regression analyses indicated this condition was associated with the greatest rate of change overall. Cannabis use during the 1‐year follow‐up increased most rapidly for the two enhanced groups. Conclusions Combining contingency management and cognitive–behavioural therapy does not appear to improve success rates of treatment for cannabis dependence in clients involved with the criminal justice system.     

Differences in Treatment Outcome among Marijuana-Dependent Young Adults with and without Antisocial Personality Disorder

Background: Few studies have addressed comorbid antisocial personality disorder (ASPD) and marijuana dependence in young adults, and results from previous studies are inconsistent. Objectives: This study evaluated differences in pretreatment characteristics and treatment outcomes between marijuana-dependent young adults with and without ASPD. Methods: Data for this study were derived from a randomized trial, in which marijuana-dependent young adults (n = 136) between 18 and 25 years of age were randomized to four behavioral conditions: (1) MET/CBT with CM, (2) MET/CBT without CM, (3) DC with CM, and (4) DC without CM. Results: Forty-four percent of the participants met DSM-IV-TR criteria for ASPD. ASPD clients had significantly more lifetime alcohol dependence disorders, marijuana use in the 28 days pretreatment, arrests, and assault and weapon charges compared to those without ASPD. ASPD clients did not differ in retention or substance use outcomes at 8 weeks posttreatment or the 6-month follow-up. In general, both groups had more attendance in the voucher condition, but there were no significant ASPD by treatment interactions. Conclusions: These data suggest that marijuana-dependent young adults with comorbid ASPD do not necessarily have poorer retention or substance use outcomes compared with marijuana-dependent young adults who do not have ASPD when treated in a well-defined behavioral therapy protocol. Scientific significance: Previous research has shown increased risks for clients with comorbid ASPD and marijuana dependence; however, our findings suggest that specialized programs for clients with ASPD may not be necessary if they are provided with empirically supported, structured treatments.     

Variation in GABRA2 predicts drinking behavior in project MATCH subjects

BACKGROUND: Previous studies demonstrated, and replicated, an association between single nucleotide polymorphisms (SNPs) within the GABRA2 gene and risk for alcohol dependence. The present study examines the association of a GABRA2 SNP with another definition of alcohol involvement and with the effects of psychosocial treatment. METHODS: European-American subjects (n = 812, 73.4% male) provided DNA samples for the analysis. All were participants in Project Matching Alcoholism Treatment to Client Heterogeneity (MATCH), a multi-center randomized clinical trial evaluating the efficacy of 3 types of psychosocial treatment for alcoholism: Cognitive Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), or twelve-step facilitation (TSF). The daily probabilities of drinking and heavy drinking were estimated during the 12-week treatment and 12-month post-treatment periods. RESULTS: Subjects homozygous for the allele associated with low risk for alcohol dependence in previous studies had lower daily probabilities of drinking and heavy drinking in the present study. This low-risk allele was also associated with a greater difference in drinking outcomes between the treatments. In addition, it enhanced the relative superiority of TSF over CBT and MET. Population stratification was excluded as a confound using ancestry informative marker analysis. CONCLUSIONS: The assessment of genetic vulnerability may be relevant to studies of the efficacy of psychosocial treatment: GABRA2 genotype modifies the variance in drinking and can therefore moderate power for resolving differences between treatments.     

Extended treatment of older cigarette smokers

Aims Tobacco dependence treatments achieve abstinence rates of 25–30% at 1 year. Low rates may reflect failure to conceptualize tobacco dependence as a chronic disorder. The aims of the present study were to determine the efficacy of extended cognitive behavioral and pharmacological interventions in smokers ≥ 50 years of age, and to determine if gender differences in efficacy existed. Design Open randomized clinical trial. Setting A free‐standing, smoking treatment research clinic. Participants A total of 402 smokers of ≥ 10 cigarettes per day, all 50 years of age or older. Intervention Participants completed a 12‐week treatment that included group counseling, nicotine replacement therapy (NRT) and bupropion. Participants, independent of smoking status, were then assigned randomly to follow‐up conditions: (i) standard treatment (ST; no further treatment); (ii) extended NRT (E‐NRT; 40 weeks of nicotine gum availability); (iii) extended cognitive behavioral therapy (E‐CBT; 11 cognitive behavioral sessions over a 40‐week period); or (iv) E‐CBT plus E‐NRT (E‐combined; 11 cognitive behavioral sessions plus 40 weeks nicotine gum availability). Measurements Primary outcome variable was 7‐day point prevalence cigarette abstinence verified biochemically at weeks 24, 52, 64 and 104. Findings The most clinically important findings were significant main effects for treatment condition, time and the treatment × time interaction. The E‐CBT condition produced high cigarette abstinence rates that were maintained throughout the 2‐year study period [(week 24 (58%), 52 (55%), 64 (55%) and 104 (55%)], and was significantly more effective than E‐NRT and ST across that period. No other treatment condition was significantly different to ST. No effects for gender were found. Conclusions Extended cognitive behavioral treatments can produce high and stable cigarette abstinence rates for both men and women. NRT does not add to the efficacy of extended CBT, and may hamper its efficacy. Research is needed to determine if these results can be replicated in a sample with a greater range of ages, and improved upon with the addition of medications other than NRT.     

The process of relapse in severely dependent male problem drinkers

Aims. The aim of the study was to investigate factors hypothesized to influence the relapse process, with a focus on the role of self-efficacy, alcohol dependence and cognitive functioning. Design. The study was conducted in the context of a controlled trial of a relapse prevention programme. Subjects were assessed prior to treatment, at immediate conclusion of treatment and at 6- and 12-month follow-up. Setting. The study was conducted in an Alcohol Treatment Unit (ATU) in Scotland. Participants: Subjects were 60 male problem drinkers who were patients at the ATU. They were heavy drinkers, with corresponding high levels of alcohol dependence and alcohol-related harm. Measurements. The independent variables were posttreatment self-efficacy, alcohol dependence, cognitive functioning, level of depression and alcohol consumption prior to admission to treatment. The dependent variables were post-treatment drinking behaviour and functioning and time to lapse and relapse. Findings. Although the methodology does not allow identification of causality, support was found for the hypothesis that post-treatment self-efficacy was an intervening variable between treatment and outcome. Higher post-treatment self-efficacy predicted better outcome at 6-month follow-up and was associated with a reduced risk of lapse and relapse over the 12-month follow-up. Poorer cognitive functioning was significantly associated with being categorized as a problem drinker at 6-month follow-up and with higher risk of a lapse over the 12-month follow-up. Level of alcohol dependence did not predict outcome. Conclusions. It was concluded that post-treatment self-efficacy rating is a predictor of treatment outcome and time to lapse and relapse and that cognitive functioning is a predictor of treatment outcome and time to lapse.     

Alcoholism treatment and medical care costs from Project MATCH

Aims. This paper examines the costs of medical care prior to and following initiation of alcoholism treatment as part of a study of patient matching to treatment modality. Design Longitudinal study with pre- and post-treatment initiation. Measurements. The total medical care costs for inpatient and outpatient treatment for patients participating over a span of 3 years post-treatment. Setting. Three treatment sites at two of the nine Project MATCH locations (Milwaukee, WI and Providence, RI). Participants. Two hundred and seventy-nine patients. Intervention. Patients were randomly assigned to one of three treatment modalities: a 12-session cognitive behavioral therapy (CBT), a four-session motivational enhancement therapy (MET) or a 12-session Twelve-Step facilitation (TSF) treatment over 12 weeks. Findings. Total medical care costs declined from pre- to post-treatment overall and for each modality. Matching effects independent of clinical prognosis showed that MET has potential for medical-care cost-savings. However, patients with poor prognostic characteristics (alcohol dependence, psychiatric severity and/or social network support for drinking) have better cost-savings potential with CBT and/or TSF., Conclusions. Matching variables have significant importance in increasing the potential for medical-care cost-reductions following alcoholism treatment.     

The influence of coping and depression on abstinence from illicit drug use in methadone-maintained patients

Use of illicit drugs by opioid-dependent patients maintained on methadone undermines the benefits of methadone maintenance treatment. Because supplemental pharmacologic approaches have met with limited success, it is important to identify psychological mechanisms associated with drug use that potentially could contribute to the development of more effective treatments. To investigate this issue, the current study assessed coping and depression in 307 methadone-maintained patients and found a reliance on avoidant coping strategies, most notably by depressed patients. Patients who achieved abstinence following a 12-week coping skills training intervention decreased the use of avoidant coping strategies. Drug use at the 6-month follow-up was related to gains made during treatment, specifically reduced cognitive avoidance, reduced depression, and number of drug-free weeks during treatment.     

Cognitive and behavioural factors as predictors of abstinence following treatment for alcohol dependence

Aim. To assess how far causal attributions about abstinence and relapse, drinking self-efficacy, drinking locus of control expectancy and coping behaviour discriminate abstainers from relapsers following treatment for alcohol dependence. Design. A multicentre 6-month follow-up study. Setting. Mental health centres and self-help groups in Vizcaya (Spain). Participants. The sample was formed by 201 alcoholics who were assessed at their centres and groups on two occasions: while they were in treatment and 6 months later. Measurements. During treatment, participants completed several questionnaires related to cognitive and behavioural variables. Drinking problem and background variables were also assessed. Six months later their drinking status and treatment attendance were examined. Findings. Multivariate tests showed that self-efficacy expectancy and long previous time in abstinence independently discriminated alcoholics who maintained abstinence from those who did not. Other cognitive-behavioural variables showed bivariate association with abstinence, but did not add predictive power to these two measures. Conclusions. The results of this study are consistent with the extensive literature that confirms the predictor power of self-efficacy. Unexpectedly, it did not find independent positive relationships between other psychological variables and abstinence. Given that self-efficacy can predict outcome in the medium term, it is suggested that treatment could target this variable.     

Dual diagnosis patients in substance abuse treatment: relationship of general coping and substance-specific coping to 1-year outcomes

Aims. This study examined general and substance-specific coping skills and their relationship to treatment climate, continuing care and 1-year post-treatment functioning among dual diagnosis patients (i.e. co-occurrence of substance use and psychiatric disorders). Design. In a prospective multi-site study, dual diagnosis patients participating in substance abuse treatment were assessed at intake, discharge and at a 1-year follow-up. Setting. Patients were recruited from 15 substance abuse treatment programs, which were selected from a larger pool of 174 inpatient treatment programs in the Department of Veterans Affairs Health Care System. Participants. A total of 981 male dual diagnosis patients participated in the study. Measurements. Assessments included general and substance-specific coping skills, treatment climate, continuing outpatient care, abstinence and clinically significant psychiatric symptoms. Findings. Dual diagnosis patients modestly improved on general and substance-specific coping skills over the 1-year follow-up period. Patients who were in programs with a 'dual diagnosis treatment climate' and who participated in more 12-Step self-help groups showed slightly more gains in adaptive coping. Both general and substance-specific coping were associated with abstinence, but only general coping was associated with freedom from significant psychiatric symptoms. Conclusions. Enhancing general and substance-specific coping skills in substance abuse treatment may reduce dual diagnosis patients' post-treatment substance use and improve their psychological functioning.     

Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH Three-Year Drinking Outcomes

This study reports 3-year outcomes for clients who had been treated in the five outpatient sites of Project MATCH, a multisite clinical trial designed to test a priori client treatment matching hypotheses. The main purpose of this study was to characterize the status of the matching hypotheses at the 3-year follow-up. This entailed investigating which matching findings were sustained or even strengthened across the 3-year study period, and whether any hypotheses that were not supported earlier eventually emerged at 3 years, or conversely, whether matching findings discerned earlier dissipated at this later time. This research also examines the prognostic effects of the client matching attributes, characterizes the overall outcomes at 37 to 39 months, and explores differential effects of the three treatments at extended follow-up. With regard to the matching effects, client anger demonstrated the most consistent interaction in the trial, with significant matching effects evident at both the 1-year and 3-year follow-ups. As predicted, clients high in anger fared better in Motivational Enhancement Therapy (MET) than in the other two MATCH treatments: Cognitive-Behavioral Therapy (CBT) and Twelve-Step Facilitation (TSF). Among subjects in the highest third of the anger variable, clients treated in MET had on average 76.4% abstinent days, whereas their counterparts in the other two treatments (CBT and TSF) had on average 66% abstinent days. Conversely, clients low in anger performed better after treatment in CBT and TSF than in MET. Significant matching effects for the support for drinking variable emerged in the 3-year outcome analysis, such that clients whose social networks were more supportive of drinking derived greater benefit from TSF treatment than from MET. Among subjects in the highest third of the support for drinking variable, TSF participants were abstinent 16.1 % more days than MET participants. At the lower end of this variable, difference in percent days abstinent between MET and TSF was 3%, with MET clients having more abstinent days. A significant matching effect for psychiatric severity that appeared in the first year posttreatment was not observed after 3 years. Of the 21 client attributes used in testing the matching hypotheses, 11 had prognostic value at 3 years. Among these, readiness-to-change and self-efficacy emerged as the strongest predictors of long-term drinking outcome. With regard to the overall outcomes, the reductions in drinking that were observed in the first year after treatment were sustained over the 3-year follow-up period almost 30% of the subjects were totally abstinent in months 37 to 39, whereas those who did report drinking nevertheless remained abstinent an average of two-thirds of the time. As in the 1-year follow-up, there were few differences among the three treatments, although TSF continued to show a possible slight advantage.     

Engaging young probation-referred marijuana-abusing individuals in treatment: a pilot trial

Young marijuana abusers rarely seek treatment themselves and are difficult to engage in treatment when referred by social agencies. To evaluate treatment engagement strategies in this population, 65 young probation-referred marijuana abusers were randomly assigned to either three-session motivational enhancement therapy (MET alone) or three-session MET plus contingency management (MET/CM), with vouchers for treatment attendance. A significantly higher number of participants in the MET/CM condition completed the three-session intervention as compared with MET alone. Participants in both conditions reported significant reductions in marijuana use and improvement in legal problems. These findings suggest that young marijuana abusers benefit from scientifically validated treatments.     

Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial

Context Due to the chronic nature of cocaine dependence, long‐term maintenance treatments may be required to sustain abstinence. Abstinence reinforcement is among the most effective means of initiating cocaine abstinence. Practical and effective means of maintaining abstinence reinforcement programs over time are needed. Objective To determine whether employment‐based abstinence reinforcement can be an effective long‐term maintenance intervention for cocaine dependence. Design Participants (n = 128) were enrolled in a 6‐month job skills training and abstinence initiation program. Participants who initiated abstinence, attended regularly and developed needed job skills during the first 6 months were hired as operators in a data entry business and assigned randomly to an employment‐only (control, n = 24) or abstinence‐contingent employment (n = 27) group. Setting A non‐profit data entry business. Participants Unemployed welfare recipients who used cocaine persistently while enrolled in methadone treatment in Baltimore. Intervention Abstinence‐contingent employment participants received 1 year of employment‐based contingency management, in which access to employment was contingent upon provision of drug‐free urine samples under routine and then random drug testing. If a participant provided drug‐positive urine or failed to provide a mandatory sample, then that participant received a temporary reduction in pay and could not work until urinalysis confirmed recent abstinence. Main outcome measure Cocaine‐negative urine samples at monthly assessments across 1 year of employment. Results During the 1 year of employment, abstinence‐contingent employment participants provided significantly more cocaine‐negative urine samples than employment‐only participants [79.3% and 50.7%, respectively; P = 0.004, odds ratio (OR) = 3.73, 95% confidence interval (CI) = 1.60–8.69]. Conclusions Employment‐based abstinence reinforcement that includes random drug testing is effective as a long‐term maintenance intervention, and is among the most promising treatments for drug dependence. Work‐places could serve as therapeutic agents in the treatment of drug dependence by arranging long‐term employment‐based contingency management programs.     

Do coping skills mediate the relationship between cognitive–behavioral therapy and reductions in gambling in pathological gamblers?

AIMS: Cognitive-behavioral therapy (CBT) is useful for treating substance abusers, and recent data suggest it is also efficacious for pathological gamblers. CBT is purported to exert its beneficial effects by altering coping skills, but data supporting coping changes as the mechanism of action are mixed. This study examined whether coping skills acquisition mediated the effects of CBT on decreasing gambling in pathological gamblers. DESIGN: Participants were assigned randomly to CBT plus referral to Gamblers Anonymous (GA) or to GA referral alone. Setting Out-patient clinic. PARTICIPANTS: A total of 127 pathological gamblers. MEASUREMENTS: Participants completed the Coping Strategies Scale (CSS) before treatment and 2 months later; indices of gambling behavior and problems were administered pretreatment and at months 2 and 12. FINDINGS: Overall, CSS scores increased for participants in both conditions, but those receiving CBT evidenced larger increases than those in the GA condition (P < 0.05), and they also reduced gambling more substantially between pretreatment and month 2. Changes in CSS scores mediated the relationship between treatment assignment and gambling outcomes from pretreatment to month 2, but little evidence of mediation occurred for the long-term follow-ups. CONCLUSIONS: CBT's beneficial effects in decreasing gambling may be related partly to changes in coping responses, and improvements in coping are associated with long-term changes in gambling. However, relationships between coping skills and gambling behavior are fairly strong, regardless of treatment received.     

A comparison of contingency management and cognitive-behavioral approaches for stimulant-dependent individuals

AIMS: Previous research has reported that both contingency management (CM) and cognitive-behavioral therapy (CBT) are efficacious interventions for the treatment of stimulant abusers. The present study sought to directly compare the effectiveness of (CM) and (CBT) alone and in combination in reducing stimulant use. DESIGN: Randomized clinical trial. PARTICIPANTS: Stimulant-dependent individuals (n = 171). INTERVENTION: CM, CBT or combined CM and CBT, 16-week treatment conditions. CM condition participants received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week. MEASUREMENTS: Participants were interviewed at baseline and weeks 17, 26 and 52. Measures included psychiatric disorders and alcohol and drug use and concomitant social problems. FINDINGS: CM procedures produced better retention and lower rates of stimulant use during the study period. Self-reported stimulant use was reduced from baseline levels at all follow-up points for all groups and urinalysis data did not differ between groups at follow-up. While CM produced robust evidence of efficacy during treatment application, CBT produced comparable longer-term outcomes. There was no evidence of an additive effect when the two treatments were combined. CONCLUSIONS: This study suggests that CM is an efficacious treatment for reducing stimulant use and is superior during treatment to a CBT approach. CM is useful in engaging substance abusers, retaining them in treatment and helping them achieve abstinence from stimulant use. CBT also reduces drug use from baseline levels and produces comparable outcomes on all measures at follow-up.     

Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram

Aims. To evaluate disulfiram and three forms of manual guided psychotherapy for individuals with cocaine dependence and concurrent alcohol abuse or dependence. Design. Randomized controlled trial. Setting. Urban substance abuse treatment center. Participants. One hundred and twenty-two cocaine/alcohol abusers (27% female; 61% African-American or Hispanic). Interventions. One of five treatments delivered over 12 weeks: cognitive behavioral treatment (CBT) plus disulfiram; Twelve Step facilitation (TSF) plus disulfiram; clinical management (CM) plus disulfiram; CBT plus no medication; TSF plus no medication. Measurements. Duration of continuous abstinence from cocaine or alcohol; frequency and quantity of cocaine and alcohol use by week, verified by urine toxicology and breathalyzer screens. Findings. Disulfiram treatment was associated with significantly better retention in treatment, as well as longer duration of abstinence from alcohol and cocaine use. The two active psychotherapies (CBT and TSF) were associated with reduced cocaine use over time compared with supportive psychotherapy (CM). Cocaine and alcohol use were strongly related throughout treatment, particularly for subjects treated with disulfiram. Conclusions. For the large proportion of cocaine-dependent individuals who also abuse alcohol, disulfiram combined with outpatient psychotherapy may be a promising treatment strategy. This study underlines (a) the significance of alcohol use among treatment-seeking cocaine abusers, (b) the promise of the strategy of treating co-morbid disorders among drug-dependent individuals, and (c) the importance of combining psychotherapy and pharmacotherapy in the treatment of drug use disorders.