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National Institute on Drug Abuse

Behavioral Therapies Development Program - Basic Research and Development

Research Project Grant (R01)

Efficacy of Three Models of Nicotine Patch Treatment

Alterman, Arthur; University of Pennsylvania

The primary goal of this project is to compare and determine the effectiveness of three levels of medical/behavioral treatments intensity used in conjunction with the nicotine patch in a diverse population. The major specific objective is to compare the short and long term efficacy, as well as the cost-effectiveness, of three levels of treatment: 1) a minimal control condition consisting of nicotine patch detoxification for 8 weeks plus one session consisting of an instructional videotape + advice and education by a nurse practitioner (NP; n=80); 2) an experimental condition consisting of nicotine detoxification plus three additional brief advice and educational (A&E) sessions with a nurse practitioner (A&E; N=80); and 3) an experimental condition consisting of the foregoing A&E treatment combined with 12 weeks of individualized, manually-driven cognitive behavioral therapy (CB; N=80). Completion of patch treatment and smoking cessation and reduction rates at 9, 26, and 52 weeks post-intake into the study will be the measures of efficacy. Secondary objectives of the research are to examine the moderating effects of a number of variables that may affect response to treatment: 1) to determine the extent to which baseline nicotine dependence severity is a negative predictor of treatment response, reflected in treatment completion and in smoking cessation and reduction rates; 2) to determine the extent to which low nicotine patch serum cotinine replacement values are a negative predictor of treatment response; 3) to compare treatment completion rates and smoking cessation/reduction rates in smokers with versus without a history of an Axis l/II disorder; 4) to determine the predictive validity of pre- and treatment cue reactivity in accounting for outcomes in each treatment condition; 5) to determine whether there is a positive relationship between the initial level of motivation to quit smoking and actual smoking cessation; 6) compare the cost effectiveness of the three forms of treatment; and 7) to determine whether any sociodemographic characteristics of the subject are predictive of treatment response.

This is an outpatient, prospective, matched, random assignment, experimental study which will take place over a five year period. Two hundred forty (n=240) nicotine dependent cigarette smokers will be randomized over a three year period. All groups must complete patch treatment in 8 weeks from the start of patch treatment. Abstinence at the 9, 26, and 52 week post-intake follow-up evaluations will be based on a combination of self report, CO readings, and urine cotinine data. Other measures will include the Fagerstrom Nicotine Addiction questionnaire, the Shiffman-Jarvik Smoking Withdrawal questionnaire, time line followback for weekly cigarette use for six months prior to treatment and for the 52 weeks following entry into the study, Axis I and Axis II semi-structured interviews, serum cotinine levels prior to and following use of the patch, cue reactivity data, the URICA measure of motivation, cost and cost effectiveness data, the SCL-90, and urine drug screens and blood alcohol concentrations. Assessments will be done at 0, 3, 6, 9, 26, and 52 weeks.

The study findings will inform the treatment community about the most effective and cost effective patch treatments; the association between a number of significant subject variables and treatment response, and the most effective combination of patch treatment for individuals with different kinds of presenting problems.

Reducing High Risk Behavior in HIV-Positive Drug Abusers

Avants, Kelly; Yale University

An urgent need exists for treatments to reduce HIV risk behaviors among HIV-seropositive injection drug users as well as to determine optimal treatment intensity to accomplish this goal. One hundred HIV-SEROPOSITIVE cocaine-abusing methadone-maintained patients will be stratified by severity of cognitive impairment and randomly assigned to receive either a comprehensive Risk Reduction Methadone Program, developed specifically for HIV-positive injection drug users, or a standard methadone program that includes NIDA's HIV Counseling and Education Intervention. The specific aims of this study are: (a) to determine the relative efficacy of a specialized Risk Reduction Methadone Program for reducing high risk behaviors and increasing compliance with medical regimens in HIV-SEROPOSITIVE injection drug users, at treatment completion and at a three month follow-up; and (b) to explore predictors of treatment outcome, such as cognitive ability, disease progression, psychosocial functioning, and motivation for behavior change.

Matching Patients to Smoking Treatments

Baker, Timothy; University of Wisconsin, Madison

Smoking is the leading preventable cause of death and morbidity in the United States. The chief aim of this research is to demonstrate that particular kinds of smokers quit smoking more successfully with one treatment than another. Such a result would permit the optimal matching of smokers with cessation treatments and increase smoking treatment efficacy. The two smoking cessation treatments contrasted in this research are support counseling and skill training. These are frequently used treatments and are easy to implement. 560 smokers, stratified on their pretreatment affect, will be randomly assigned to one of four interventions: skill training, support counseling, combined skill training and support counseling, or an attention/placebo control condition. All subjects will receive the nicotine patch as an adjuvant.

The three active-counseling treatments should produce significantly greater long-term abstinence than the control treatment. The most important predicted result is that subjects' pretreatment negative affect (mood) will interact with treatment type. Among subjects high in negative affect prior to treatment, support counseling will produce better outcomes than any other treatment. Among subjects with little pretreatment negative affect, skill training will produce better outcomes than any other treatment. Finally, this research will reveal the mechanisms by which the various treatments produce their beneficial effects, and materials will be developed that will promote the widespread use of the identified matching rules. Because quitting smoking has large health benefits, this research should reduce death and disease produced by smoking.

Cognitive Therapy in Personality Disordered Drug Abusers

Ball, Samuel; Yale University

Substance abuse and personality disorders frequently co-occur in clinical populations. The presence of a personality disorder may lead to higher relapse rates, noncompliance, and poor outcome in substance abuse treatment programs. Although treatments for antisocial and borderline personality disordered drug abusers are being developed, there have been no systematic evaluations of integrated treatments of a more diverse range of disorders. This project will modify and develop a 24-week individual cognitive-behavioral therapy which integrates relapse prevention with a schema-focused approach to treat the interrelated symptoms of substance abuse and personality disorders. Developing a theoretically and technically integrated psychotherapy which is systematically linked to assessment results may improve drug abuse treatment retention and efficacy for this difficult to treat population.

The goals of this Stage I behavioral therapy development study are to: 1) pre-pilot (n=10) and develop a manual for schema-focused cognitive-behavioral therapy for substance abusers with any Axis II personality disorder (SCT-II); 2) develop an SCT-II training manual, train therapists, and develop and implement competence and adherence rating scales; (3) conduct a pilot study of the SCT-II manual, which will evaluate the effectiveness, feasibility, and acceptability of SCT-II in comparison with drug counseling with 30 opioid dependent patients in methadone maintenance. Primary outcomes of the pilot study will be: 1) treatment retention; 2) substance use; 3) psychological symptoms.

Therapist Adherence to Treatment of Cocaine Abuse

Barber, Jacques; University of Pennsylvania

The goals of this project are: to develop further measures of adherence to treatment manuals and of the quality of delivery of treatment for three modalities (Cognitive Therapy (CT), Drug Counseling (DC), and Supportive-Expressive Dynamic Psychotherapy (SE)) included in the Treatments for Cocaine Addiction Collaborative Study (TCACS); and to provide additional evidence for the reliability and validity of these measures. Reliability will be examined by calculating coefficients of interjudge reliability; internal consistency and test-retest reliability of the scales. Scales validity will be addressed by examining: 1) face validity; 2) concurrent validity; and, 3) predictive validity. Concurrent validity of the scales will be examined by evaluating: a) whether the TCACS modalities as they are delivered indeed differ; and, b) by correlating the independent expert judges' ratings of therapists' actions with the ratings from the TCACS' supervisors. Predictive validity of the scales will be explored by examining the relations between therapists' behavior and patient outcome in a sample of the patients.

The pilot reliability (interjudge and internal consistency) and developmental studies of the adherence measures will be performed in three initial samples. Each pilot sample will include 15 audiotapes from the training phase of the TCACS, each one of them are rated by experts from all modalities. Further reliability and validity (discriminant, concurrent, and predictive) will be examined by having experts in the three modalities rate 2 tapes from a sample of patients who participated in the TCACS. Expert judges in SE, CT, and IDC will rate 2 tapes from 5 randomly selected patients for each therapist enrolled in each modality.

In view of the fact that psychosocial approaches are the treatment of choice for cocaine abuse, the significance of the current research program is that: 1) it will provide the field with measures of adherence and quality of applying techniques for widely used forms of psychosocial treatments (cognitive, dynamic and drug counseling) for cocaine abuse; 2) it will examine whether TCACS therapists' actions in each of these different psychosocial treatments for cocaine abuse, can be differentiated; and, 3) it will explore the complex relations among therapists' behavior and treatment outcome in a sample of TCACS patients.

Behavioral Therapy for Substance Abuse by Schizophrenics

Bellack, Alan; University of Maryland, Baltimore

Substance abuse by schizophrenia patients is one of the most pressing problems facing the mental health system. The lifetime prevalence rate of substance abuse in schizophrenia is close to 50%, and estimates of current abuse range from 20-65%. Excessive substance use by schizophrenics increases the risk of symptom exacerbation and relapse, decreases compliance with treatment, serves as a significant source of conflict in families, and has a pernicious effect on neurological and cognitive functioning. Substance abusing schizophrenia patients are not adequately served by either traditional substance abuse programs or by purely psychiatric programs. There is an urgent need for empirically based programs that integrate essential elements of both psychiatric and substance abuse treatment.

The purpose of this project is to conduct a Phase I project to develop and pilot test a multifaceted behavioral therapy to reduce substance use in schizophrenia patients. The therapy will contain a number of elements, including: 1) social skills and problem solving training, 2) coping skills for managing stress and residual psychotic symptoms that contribute to substance use, 3) education about substance abuse coupled with goal setting; and 4) behavioral (social learning) techniques to decrease substance use and teach relapse prevention skills. Each component of the therapy program will first be tested in preliminary clinical trials on groups of 6-8 dually diagnosed schizophrenia patients. The procedures will be modified as needed, and a carefully monitored pilot trial of the entire package will then be conducted on 32 patients. The final version will be manualized to allow replication in subsequent studies.

Prescriptive Therapy for Drug Abuse with Depression

Beutler, Larry; University of California, Santa Barbara

Cocaine abuse represents a serious and growing problem in American society. Effective treatments are needed that both address problems of drug use and abuse and that adequately address concomitant and frequently observed depression in this group. This project is a preliminary step toward conducting a large scale, randomized clinical trial comparison of a treatment that selectively combines effective procedures from several different treatment approaches. Specifically, Prescriptive Therapy (PT) uses subject distress level, externalizing coping style, and resistance tendencies to individualize treatment and guide the selection of interventions drawn from supportive counseling, cognitive therapy, and experimental treatment models. In anticipation of the larger study, PT is being refined and contrasted with two manualized treatments, Cognitive Therapy (CT) and Supportive/Self-Directed Therapy (S/SD) through four preparatory phases. In Phase 1, this research group will select instruments and refine the rules of applying Prescriptive Therapy and the contrasting interventions. In Phase 2, the group will test procedures for selecting and training therapists in the three treatment procedures. In Phase 3, they will select a sample of patients presenting with cocaine abuse and mild to moderate dysphoria within the depressive spectrum. This phase is used to answer questions of subject availability and representativeness as well as to select participants in the final phase of the current project. In Phase 4, they will pilot test the ability to deliver the modified PT, CT, and S/SD treatments to co-morbid, cocaine abusing and depressed patients.

Concurrent Treatment of PTSD and Cocaine Dependence

Brady, Kathleen; Medical University of South Carolina

The high prevalence of victimization and its sequelae among cocaine-dependent individuals is an issue of much current concern. Recent studies have suggested meaningful relationships between substance use disorders, victimization and psychiatric disorders most notably Post-traumatic Stress Disorder (PTSD). While it has been estimated that as many as 30% of individuals with substance use disorders suffer from PTSD, the appropriate treatment of these individuals remains to be elucidated. This project was designed to develop and pilot test a treatment manual which specifically targets cocaine-dependent individuals who have current crime-related PTSD (CR-PTSD). The manual will be an integration of a cognitive behavioral therapy manual which has been developed for the treatment of PTSD with a cognitive behavioral therapy manual which has been developed for the treatment of cocaine dependence. A unique feature of the manual developed will be the addition of specific training in HIV-risk reduction strategies. The three year project is divided into 4 phases: manual development and the development of specific integrity, competence and adherence measures for the manuals; therapist training and pilot therapy (10 subjects) deliveries; manual revision; and pilot testing of the manual in 25 subjects. Process evaluation will guide the refinement of the manual during the course of the project. Treatment outcome will be evaluated along multiple dimensions. The specific aims of this project are: 1) To develop and refine a treatment manual for CBT targeting issues specific to cocaine-dependent individuals with CR-PTSD which also addresses HIV-RISK behaviors. 2) To develop measures of therapist competence, adherence and integrity specific to the integrated treatment manual, 3) To develop and implement a training program for therapists to use the integrated treatment manual, 4) To pilot test the manual in 25 individuals with concurrent CRPTSD and cocaine-dependence.

In summary, this project targets the treatment of cocaine-dependent individuals who have been victims of violence and have current CR-PTSD. If the data gathered in this project is promising, a proposal to support the implementation of the manual developed in a larger, Stage II, controlled clinical trial will be developed.

All participants will be assessed initially and at 6 and 12 months by two structured interviews, the Individual Assessment Profile (IAP) and the Risk for AIDS Behaviors Questionnaire (RAB). Outcome measures of interest for each six month period are: number of positive urinalysis, self reported drug use days, days in treatment, number of people with whom drug injection equipment was shared, number of arrests, days employed or in school. To study intensively immediate precipitants of first events of drug use following a period of abstinence. Such study is to include the context of background, person, treatment, and environmental determinants of lapses. To evaluate the adequacy of the proposed model in explaining lapses and empirical definitions of relapse. The breadth of these analyses will also reflect on and sharpen existing theories of relapse.

The methodology for pursuing these goals entails a multivariate correlational design that incorporates an initial classification of clients according to gender. A detailed assessment of clients will occur at treatment entry. Subjects and their collaterals will be interviewed at months 1 through 6, 9, and 12 after treatment entry to collect detailed information on their substance use and on lapses/relapses that have occurred since their last assessment. Taken together, this research will provide important information needed to expand knowledge regarding the myriad of factors and processes associated with lapse/relapse and their interplay.

Antisocial Drug Abusers - Diagnosis and Treatment

Brooner, Robert; Johns Hopkins University

Antisocial personality disorder is a common condition in intravenous opioid abusers. More importantly, the diagnosis of antisocial disorder in opioid abusers is associated with a poor response to routine treatment, high rates of drug use (especially cocaine), high rates of aggressive and criminal behaviors, and high rates of HIV-l infection. Efforts to improve the treatment outcome of this group is a major therapeutic challenge with compelling public health implications. Dr Brooner's group was funded approximately 48 months ago to do specific work in that area. The work included: 1) determining the prevalence of antisocial disorder in a previously unsurveyed population of opioid abusers; 2) examination of the diagnostic concordance rate for antisocial disorder using two structured interviews; 3) characterization of antisocial patients using dimensional measures of personality and psychopathy; and 4) evaluation of routine drug abuse treatment outcome and the efficacy of a novel behavioral intervention developed to reduce drug use and improve retention of these patients. Considerable progress has been made. Two studies will extend the work in this important area. The group will complete a randomized, controlled clinical trial that is evaluating the efficacy of a highly structured behavioral intervention that utilizes a novel contingency contracting approach in treating antisocial opioid abusers. This new treatment intervention should be especially effective with these patients since it provides a motivating set of contingencies that specify exactly what behaviors are expected and provides timely reinforcements for those behaviors (e.g., reduced drug use).

The second study will focus on two relatively common dimensions of antisocial disorder - chronic aggressiveness and deficits in aversive reactivity (diminished ability to inhibit previously punished behaviors). The study will be conducted in a residential laboratory environment with opioid abusers who will be carefully selected to represent three distinct levels of antisocial behavior (low, mid, high) based on both diagnostic DSM-III-R/DSM-IV) and dimensional assessment measures (e.g., Psychopathy Checklist-revised; PCL-R). Both aggression and diminished aversive reactivity are features of antisocial disorder that possess important complications for future studies on diagnosis, etiology, and treatment of the disorder. To summarize, there are two major research components in this project (the clinical trial and the laboratory evaluation). They will provide valuable new information on both the characterization and treatment of antisocial disorder in opioid abusers. The first study will evaluate the efficacy of a novel behaviorally contingent approach to treatment aimed at reducing drug use and increasing treatment retention. The second study will provide new information on two behavioral domains important to the conceptualization of antisocial disorder - by establishing the utility of a novel procedure for behavioral indexing of aggressive tendencies in subgroups of opioid abusers with and without antisocial disorder, and through the psychophysiological assessment of aversive reactivity of these patients.

Coping with Depression in Smoking Cessation

Brown, Richard, A.; Butler Hospital (Providence, R.I.)

Research has linked depression with morbidity and mortality from chronic medical conditions. Given findings that depression is a mediator of smoking relapse, cigarette smoking provides fertile ground for research in this area. Smokers with a history of major depressive disorder (MDD) represent a significant proportion of smokers; these individuals experience more depressive symptoms upon cessation and higher relapse rates than other smokers. This project will test the hypothesis that intensive treatment(s) intended to address depressive symptoms and negative mood will enhance the achievement and maintenance of smoking cessation in adult smokers with a history of MDD. This group will also examine the relationship between mood-related symptoms and smoking cessation outcomes. Finally, they will identify cognitive and behavioral mediators of the effects of depressive symptoms on smoking cessation.

The study employs an additive, randomized, double-blind, placebo-controlled design to test the incremental efficacy of: 1) standard smoking cessation treatment + placebo, vs. 2) standard smoking cessation + intensive cognitive behavioral treatment for depression + placebo, vs. 3) standard smoking cessation + intensive cognitive-behavioral treatment for depression + antidepressant (bupropion hydrochloride). All smokers will receive 14 group sessions of standard smoking cessation treatment, which includes 8 weeks of transdermal nicotine replacement. A sample of 396 subjects will be recruited to include only smokers with a positive history of MDD. Subjects will be treated for 12 weeks and followed for 12 months.

Current and past psychiatric diagnoses will be assessed, as will changes in depressive symptoms and mood states. Smoking cessation outcomes will be validated by saliva cotinine. It is expected that this study will result in the development of a specialized, efficacious treatment for the large percentage of smokers with past MDD, and will therefore have important clinical and public health significance in reducing the overall prevalence of cigarette smoking. It is further expected that this study will increase our basic knowledge about the role of depressive symptoms, the effects of selected cognitive and behavioral mediators, and the interaction of pharmacological and psychosocial factors in the process of smoking cessation.

Stop-Smoking Treatment for Drug/Alcohol Abuse Inpatients

Burling, Thomas; American Institutes for Research

This 4-year, randomized, controlled clinical trial will investigate the impact of stop-smoking treatment on drug/alcohol abuse inpatients. Stop-smoking treatment will be offered to cigarette smoking, drug/alcohol abuse inpatients of a residential treatment program for homeless veterans. Volunteers (N = 150) will be randomly assigned to one of three stop-smoking treatment conditions: (1) a multi-component stop-smoking treatment consisting of standard smoking cessation strategies; (2) the same multi-component treatment with a specialized component that uses the smoking cessation experience as an opportunity for in vivo practice and generalization training of relapse prevention skills; or (3) an attention-control treatment consisting of stop-smoking bibliotherapy and nondirective counseling. Inpatients who do not volunteer for stop-smoking treatment, but who agree to participate in the study assessment procedures (N = 50) also will be studied to determine if volunteers for stop-smoking treatment differ from nonvolunteers on pretreatment measures, inpatient treatment course, or posttreatment drug/alcohol abuse. Treatment outcome will be assessed for both cigarette smoking and drug/alcohol use. Objective biochemical and self-report assessments will be conducted throughout the inpatient program, and at paid follow-ups 3, 6, 9, and 12 months after discharge from the residential treatment program. Data from this study will provide critical information about the feasibility and treatment efficacy of stop-smoking treatment for inpatient drug/alcohol abusers, the impact of the stop-smoking program on the course of inpatient treatment and post-discharge drug/alcohol use, and the incremental impact of special therapeutic techniques designed to enhance generalization of positive treatment effects from smoking to drug/alcohol use. In addition, this study will provide important information about the commonalities between nicotine and other dependence-producing drugs. Such information may ultimately contribute to a unified theory of substance abuse, improved treatment outcome and reduced health risks among drug/alcohol abusers who smoke.

Enhancing Readiness to Change is Schizophrenics

Carey, Kate; Syracuse University

The long-term goal of this Stage I therapy development project is to reduce drug abuse and its negative consequences in persons with co-occurring schizophrenia. Persons diagnosed with both schizophrenia and a drug use disorder experience substantial dysfunction and poor treatment outcomes. Most receive treatment in the mental health system and do not acknowledge drug abuse as a problem. The Transtheoretical Model of Change, along with recent advances in motivational interventions, provides a useful framework to understand and change drug abuse in this context. The research will occur in three phases. First, formative research will be conducted to guide the adaptation of assessment and intervention materials for use with persons with schizophrenia. Second, the reliability and validity of two theoretically important measures (readiness-to-change, decisional balance) will be evaluated in a sample of 100 outpatients with schizophrenia; these instruments will serve as the primary change measures in the pilot test of the motivational intervention. Third, feasibility of a brief motivational intervention intended to enhance readiness for drug abuse treatment will be developed and evaluated. Twenty outpatients with DSM-IV diagnoses of schizophrenia and drug abuse or dependence will receive an individualized motivational intervention, designed to supplement their ongoing psychiatric treatment. Assessments at pre- and post-treatment and at a 12-week follow-up will evaluate therapy acceptability, readiness-to-change, psychiatric status, drug use, treatment involvement, and HIV risk behaviors. It is predicted that participants receiving the motivational intervention will increase their readiness to engage in drug abuse treatment and their perception of the advantages of reducing drug use, and decrease their perception of the disadvantages of such change. Exploratory analyses will evaluate the effects of the motivational intervention on treatment involvement, HIV risk behavior, and drug use.

Matching & Maintenance Treatments for Cocaine Dependence

Carroll, Kathleen; Yale University

There is yet no consensus regarding effective treatment for cocaine dependence. However, matching subtypes of patients to specific treatments and extending the benefits of short-term ambulatory treatments through the addition of maintenance treatment are promising strategies for enhancing and strengthening treatment response. This project will be conducted in two distinct phases:

1. In the first phase of this study, a randomized clinical trial with 200 cocaine abusers will be conducted which will prospectively test a matching hypothesis, that is, more severe cocaine abusers will have better outcome when treated with cognitive-behavioral coping skills therapy (Relapse Prevention) over a less structured, supportive approach (Interpersonal Psychotherapy). In this phase, up to 16 individual sessions will be offered over twelve weeks.

2. In the second phase of this study, the value of maintenance therapies as a strategy to improve the durability of the effects of brief psychotherapeutic approaches will be evaluated. Subjects who complete the twelve-week course of treatment and whose cocaine use has improved significantly over pretreatment levels will be randomly assigned to either (a) maintenance treatment, consisting of continuing their initial study treatment (Relapse Prevention or IPT) on a less frequent basis for six months, or (b) monthly assessment only for six months. The maintenance phase will be followed by six months of naturalistic follow-up for both groups to assess the durability of treatment effects.

All treatments will be manual-guided and delivered by experienced doctoral level therapist who will receive training and ongoing supervision to prevent drift during the course of the study. Multidimensional assessment will include ratings by a clinical evaluator blind to the subject's treatment condition. Supervised urine monitoring will be conducted twice weekly during the initial treatment phase and each assessment contact during maintenance and follow-up. All initial and maintenance treatment sessions will be videotaped for ongoing therapist supervision and process assessment. For both phases of the study, detailed process and outcome assessments will be conducted which will seek to (1) assess the discriminability and specificity of the two manual guided treatment approaches, (2) evaluate the impact of nonspecific aspects of treatment on outcome and matching effects, and (3) detect aspects of therapy process which mediate or moderate matching effects.

Dual Diagnosis Adherence Strategies

Daley, Dennis; University of Pittsburgh

Motivational Training (MT) strategies will be developed, refined and tested for patients recently discharged from a psychiatric hospital with a diagnosis of crack/cocaine dependence and comorbid major depression of such severity to warrant pharmacotherapy. These dual disordered (DD) patients are increasingly prevalent in treatment systems and represent a high risk clinical population who are difficult to engage and keep in outpatient treatment following inpatient hospitalization. This program is based on cognitive and behavioral principles, and adapts Marlatt's model of Relapse Prevention and Miller and Rollnick's model of Motivational Counseling for cocaine dependent patients with depression. The following aims will be met: 1) Develop and refine a theoretically based and procedurally specific MT strategy aimed at increasing DD patients' adherence to, and completion of, month 01 of outpatient treatment; 2) Conduct a pilot test comparing DD patients who receive MT against a Treatment-As-Usual (TAU) control group; and 3) Standardize MT protocol, procedures, methods and techniques so that the interventions are delivered with a high degree of competence and adherence. During months 01-06, the MT protocol will be further developed and refined, and staff will be trained to conduct the sessions. At month 07, following successful entry at the initial outpatient assessment and orientation session, study subjects will be randomized to receive one month of MT (N=38) or TAU (N=38) Control condition. The TAU Control Condition will draw upon the Individual Drug Counseling Model and will be operationalized in a treatment manual. Both the MT and the TAU protocols include 4 individual, 4 group sessions, and one AIDS Awareness and Prevention session. After month 01, patients will continue in active TAU dual diagnosis treatment for up to an additional five months followed by maintenance treatment. This research is likely to lead to more effective methods of improving outpatient adherence and treatment completion rates of cocaine dependent patients with depressive illness, and help to fill in deficiencies in existing treatment interventions. This project also involves development of a counseling manual describing MT interventions and a companion patient Recovery Workbook. It builds on our work in an open dual diagnosis treatment clinic and will complement, not conflict with, the aims of our NIDA cocaine collaborative study.

Cognitive Enhancements for Treatment of Probationers

Dansereau, Donald; Texas Christian University

In response to the high rate of illicit drug use by criminal offenders, Texas and other states are making large investments in drug abuse treatment for criminal justice settings. Included in this trend is an increase in short-term intensive supervision facilities for felony probationers with non-violent drug offenses who are eligible for participation in treatment programs as an alternative to prison. A 5-year project will be conducted for assessing the impact of using cognitive strategies to enhance the effectiveness of intervention components in an involuntary residential treatment program for court-referred drug abusing probationers. The study will be carried out in collaboration with the 140-bed (90 male and 50 female) Tarrant County Substance Abuse Treatment Facility (SATF), which provides 4 months of residential treatment to 420 probationers each year.

The enhancement strategies - derived from our previous research and development in the area of applied cognitive psychology - include "node-link mapping" with associated graphic approaches (i.e., visual representations of ideas, actions, and feelings) and "scripted collaboration" (i.e. guided peer interactions to improve learning and self-understanding). In particular, they will be introduced into three central intervention components - induction/ transition (representing self-assessments for guiding initiation and transition to progressive recovery stages), drug abuse counseling, and life skills and recovery education - with an expected positive impact on probationers leading to improved compliance with program rules, satisfaction with the program and personal progress, rapport with staff, and learning during treatment. After treatment, lower rates of drug abuse relapse and criminal recidivism are predicted benefits of these enhancements.

The empirical objectives are (1) to evaluate the impact of enhancement strategies on during-treatment and follow-up outcomes, and (2) to identify individual difference variables related to the effectiveness of the enhancement strategies. Intake measures of probationer characteristics (e.g., clinical assessment and self-reports of behavior and psychosocial functioning) will be related to process and outcome measures via multiple-regression analyses. The project is also expected to help improve our methodologies for examining treatment processes and outcomes. Specialized manual-driven training materials on the implementation of successful enhancement techniques will be prepared for transfer to other settings.

HIV Risk Reduction for Women in Drug Treatment

Eldridge, Gloria; Jackson State University

Women in drug treatment are at high risk for HIV-infection because of high risk sexual activities and high risk sexual contexts often related to obtaining and consuming drugs; drug use; physiological vulnerability to sexually transmitted diseases and HIV; and social, cultural, and economic barriers which interfere with implementing self-protective behavior. This project will compare (1) a Behavior Skills Training (BST) HIV-RISK reduction intervention based on Social Cognitive Theory (2) an HIV-RISK reduction intervention based on Motivational Enhancement (ME) and the Theory of Gender and Power; and (3) a control educational program in reproductive health (RH); One hundred fifty women in drug treatment will be recruited for each condition and will be evaluated during a 12 month follow-up period after discharge. Hypotheses are that both interventions compared to the control condition will (1) increase knowledge about HIV/AIDS, self-efficacy, attitudes toward condoms, and perceptions of social support for precautionary behavior; (2) decrease perceived barriers to condom use; (3) produce greater exchanges of condom redemption coupons; (4) increase the proportion of intercourse occasions which are condom-protected and decrease rates of unprotected sexual activity; and (5) decrease rates of needle-sharing among women who use injecting drugs. The BST intervention when compared with the ME intervention and the RH control, will improve social competency in safer sex negotiation and high risk refusal assessed through role play simulations. The ME intervention when compared with BST and the RH control, will increase self-efficacy, attitudes toward condom use perceptions of social support for precautionary behavior; (2) decrease perceived barriers to condom use; (3) produce greater exchanges of condom redemption coupons; (4) increase the proportion of intercourse occasions which are condom-protected and decrease rates of unprotected sexual activity; and (5) reduce rates of drug reinvolvement following discharge. By experimentally evaluating two theoretically driven HIV-RISK reduction interventions and comparing both to a condition which controls for time, history, attention, and the effects of being in drug treatment, this study will attempt to identify a practical prevention intervention for women in drug treatment and assess maintenance and generalization for 12 months after discharge.

Outpatient Aversion Therapy For Cocaine Abuse

Elkins, Ralph; Medical College of Georgia

This research is designed to evaluate the feasibility of administering a consummatory aversion therapy to cocaine dependent individuals in an outpatient setting. This therapy, known as emetic or chemical aversion therapy, has been successfully implemented as an adjunctive treatment for cocaine dependent inpatients during the PI's ongoing Phase II project. It involves pairings of nausea and vomiting, induced by an oral dose of emetine hydrochloride with the consumption of highly realistic placebo cocaine. The treatment led to decreased cocaine craving during treatment and to elevated post-discharge abstinence. The absence of unexpected adverse reactions plus the subjects' typical prompt recovery from emetically induced nausea and emesis strongly support the treatment's applicability to outpatient delivery. Subjects will be recruited from patients of the Regional Medical Hospital at Augusta and through local newspaper advertisements and referrals. After determination of cocaine dependency, medical clearance and extensive psychological testing, subjects will be randomly assigned to emetic therapy or to one of two comparison conditions, faradic therapy or group therapy. Faradic therapy, which pairs the placebo cocaine with a mild but uncomfortable electric shock, involves patient-therapist contact time as well as cue exposure to and consumption of placebo cocaine that is comparable to that of emetic therapy. However, based on the PI's inpatient study, faradic therapy should not produce conditioned consummatory aversions to cocaine, should not eliminate within treatment subjective craving for cocaine nor increase six-month post discharge abstinence rates. The group therapy will focus on abstinence maintenance and relapse prevention. Since aversion therapies are appropriately viewed as adjunctive procedures, all aversion therapy recipients also will receive group therapy. This design (emetic plus group therapy, faradic plus group therapy and group therapy alone) will address the acceptability of aversion therapy as an adjunctive treatment in comparison to the baseline group only alternative. A rigorous six month posttreatment follow-up will feature six scheduled subject interviews, including three in person visits with urine collected for drug screens, plus concomitant interviews with collateral contacts. Dependent variables include abstinence performance, drug usage and multiple indices of adjustment.

Development of Network Therapy for Cocaine Abuse

Galanter, Marc; New York University Medical Center

Dropout and uncontrolled relapse are major problems in rehabilitation of cocaine abuse and dependence. Network Therapy (NT) is a theoretically-grounded treatment modality designed to aid in averting these problems in addiction treatment, and can be applied without extensive specialized training. In NT, the therapist engages a group of the patient's family and friends in sessions with the patient. This network serves as part of the therapist's task-oriented working team. It allows him or her to draw on the potent cohesive ties of family and peers to stabilize compliance with treatment. The NT sessions, complemented by individual sessions, is employed to establish abstinence and avert relapse. They are also employed to enhance the introduction of cognitive/behavioral techniques and promote engagement in 12 Step programs. NT has been described extensively in previous publications.

The current objective is to develop and evaluate structured packages for introducing NT into the training of a diverse group of health professionals to treat cocaine abusers, and to pilot treatment in anticipation of future studies. The specific aims are to: 1) develop manuals and evaluation instruments suitable to training two groups of therapists, psychiatric residents and addition counselors; 2) have therapists experienced in NT train and evaluate these therapy trainees; 3) study the effectiveness of NT on a pilot population; and, 4) disseminate the training curriculum and results of the pilot assessment.

The design of the project is to: 1) prepare two curricula, including treatment manuals and videotapes, for the residents and counselors, respectively, and instruments designed to assess therapist effectiveness and NT effect; 2) prepare 5 NT-experienced faculty to train and evaluate the therapists; 3) train 6 residents in phase one; and 6 residents and 6 counselors in phase two; 4) conduct a study to assess the outcome of 54 patients, 3 treated by each of the NT-trained therapists. The residents will use a modified interpersonally-oriented therapy for individual sessions, and counselors will use a drug counseling format; and, 5) publish the NT curricula and manuals, as well as results of the training initiative and pilot study, for use in conducting future controlled studies.

Matching Coping Styles and Treatment Strategies

Gottheil, Edward; Thomas Jefferson University/Medical College

The objectives of this research are to investigate the relative contributions of treatment, client and counselor factors in determining the outcomes of polysubstance abuse clients exposed to brief individual counseling in a publicly supported, center-city, drug-free treatment program. Specifically, the objectives are to: (1) compare the effects of a high-structure, behaviorally-oriented with a low-structure, facilitative individual counseling style; (2) contrast the treatment benefits received for clients whose coping styles are matched to treatments with those whose styles are mismatched; (3) investigate differences in counselor effectiveness as these might combine or interact with treatment and/or client factors; and (4) examine the relationships among several measures of client coping style and compare their predictive validities within this polysubstance abuse population. Post-hoc analyses will focus on clients' perceptions of their counselors and of benefits received, on factors predictive of client retention, and on the role of counselors' coping styles in affecting client benefit.

This five-year study involves the random assignment of 160 polysubstance abuse clients to ten graduate student counselors, each of whom will be trained to conduct both treatment styles in serial but counterbalanced order, while pretreatment, intreatment, posttreatment and follow-up measures are obtained.

The research design attempts to address several priority issues in the substance abuse field, including the differential effectiveness of particular counseling approaches, the development and use of manual-driven therapies, the identification of optimal client-treatment matches, and the separation of "counselor effects" from true treatment effects in outcome studies. The eventual goal is to contribute toward better retention and outcome for polysubstance abuse clients in individual, drug-free outpatient counseling.

Behavioral/Pharmacologic Treatments to Reduce Drug Abuse

Grabowski, John; University of Texas-Houston

Cocaine dependence and opiate+cocaine dependence are important public health problems. They have proven difficult to treat. Some behavioral approaches are promising, but medications reducing intake, or desire to use drugs will be important treatment adjuncts. Setting conditions can influence outcome. Methadone is an effective medication for opiate dependence. Drugs that act at dopamine pathways either directly or indirectly are reported to alter cocaine intake and other measures in preclinical and human studies. Risperidone may be effective for cocaine dependence. The combination of methadone+risperidone may be particularly effective in treating concurrent opiate-cocaine dependence. Medication effects, however, will be modulated by optimal setting and behavioral-psychological factors.

Visit frequency is a setting condition that has been demonstrated to modulate treatment results. Similarly, group and individual treatment are setting conditions for therapy delivery that may alter outcome. Enhancement of behaviorally based "talk" therapy with contingency management procedures may improve outcome. These studies, like the investigators' earlier work, will examine the joint action of behavioral-psychological treatments and medication using logical combinations of these interventions.

The investigators will carry out two sets of three parallel studies. The baseline behavioral-psychological intervention will be a highly structured professionally delivered therapy (2/wk). In Studies 1-3, the cocaine treatment medication will by risperidone (placebo, 4 or 8 mg). In Studies 3-6, methadone (approximately 1.1 mg/kg); risperidone (0, 4, or 8 mg) will be administered to opiate+cocaine dependent patients. Risperidone components will be double-blind placebo-controlled. There will be 150 patients in each study randomly assigned but with stratification on some dimensions. Cocaine dependence Studies (13) will be 12 weeks and methadone-cocaine dependence Studies (4-6) will be 26 weeks. All studies include self-report, standard medical with HIV and TB tests, and psychiatric evaluations. Phases are consent, intake, 2 week stabilization, treatment, and study end periods, with 3 month follow-up. Major independent variables are medication and dose with setting\treatment variables of visit frequency (2 or 5/week), group vs individual therapy, standard behavioral vs reinforcer enhanced therapy. Major dependent variables are drug use (2/wk urine screens) and retention, with other secondary analysis. The setting/treatment factors have joint actions with medication that can be critical to retention, drug abuse, and reduction of HIV exposure risk. These studies are logical extensions of the investigators' ongoing work.

Maintaining Non-Smoking

Hall, Sharon; University of California, San Francisco

The objective of this research is to gain an understanding of relapse to tobacco dependence, and to develop treatments based on this understanding. The first study of the current funding period (N=201) was based on the earlier findings of Hall, Munoz & Reus, (1994) who reported that a 10-session mood management intervention was differentially more efficacious than a 5-session standard treatment control for smokers with a history of Major Depressive Disorder (MDD). In a 2 (mood management vs. contact-equivalent, 10 session control) x2 (2 vs. 0 mg. nicotine gum) x2 (MDD history vs. not) design, they found a non-significant difference in efficacy for the mood management intervention for MDD history vs. not) design, and found a non-significant difference in efficacy for the mood management intervention for MDD history positive subjects, and no effect for 2 mg. nicotine gum. MDD history positive subjects reported higher levels of negative moods during quitting, and subjects whose negative moods increased during quitting were more likely to continue smoking. The second study (N=200) was a 2 (nortriptyline vs. placebo) x 2 (mood management vs. 5 session standard treatment control) X 2 (MDD history vs. not) design. Results on the first 119 subjects indicate differences between active and placebo nortriptyline at 12 and 24 weeks at p<.05 and differences at 38 weeks at p<.10. Also, the differential efficacy of mood management for MDD history positive smokers, observed in Hall et al. (1994) re-emerged, suggesting that MDD history positive smokers are differentially helped by therapeutic support, but the precise theory-derived content is not crucial. This group is conducting two clinical trials. In the first, smokers (N=240) are randomly assigned, in a 3 X 2 design, to nortriptyline, bupropion, or placebo and to medical management alone or medical management plus psychosocial support, treated for 12 weeks, and assessed at baseline, 12, 24, 36 and 52 weeks. Variables assessed are smoking behavior and biochemically verified smoking status, diagnosis, demographics and treatment history, state and trait measures of mood, support for quitting smoking, cigarette craving, and medication side effects. In the second study, (N=200) smokers are randomly assigned to either brief (12 week) or extended (52 week) treatment and to nortriptyline vs. placebo. The brief treatment is the medical management plus psychosocial support condition of the first experiment; extended treatment includes year-long access to drug, group meetings, frequent telephone contacts, and counseling sessions if a relapse is reported. Measures and times of assessment parallel those for the first experiment. In both studies, the cost-effectiveness of the treatment conditions is determined. These studies will provide data about the efficacy and cost-effectiveness of treatments for smoking cessation based on rigorously designed clinical experiments. These data have implications for treatment providers and policy-makers.

Acceptance Theory and the Treatment of Polydrug Abuse

Hayes, Steven; University of Nevada & Community College

Drug abuse is a severe problem that requires the development of more effective intervention. While the psychological models that have been applied to substance abuse and its treatment vary widely, they almost all deal with the issue of emotions and thoughts. Many of these theories assume that some substance abusers use, in part, to reduce (i.e., escape or avoid) negative emotions such as stress, depression, or anxiety. Few of the empirically based approaches attempt to change this emotional avoidance directly - rather emotional avoidance is taken as a given and attempts are made to modify other components, such as reducing the emotional or cognitive states that the drug user seeks to change through drugs. Some of the less empirically-oriented therapeutic perspectives (e.g., humanistic therapies, Gestalt therapy, and so on) are directed at emotional avoidance per se, but there are few data on the efficacy of these approaches.

Data from several lines of research suggest that emotional avoidance itself can be changed through psychological acceptance methods. If drug users can become more willing to feel emotions without needless resistance, they may have fewer reasons to use drugs. This project will develop a psychological acceptance protocol, to develop several process measures that can be used to assess changes in emotional willingness and to pilot test the effectiveness of an acceptance approach compared to the treatment typically given drug users with a group of polydrug abusers.

PTSD Treatment Outcomes for Cocaine-Dependent Women

Hien, Denise; St. Luke's Roosevelt Hospital Center

For the majority of inner-city women with crack/cocaine dependence, chronic traumatic victimizations and their far-reaching psychological consequences are ongoing obstacles to achieving abstinence in early recovery from drug addiction. One psychiatric consequence of chronic victimization is developing a posttraumatic stress disorder (PTSD). Studies have demonstrated that comorbid psychopathology such as PTSD in female substance abusers is associated with poorer outcomes, which may include any or all of the following: (1) poor substance abuse treatment compliance manifested by ongoing substance abuse, especially cocaine abuse, and high treatment drop-out rates; (2) chronic psychiatric symptoms including feelings of terror, and hopelessness, intrusive recollections, hyperarousal, affective numbing, depression and anxiety, and numerous nonspecific somatic symptoms; and (3) high-risk sexual behaviors which may lead to HIV infection. While the need for treatment approaches to address such problems has been demonstrated empirically, and the clinical literature attests to the potential of such approaches, to date there are not known controlled studies which examine the efficacy of manualized treatments with crack/cocaine-dependent women who are suffering from PTSD.

This study aims to examine the efficacy of an enhanced cocaine treatment based on relapse prevention (RPT) which includes a specific manualized component geared towards coping with and reducing PTSD symptomatology for women with cocaine dependence.

This randomized two-armed clinical trial will assess the relative efficacy of PTSDRPT versus RPT alone in treating inner-city women with cocaine dependence and comorbid PTSD over a three month period with repeated measures at baseline, completion of treatment (3 months), 3month posttreatment follow-up and 6 month posttreatment follow-up. Concurrently, it will also evaluate a nonrandomized, nonspecific "treatment-as-usual" TAU) comparison condition. The specific outcomes to be examined in the present study are efficacy in: 1a) reducing crack/cocaine use; (1b) maintaining retention rates in cocaine abuse treatment; (1c) reducing psychiatric symptoms of PTSD and other trauma-related conditions; and (1d) reducing HIV-RISK behavior.

2) The research aims to assess the impact of potential predictors (including baseline severity of cocaine use, PTSD, depression and intensity of other services received) on cocaine use and PTSD symptomatology over follow-up.

3) The research will also assess the impact of potential mediators, representing acquisition of intervention components, on cocaine use and PTSD symptomatology over the three assessment periods, especially examining concurrent level of PTSDRPT and RPT alone skill and concurrent level of perceived self-efficacy to use these skills.

This study has the particular advantages of (1) adding the rigorous assessment of DSM-IV PTSD to the study of inner-city cocaine-dependent women; and (2) adding a manualized PTSD component to cocaine abuse treatment for these women, which builds directly on the empirical findings of the researchers' prior work.

Treating Cocaine Abuse - A Behavioral Approach

Higgins, Stephen; University of Vermont

Cocaine dependence is likely to remain a serious U.S. public health problem throughout the 1990s. In an effort to address that problem, Dr. Higgins has been researching the efficacy of a multi-component, outpatient treatment for cocaine dependence that is based on the principles of behavior analysis and behavioral pharmacology. This treatment effectively retains cocaine-dependent adults in outpatient treatment and engenders clinically significant periods of continuous cocaine abstinence. The purpose of these studies is to analyze further which components of this multi-component treatment contribute to the positive outcomes observed with it. Such dismantling studies are essential to the development of empirically-based and effective treatments for drug dependence.

One of this group's prior trials demonstrated that an incentive program wherein patients earned vouchers exchangeable for retail items contingent on submitting cocaine free urine specimens was an active component of this treatment. However, that study did not determine whether the incentives directly increased cocaine abstinence via reinforcement or acted indirectly by increasing treatment retention and the amount of services received and in that manner improved outcome. Study 1 of this project will systematically replicate the prior findings and extend them by dissociating effects on retention and cocaine abstinence. Study 2 will assess whether a disulfiram-therapy component used to treat alcohol abuse in this multiple-drug abusing population contributes to positive outcomes, and, if so, whether the medication compliance procedures used in implementing this therapy are an effective feature. Preliminary results from this group's clinic and others indicate that treating alcohol abuse in this cocaine-dependent population via disulfiram therapy and medication compliance procedures significantly reduces drinking and cocaine use. Study 3 will assess whether including significant others in the treatment process improves outcome, and, if so, whether the behavioral contracting procedures used in this component are an effective feature. Preliminary results from this group's clinic indicate that including significant others in treatment and teaching them to use behavioral contracts significantly increases the probability of patients achieving clinically significant periods of continuous cocaine abstinence.

Each of the trials will contribute important new information on the efficacy of specific components of this promising behavioral treatment for cocaine dependence. This information will permit this group to empirically streamline this intervention down to its necessary components. Moreover, these studies will contribute to the longer-term goal of producing both a comprehensive treatment package and specific treatment components for dissemination as manual-guided and effective interventions for outpatient treatment of cocaine dependence.

Using Contingency Management to Enhance Methadone Detox

Iguchi, Martin; Allegheny University of Health Sciences, Hahnemann University

Opiate detoxification treatments reach many addicts not seen in methadone maintenance treatment. Unfortunately, detoxification treatments have little success eliminating opiate use. In addition to treating the physical dependence on opiates, successful treatments must extinguish drug use behaviors while cultivating competing behaviors that facilitate abstinence. Past research suggests that contingency management interventions are effective at promoting such new behaviors among opiate abusers. This group has found, for instance, that reinforcing either abstinence or behavioral progress toward treatment plan goals leads to increased abstinence rates among methadone maintenance patients. This study extends this approach to the problem of low detoxification success rates and poor naltrexone maintenance compliance. This group examines whether reinforcing both abstinence and progress toward treatment plan goals is more effective than reinforcing either behavior in isolation.

This study compares the efficacy of three different contingency management interventions used in an outpatient treatment combining a 20-week methadone detoxification and 12 weeks of naltrexone maintenance treatment. A total of 168 subjects will be randomly assigned to one of four treatment conditions - three voucher-based contingency management interventions and a control condition with no programmatically delivered reinforcement. Subjects in the experimental conditions will receive vouchers for: 1) submitting drug-free urines, 2) completing treatment plan tasks, or 3) submitting drug-free urines and completing treatment plan tasks. Vouchers will be exchanged for reimbursement of expenses related to achieving treatment plan goals (e.g., paying for health care, daycare, resume development, etc.). Assessments of treatment process and outcome will occur during treatment, and at 12-month follow-up. Measures of treatment efficacy will include number of drug-free urines submitted during the 32-week intervention, detoxification treatment completion, days of compliance with naltrexone maintenance therapy, and drug use at 12-month follow-up. This study examines a time-limited alternative for those ineligible, unable, or unwilling to participate in methadone maintenance. The development and objective evaluation of such objectives is particularly important in this era of managed care when shorter, less expensive treatments are likely to be used even in the absence of clear data supporting their efficacy.

Methadone Treatment: Behavioral/Pharmacological Variables

Iguchi, Martin; Allegheny University of Health Sciences-Hahnemann University

In methadone maintenance patients, making program privileges contingent upon the submission of drug-free urines reduces the rate of illicit drug use. Nevertheless, such urinalysis (UA) contingency programs appear to work only for a subgroup of patients, and may not be practical in all treatment settings. There is a need, therefore, for other effective treatments that may be used in conjunction with, or instead of, UA contingencies. One alternative to reinforcing abstinence is the differential reinforcement of alternative behaviors (DRA). In this study the replicability and portability of a DRA program is examined that was found effective in a small research clinic by testing it in a large VA Medical Center. In addition to replicating a promising study, the project: 1) examines the viability of transferring behavioral technologies to a setting more similar to a typical community clinic than a university research clinic, 2) compares the DRA program with an intervention of known effectiveness (UA contingencies), 3) assesses the behavioral, psychological and social factors associated with differential treatment response, and 4) evaluates the durability of treatment effects over time.

In a prior study (Iguchi, Belding et al., in press), patients received vouchers worth up to $15 per week for providing objective evidence of completing tasks planned with counselors to shape behaviors approximating treatment plan goals (TP-$15 group). Patients receiving this DRA condition improved more than those receiving either no programmatic reinforcement or $5 for each of three urines collected per week testing drug-free. Moreover, TP-$15 subjects continued to improve following cessation of the intervention. In the extension of this research, 132 newly enrolled methadone maintenance patients at the Philadelphia, VA are assigned to one of three groups: the TP-$20 group is eligible to earn vouchers worth up to $20 per week, the STD group receives the standard VA treatment and no programmed reinforcement, and the UA-TH group is eligible to earn up to 4 take-home doses of medication per week by submitting drug-free urines. Interventions begin following a 10 week baseline period and continue until week 30. Assessments occur at intake and weeks 10, 20, 30, and 52 (follow up). Outcome measures include urinalysis results, self-reported drug use and risk behaviors, and psychosocial measures. The significance of the project includes potential validation of an alternative or adjunct to UA contingencies that produces more durable behavior change using a DRA procedure.

Expectancy-Based Coping Skills for Cocaine Abuse

Jaffe, Adam; Yale University

Social Learning Theory (SLT) has been a useful model for understanding substance abuse. While approaches based on learning principles such as coping skills and relapse prevention (RP) have been promising, they have had varied results in recent empirical treatment studies involving alcohol and cocaine abuse. This group has developed a modification and extension of a RP approach using expectancies as the organizing structure and as a major focus of treatment for cocaine addiction. This group believes that this approach, Expectancy-based Coping Skills therapy (ECS) is likely to substantially improve treatment efficacy for the following reasons: (l) Expectancies are a central construct that holds much promise for clinical research involving the assessment, etiology, and treatment of cocaine addiction; (2) Cocaine-related expectancies are readily measured using a validated, multifactorial, self-report instrument developed by the principal investigator of this study (Cocaine Expectancy Questionnaire, CEQ) and represent a domain that is amenable to change with talking therapy; and (3) An extensive pilot study conducted by the principal investigator and this research group strongly supports the feasibility, acceptability, and efficacy of manualized ECS therapy for the treatment of cocaine addiction. For these reasons it is believed that expectancies have profound implications for treatment and that expectancy-based treatment warrants further evaluation and development. Because prior to the current pilot work, expectancies had received minimal clinical and empirical treatment emphasis, their implications for treatment need to be explored in a systematic fashion. Instruments such as the CEQ, combined with our manualized intervention of ECS, make it possible to assess and use expectations about cocaine in a clearly specified treatment that can be reliably delivered, monitored, and evaluated. This study will conduct a randomized clinical trial with 168 ambulatory cocaine dependent participants to evaluate whether ECS therapy improves treatment efficacy substantially in comparison to two other manualized approaches: RP and addiction counseling, a reference control condition.

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