Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse
Bupropion and Cognitive Behavioral Treatment for Depression in Smoking Cessation
Dr. Richard Brown and colleagues at Brown Medical School and Butler Hospital conducted this randomized, double-blind, placebo-controlled clinical trial to examine the effects of an intensive cognitive-behavioral mood management treatment (CBTD) and of Bupropion, both singularly and in combination, on smoking cessation in adult smokers. Participants were 524 smokers who were randomized to one of four 12-week treatments: (1) standard, cognitive-behavioral smoking cessation treatment (ST) plus Bupropion (BUP); (2) ST plus placebo (PLAC); (3) standard cessation treatment combined with cognitive-behavioral treatment for depression (CBTD) plus BUP; and (4) CBTD plus PLAC. Follow-up assessments were conducted 2, 6, and 12 months after treatment. Consistent with previous studies, Bupropion, in comparison with placebo, resulted in better smoking outcomes in both intensive group treatments. Adding CBTD to standard intensive group treatment did not result in improved smoking cessation outcomes. Also, neither CBTD nor Bupropion, either alone or in combination, was differentially effective for smokers with single past episode of major depressive disorder (MDD), recurrent MDD or elevated depressive symptoms. However, findings with regard to recurrent MDD and elevated depressive symptoms should be interpreted with caution given the low rate of recurrent MDD and the low level of depressive symptoms in the sample. An a priori test of treatment effects in smokers with these depression vulnerability factors is warranted in future clinical trials. Brown, R.A., Niaura, R., Lloyd-Richardson, E.E., Strong, D.R., Kahler, C.W., Abrantes, A.M., Abrams, D., and Miller, I.W. Bupropion and Cognitive Behavioral Treatment for Depression in Smoking Cessation. Nicotine and Tobacco Research, 9(7), pp. 721-730, 2007.
Citalopram Combined with Behavioral Therapy Reduces Cocaine Use
The purpose of this study was to evaluate whether citalopram would reduce cocaine positive urines in a 12-week, double-blind, placebo-controlled trial. Seventy-six cocaine dependent subjects received either citalopram (20 mg/day) or placebo along with cognitive behavioral therapy (CBT) and contingency management (CM). In this study, citalopram treated subjects showed a significant reduction in cocaine-positive urines during treatment compared to placebo. There were no differences in retention between the two groups. Moeller, F.G., Schmitz, J.M., Steinberg, J.L., Green, C.M., Reist, C., Lingo, Y.L., Swann, A.C., and Grabowski, J. Citalopram Combined with Behavioral Therapy Reduces Cocaine Use: A Double-blind, Placebo-controlled Trial. Am. J. Drug and Alcohol Abuse, 33, pp. 367-378, 2007.
Cognitive Interviews For Measurement Evaluation of the Fagerstro_m Test For Nicotine Dependence (FTND) in Smokers with Schizophrenia Spectrum Disorders
Dr. Judith Prochaska and colleagues at the University of California, San Francisco, conducted this study to determine if the Fagerstro_m Test for Nicotine Dependence (FTND), the most widely used measure of nicotine dependence, is appropriate to use with smokers diagnosed with schizophrenia. The current study employed cognitive interviews to evaluate the FTND with smokers diagnosed with schizophrenia spectrum disorders, recruited from an acute inpatient psychiatry setting, and a comparison group of smokers recruited from the community. The groups were comparable on tobacco use variables and FTND scores. Detailed qualitative cognitive interviews indicated all subjects understood the FTND items. For both groups, the FTND missed nocturnal smoking, reported as weekly by 80% of patients and 47% of controls. Finishing other people's cigarettes also was under-reported. The cognitive interview methodology proved useful for understanding how individuals interpreted and answered the FTND items. Overall, the qualitative findings identified limitations in the FTND for both groups, with the limitations generally more pronounced among patients with schizophrenia. Prochaska, J.J., Leek, D.N., Hall, S.E., and Hall, S.M. Cognitive Interviews for Measurement Evaluation of the Fagerstrom Test for Nicotine Dependence (FTND) in Smokers with Schizophrenia Spectrum Disorders. Addictive Behaviors, 32, pp. 793-802, 2007.
Voucher Reinforcement Improves Medication Adherence In HIV-Positive Methadone Patients: A Randomized Trial
Dr. Sorensen and colleagues conducted the present study to examine the use of voucher-based contingency management in a novel application, to reinforce taking HAART medication in HIV-positive methadone maintenance patients. After a 4-week baseline observation phase, eligible participants (N=66) were randomly assigned to (a) medication coaching sessions every other week to assist with adherence strategies (comparison group) or (b) medication coaching plus voucher reinforcement for opening electronic medication caps on time (voucher group). The intervention was provided for 12 weeks, with a 4-week follow-up. The primary outcome results of the clinical trial indicated effectiveness during the intervention, with significant mean adherence differences between voucher and comparison groups using electronic measurement (78% vs. 56%), pill count (86% vs. 75%), and self report (87% vs. 69%). Differences between groups faded after vouchers were discontinued. Contingency management shows promise as a strategy to promote antiretroviral medication adherence in this population. Sorensen, J.L., Haug, N.A., Delucchi, K.L., Gruber, V., Kletter, E., Batki, S.L., Tulsky, J.P., Barnett, P., and Hall, S. Voucher Reinforcement Improves Medication Adherence in HIV-positive Methadone Patients: A Randomized Trial. Drug and Alcohol Dependence, 88, pp. 54-63, 2007.
Contingencies for Change in Complacent Smokers
Dr. Richard Lamb and colleagues at the University of Texas Health Science Center conducted this study to determine if contingencies can be used to produce change in complacent smokers, who are less likely to quit than other smokers. The authors compared complacent smokers randomly assigned to receive incentives for breath carbon monoxide (BCO) (n=18) or noncontingent incentives (n=19) for 3 months. Contingent incentives were associated with (a) reduced BCO; (b) more BCO samples indicative of abstinence; (c) fewer cigarettes smoked and more days abstinent at study end; and (d) lower salivary cotinine. These behaviors can predict future cessation, and 2 of the 18 smokers (11%) receiving BCO-contingent incentives reported quitting as compared with none of those in the control group. Contingency management procedures may effectively promote cessation among complacent smokers and provide a model for understanding the possible effects of some environmental interventions, such as workplace smoking bans, on the behavior of complacent smokers. Lamb, R.J., Morral, A.R., Kirby, K.C., Javors, M.A., Galbicka, G., Iguchi, M. Contingencies for Change in Complacent Smokers. Experimental and Clinical Psychopharmacology, 15(3), pp. 245-255, 2007.
Delay Discounting Predicts Postpartum Relapse to Cigarette Smoking Among Pregnant Women
Investigators conducted this study to examine whether delay discounting (DD), a measure of impulsivity, predicts treatment outcome among cigarette smokers. More specifically, the authors examined whether baseline discounting for hypothetical monetary rewards predicted smoking status at 24 weeks postpartum among women who discontinued smoking during pregnancy. Participants were 48 pregnant women who participated in a clinical trial examining the use of incentives to prevent postpartum relapse. Several sociodemographic characteristics (being younger, being less educated, and reporting a history of depression) assessed at study entry were associated with increased baseline DD, but in multivariate analyses only DD predicted smoking status at 24 weeks postpartum. Greater baseline DD was a significant predictor of smoking status at 24 weeks postpartum. DD was reassessed periodically throughout the study and did not significantly change over time among those who eventually resumed smoking or those who sustained abstinence. The results extend the association of DD with risk for substance abuse to pregnant and recently postpartum cigarette smokers and demonstrate a significant relationship between DD and treatment outcome. Yoon, J.H., Higgins, S.T., Sugerbaker, R.J., Thomas, C.S., and Badger, G.J. Delay Discounting Predicts Postpartum Relapse to Cigarette Smoking Among Pregnant Women. Experimental and Clinical Psychopharmacology, 15 (2), pp. 176-186, 2007.
Improved Adherence with Contingency Management
Dr. Rosen and colleagues conducted this study to determine if contingency management (CM) can improve adherence to prescribed medications. Fifty-six participants with histories of illicit substance use who were prescribed antiretroviral medication but evidenced suboptimal adherence during a baseline assessment were randomly assigned to 16 weeks of weekly CM-based counseling or supportive counseling, followed by 16 additional weeks of data collection and adherence feedback to providers. The CM intervention involved review of data generated by electronic pill-bottle caps that record bottle opening (MEMS) and brief substance abuse counseling. CM participants were reinforced by MEMS-measured adherence with drawings from a bowl for prizes and bonus drawings for consecutive weeks of perfect adherence. Potential total earnings averaged $800. Mean MEMS-measured adherence to the reinforced medication increased from 61% at baseline to 76% during the 16-week treatment phase and was significantly increased relative to the supportive counseling group (p=.01). Furthermore, mean log-transformed viral load was significantly lower in the CM group. However, by the end of the 16-week follow-up phase, differences between groups in adherence and viral load were no longer significantly different. Proportions of positive urine toxicology tests did not differ significantly between the two groups at any phase. A brief CM-based intervention was associated with significantly higher adherence and lower viral loads. Further studies should evaluate methods to extend effects for longer term benefits. Rosen, M.I., Dieckhaus, K., McMahon, T.J., Valdes, B., Petry, N.M., Cramer, J., and Rounsaville, B. Improved Adherence with Contingency Management. AIDS Patient Care, 21(1), pp. 30-40, 2007.
A Mindfulness-Based Stress Reduction Intervention Can Be Integrated Into a Therapeutic Community Setting
Dr. Marianne Marcus of the University of Texas at Houston and colleagues report on using a stage model of therapy development to integrate a mindfulness intervention into a therapeutic community (TC) for substance abuse treatment. Consistent with the stage model, Dr. Marcus collected data to describe the target population (drug abusers in a TC setting), drafted a mindfulness intervention manual iteratively with stakeholder input, trained interventionists in the integrated mindfulness/TC approach, and tested the intervention in a small-scale pilot study comparing the experimental condition to a historical control condition at the same site. Also consistent with the stage model of therapy development, careful attention was paid to monitoring treatment integrity (i.e., the degree to which the intervention was delivered faithfully and competently). Results of the pilot test will be published in a future manuscript. Marcus, M.T., Liehr, P.R., Schmitz, J., Moeller, F.G., Swank, P., Fine, M., Cron, S., Granmayeh, L.K., and Carroll, D.D. Behavior Therapy Trials: A Case Example. Nursing Research, 56, pp. 210-216, 2007.
Helping Students Overcome Substance Abuse: Effective Practices for Prevention and Intervention
Dr. Jason Burrow-Sanchez of the University of Utah and colleague Dr. Leanne Hawken published a book aimed at translating scientific advances into practical strategies that can be implemented by school mental health professionals to address the needs of students at risk for or already abusing drugs. This book provides guidance for school counselors about screening for substance use and abuse, designing individual-based or group-based intervention programs in school settings, and interpreting the implications of policy for school-based intervention. Burrow-Sanchez, J.J., and Hawken, L.S. Helping Students Overcome Substance Abuse: Effective Practices for Prevention and Intervention. The Guilford Press, New York, NY, 2007.
If Substance Abuse Is a Chronic, Relapsing Condition, Substance Abuse Treatment May Need to Be Chronic and Addressing Relapse Too
Drs. Suniya Luthar of Columbia University, Nancy Suchman of Yale University, and Michelle Altomare published the results of a randomized clinical trial testing Relational Psychotherapy Mothers' Group (RPMG) for substance-abusing, methadone-maintained mothers with young children. A total of 60 mothers participated in RPMG and 67 participated in recovery training (RT). At 6 months after starting treatment, women in the RPMG group showed greater improvements in child maltreatment and cocaine abuse, and children of women in RPMG reported greater improvements in emotional adjustment than did other children. However, these treatment gains were not sustained once treatment was discontinued. These results lend support to the notion of substance abuse as a chronic, relapsing condition that may best be treated by ongoing monitoring and intervention. Luthar, S.S., Suchman, N.E., and Altomare, M. Relational Psychotherapy Mother's Group: A Randomized Clinical Trial for Substance Abusing Mothers. Development and Psychopathology, 19, pp. 243-261, 2007.