Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse
Escalating Reinforcement Schedule with Resets Results in Faster Abstinence and More Resistance to Relapse in Methamphetamine Users
Dr. John Roll and others at Friends Research Institute examined five different schedules for delivering vouchers exchangeable for goods and services, contingent on providing a methamphetamine abstinent urine specimen within the context of a group outpatient behavioral treatment setting. Although the total monetary value for vouchers earned was approximately equal in all conditions, schedules differed in terms of whether the values escalated over time, remained stable or decreased over time, whether they reverted to baseline levels in response to a drug positive urine, and whether participants were offered bonus incentives for obtaining several drug free urine tests in a row. Reinforcement schedules differed in terms of the speed at which participants initiated abstinence. The schedule which provided a stable reinforcement value of $25.00 per abstinence episode, along with a $50.00 bonus for three consecutive drug negative urines, resulted in 50% fewer participants obtaining a 4 week long period of abstinence. Additionally, the schedule, which began at $2.50 for first negative specimen increased the abstinence contingency by $1.25 for each consecutive drug abstinent specimen provided, gave a $10.00 bonus for each block of three consecutive drug free urines, and which reset the voucher value to the previously earned level for any drug positive urine, produced the most resistance to relapse. The total amount of reinforcement available under this schedule was $997.50 for 12 weeks of treatment if a participant remained 100% abstinent. These findings are significant because they underscore the value of providing contingent reinforcement for abstinence as a component of methamphetamine treatment. Additionally they demonstrate that using the escalating schedule with a reset contingency for drug use can substantially improve outcomes beyond what can be obtained for the same amount of money distributed without such contingencies. Roll, J. M., Huber, A.M., Sodano, R., Chudzynski, J.E., Moynier, E. and Shoptaw, S. The Psychological Record, 56, pp. 67-81, 2006.
Comparing Intervention Outcomes in Smokers Treated for Single Versus Multiple Behavioral Risks
Investigators conducted this study to determine whether smoking cessation outcome differed in smokers at risk and treated for smoking only versus those at risk and treated for one or two additional risk behaviors (high fat diets and high-risk sun exposure). The sample consisted of participants from three population-based studies (N=2,326). In each trial, participants were randomized to one of two groups: an expert system intervention or an assessment-only control condition. The stage-based expert system used tailored communications for treating the cancer-related risk behaviors of cigarette smoking, high-fat diet, or high-risk sun exposure. Findings indicate that there was no reduction in smoking cessation success when additional behavioral risks were treated. The smoking cessation expert system intervention resulted in significantly enhanced abstinence rates at long-term follow-up, with similar treatment effects among individuals at risk and treated only for smoking compared with persons at risk and treated for smoking plus one or two additional risk behaviors. The current findings support the strategy of treating multiple rather than single behaviors within individuals and populations that have multiple risks. Prochaska, J.J., Velicer, W.F., Prochaska, J.O., Delucchi, K., and Hall, S.M. Health Psychology, 25, pp. 380-388, 2006.
Do Smokers with Alcohol Problems have More Difficulty Quitting?
This paper reviews studies comparing smokers with and without alcohol problems on their nicotine dependence, ability to quit on a given quit attempt, whether they ever quit (lifetime quitting), and number of quit attempts. Almost all studies found that smokers with current and past alcohol problems were more nicotine dependent than smokers with no alcohol problems. Smokers with past alcohol problems were as likely to stop smoking on a given quit attempt as smokers with no problems, despite their increased nicotine dependence. It is hypothesized that this may be because smokers with past alcohol problems learned certain motivational and coping skills during alcohol recovery that helped them stop smoking and this counteracted the effect of greater nicotine dependence. Smokers with current or past alcohol problems appear to be less likely to quit in their lifetime. Given their equal ability to quit on a given attempt, this could be due to fewer quit attempts; however, whether this is actually so is unclear. The finding that smokers with past alcohol problems can quit as easily as those without alcohol problems suggests that smokers with past alcohol problems may respond to minimal treatments to stop smoking and may not necessarily need specialized treatment. Hughes, J.R., and Kalman, D. Drug and Alcohol Dependence, 82, pp. 91-102, 2006.
Characterizing Nicotine Withdrawal in Pregnant Cigarette Smokers
The aim of this study was to characterize nicotine withdrawal and craving in pregnant cigarette smokers. These data were collected as part of prospective clinical trials assessing the efficacy of voucher-based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum. Results from 27 abstainers and 21 smokers during the first 5 days of a cessation attempt were examined. Abstinent pregnant smokers reported more impatience, anger and difficulty concentrating than did smokers. The results also suggest that pregnant smokers generally may have elevated baseline levels of withdrawal, which need to be considered in the design and analysis of future studies. Heil, S.H., Higgins, S.T., Mongeon, J.A., Badger, G.J., and Bernstein, I.M. Experimental and Clinical Psychopharmacology, 14, pp. 165-170, 2006.
A Comparison Between Low-Magnitude Voucher and Buprenorphine Medication Contingencies in Promoting Abstinence from Opioids and Cocaine
Investigators conducted this study to determine the relative efficacy of low-magnitude, contingency monetary vouchers, contingent buprenorphine medication, and standard counseling in promoting abstinence from illicit opioids and cocaine among opioid dependent adults. Following an 8 week baseline period during which participants received buprenorphine maintenance treatment with no contingencies in place, 60 participants were randomly assigned to one of 3 treatment groups for 12 weeks: 1) participants in the voucher group earned vouchers for each opioid and cocaine negative urine sample, in accordance with an escalating schedule. Continuous abstinence resulted in voucher earnings equivalent to a total of $269, which participants could exchange for material reinforcers of their choice. 2) Participants in the medication contingency group received half of their scheduled buprenorphine dose for clinic attendance and the other half for remaining abstinent from opiates and cocaine. 3) Participants in the standard counseling group did not receive programmed consequences contingent on urinalysis results. All participants were maintained on buprenorphine according to a 3 times per week dosing regimen and participated in behavioral drug counseling. Retention rates did not differ significantly across groups; however, participants in the medication contingency group achieved significantly more weeks of continuous abstinence from opiates and cocaine compared with participants in the voucher group. Results suggest that the use of medication-based contingencies in combination with behavioral therapy may have clinical utility in promoting abstinence. Gross, A., Marsch, L.A., Badger, G.J., and Bickel, W.K. Experimental and Clinical Psychopharmacology, 14 (2), pp. 148-156, May 2006.
Randomized, Placebo Controlled Trial of Sertraline and Contingency Manangement for the Treatment of Methamphetamine Dependence
Investigators evaluated the efficacy of sertraline (50mg twice a day) and contingency management for the treatment of methamphetamine dependence. In this randomized, placebo-controlled, double-blind trial, participants completed a 2 week non medication baseline and were randomized to one of four conditions for 12 weeks: sertraline plus contingency management (n=61); sertraline only (n=59); matching placebo plus contingency management (n=54); or matching placebo only (n=55). All participants attended clinic three times per week for data collection, medication dispensing, and relapse prevention groups. Outcomes included methamphetamine use (urine drug screening and self reported days of use), retention (length of stay), drug craving (visual analogue scale), and mood symptoms (Beck Depression Inventory). Study findings showed no statistically significant main or interaction effects for sertraline or contingency management in reducing methamphetamine use using a generalized estimating equation, although post hoc analyses showed the sertraline only condition had significantly poorer retention than the other conditions. Sertraline conditions produced significantly more adverse events than placebo conditions. A significantly higher proportion of participants in contingency management conditions achieved three consecutive weeks of methamphetamine abstinence than those in the non-contingency management conditions. These data do not demonstrate improved outcomes for sertraline versus placebo for treatment of methamphetamine dependence and suggest that sertraline may be contraindicated for methamphetamine dependence. However, the findings provide support for the use of contingency management in the treatment of methamphetamine dependence. Shoptaw, S., Huber, H., Peck, J., Yang, X., Liu, J., Dang, J., Roll, J., Shapiro, B., Rotheram-Fuller, E., and Ling, W. Drug and Alcohol Dependence, April 2006.
The Role of Homework in Cognitive-Behavioral Therapy for Cocaine Dependence
This study examined the effects of homework compliance on treatment outcome in 123 participants receiving cognitive behavioral therapy for cocaine dependence. Regression analyses revealed a significant relationship between homework compliance and cocaine use that was moderated by readiness to change. Homework compliance predicted less cocaine use during treatment but only for participants higher in readiness to change. For those lower in readiness to change, homework compliance was not associated with cocaine use during treatment. Homework compliance early in therapy was associated with better retention in treatment. Homework compliance was not predicted by participants' level of education or readiness to change. These findings support the use of homework during cognitive behavioral therapy for substance use disorders. Gonzales, V.M., Schmitz, J.M., and Delaune, K.A. J. Consulting and Clinical Psychology, 74(3), pp. 633-637, June 2006.
Recommendations for Managing Analytic Complexities Associated with Group Therapy for Substance Abuse Treatment
Using state-of-the-science group therapy studies as examples, Drs. Antonio Morgan-Lopez and William Fals-Stewart, of the Research Triangle Institute, highlight the logistical, methodological, and analytic complexities of group therapy research and provide clarifying recommendations. Complexities discussed include whether to constitute "closed" groups with fairly stable group membership, or "rolling" groups with frequently changing membership; the interdependence of group participants, and changes in group membership; and assuming group data is hierarchical, with group members fully nested within a group. Recommendations include matching the analytic approach to the study goals, working toward development of new statistical approaches, and collecting time series data to inform these new approaches. Given that the vast majority of substance abuse treatment is delivered in group settings, and the tremendous complexity of evaluating group therapy data, this sort of guidance to investigators is sorely needed to advance the field of treatment research. Morgan-Lopez, A. A., and Fals-Stewart, W. Experimental and Clinical Psychopharmacology, 14, pp. 265-273, 2006.
Making Sense of Therapeutic Alliance as a Mechanism in Adolescent Substance Abuse Treatment: Not All Behavior Change in Treatment Can be Explained by Therapeutic Alliance
Dr. Aaron Hogue and colleagues at the National Center on Addiction and Substance Abuse at Columbia University, Dr. John Cecero of Fordham University, and Dr. Howard Liddle of the University of Miami conducted a secondary analysis study of the role of therapeutic alliance in treatment success for adolescent substance abusers. In general, therapeutic alliance is conceptualized as the degree to which a therapist and client(s) develop a positive, collaborative relationship, and the strength of this relationship is thought by some to be one of the key ingredients in therapy success. But others have argued that therapeutic alliance is not sufficient to produce change, that alliance is a product of success rather than a cause of it, and that the role of alliance may differ depending on the therapy model and the developmental stage of the patient. This groundbreaking study tested the role of therapeutic alliance for adolescents in treatment, and compared the role of alliance in two different therapy models (individual-based cognitive-behavioral therapy, or CBT, vs. family-based Multi-Dimensional Family Therapy, or MDFT). Overall, the investigators found that therapeutic alliance was not a significant predictor of treatment outcome for adolescents in CBT, but both parent and adolescent alliance predicted outcome for MDFT. Importantly, while stronger parent-therapist alliances predicted better outcomes in MDFT, stronger adolescent-therapist outcomes predicted worse outcomes in MDFT, based on parent reports of their teens' externalizing behavior. The results of this study caution against a simple alliance explanation for therapeutic success, and suggest that a simple focus on the therapeutic relationship or on the therapy technique alone is likely to be an inadequate explanation of complex behavior change. Hogue, A., Dauber, S., Stambaugh, L. F., Cecero, J. J., and Liddle, H. A. Journal of Consulting and Clinical Psychology, 74, pp. 121-129, 2006.