Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse
Prize-based Contingency Management Enhances Retention in People with High Psychiatric Symptom Severity
Dr. Nancy Petry and colleagues at University of Connecticut Health Center examined the impact of psychiatric symptom severity on treatment retention for 393 drug abusers enrolled in several clinical trials comparing either standard care or standard care plus a novel intervention, Prize-Based Contingency Management (PBCM). In PBMC participants are offered the opportunity to draw for prizes based when they either submit drug negative urine samples or complete treatment related goals. The researchers ranked participants into high, medium, and low psychiatric symptom severity based on their ASI Psychiatric Index score. Although researchers found a positive association between Psychiatric Index score severity and risk of drop out in people receiving the standard care condition, they did not observe such a relationship for participants assigned to standard care plus PBCM. These results indicate that the addition of PBCM to standard care may be especially useful for enhancing retention in people with dual psychiatric and substance use disorders, a group which is vulnerable to treatment dropout. Weinstock, J., Alessi, S.M., and Petry, N.M. Drug Alcohol Dependence, [epub ahead of print], September, 2006.
Contingency Management among More Effective Treatments Based on Meta-analysis
Dr. Michael Pendergast and colleagues at UCLA conducted a meta-analysis of 47 studies that used contingency management (CM) to treat addictions. Studies included in the meta-analysis most commonly used methadone take home doses, voucher based reinforcement, and cash as reinforcers, although all CM studies conducted since the 1970s were eligible for inclusion. The mean effect size on drug use outcomes at the end of treatment (d = .42) was stronger than what is often observed for behavioral interventions. Effect sizes for treatments targeting cocaine and opioids (d = .66) and (d = .65) respectively were higher than when tobacco (d =.31) or multiple drugs (d =.42) were targets. Results suggest that regardless of the method used, CM can provide a powerful incentive for abstinence during and at the end of treatment. Prendergast, M., Podus, D., Finney, J., Greenwell, L., and Roll, J. Addiction, pp. 1546-60, 2006.
Risky Behaviors and Mental Health in Homeless Men Who Have Sex with Men
Cathy Reback and researchers at Friends Research Institute examined the psychiatric, demographic, drug use, and HIV risk characteristics of 20 men seeking services for homeless people in San Francisco who were not currently seeking drug abuse treatment. Most were Caucasian (65%) and self identified as gay or bisexual (95%). Self-reported seroprevalence of HIV was 21%. All met criteria for substance use diagnoses with alcohol and amphetamine being the most prevelant disorders. Additionally, 75% met criteria for Mood Disorder. Almost 50% had injected drugs during the previous month and most of those failed to clean needles with bleach. In terms of risky sexual behavior, individuals generally reported multiple risk behaviors, and rates of sex while high on drugs, exchanging sex for money or drugs, and unprotected sex including heterosexual vaginal intercourse was frequently reported. This study provides insights into the risk behavior of an infrequently studied population at extremely high risk for HIV transmission. Although none of these individuals were seeking treatment, they all accessed community AIDS services. Novel treatment and HIV prevention interventions may be developed that motivate treatment engagement in non-traditional settings such as the Community AIDS service centers frequented by these individuals. Reback, C.J., Kamien, J.B., and Amass, L. Addictive Behaviors. [epub ahead of print] July, 2006.
Contingency Management Efficacious for Methamphetamine Users
John Roll and researchers at Friends Research Institute and in the NIDA Clinical Trials Network evaluated the results of a trial in which people at several clinics in the western US were assigned to either treatment as usual available at that clinic (TAU) or TAU plus a novel contingency management intervention (CM). During the CM intervention, participants submitting drug negative urine samples could draw for prizes according to an escalating schedule, such that for each week they remained abstinent they received an additional opportunity to draw for a prize. In the prize drawing, fifty percent (250) of tokens were marked "good job" but had no prize value. Other prize tokens were distributed as follows; a single high value token (worth $80-$100), 8% medium value tokens (worth $20.00) and 41.8% small value tokens (worth $1-$5). Participants could turn in tokens for prizes such as toiletries, soft drinks, fast food coupons, electronic devices or television sets depending on the value. Participants in the TAU+CM group submitted significantly more drug negative urines and had longer mean period of abstinence than those in the TAU group. These results are significant because they are the first controlled trial of a CM intervention as an adjunct to TAU in Methamphetamine users. Even when TAU was the Matrix Model treatment, a comprehensive psychosocial intervention the CM still improved outcomes. Roll, J.M., Petry, N.M., Stitzer, M.L., Brecht, M.L., Peirce, J.M., McCann, M.J., Blaine, J., Macdonald, M., Dimaria, J., Lucero, L. and Kellogg, S. American Journal of Psychiatry, pp. 1993-1999, 2006.
Smoking Status in the Initial Weeks of Quitting as a Predictor of Smoking-Cessation Outcomes in Pregnant Women
In the general population of smokers, seminal findings of Kenford et al. (1994) suggest a robust relationship between early smoking during a quit attempt and later smoking. The findings indicate that any smoking during the initial 2 weeks of a quit attempt predicts poor longer-term outcomes. However, it is not known whether this same predictor rule applies under conditions where patients are quitting related to a medical condition for which smoking is contraindicated, like pregnancy. Investigators at the University of Vermont conducted this study to examine the association between smoking status during the initial 2 weeks of attempting to quit and smoking status at an end-of-pregnancy assessment among women enrolled in smoking cessation studies. Data were obtained from 129 women participating in clinical trials on smoking-cessation examining the efficacy of voucher-based incentives delivered contingent on biochemically-verified abstinence or a control conditions wherein incentives were given independent of smoking status. Smoking status was assessed in weeks 1 and 2 of the cessation effort and again at an end-of-pregnancy. The findings show that women who smoked in the first 2 weeks of quitting had a greater than 80% chance of being classified as smokers at an end-of-pregnancy assessment and that relationship held across the two treatment conditions. These finding indicate that the predictor rule for the general population of smokers applies to pregnant women who are smokers. Thus, it is recommended that clinicians monitor smoking status during the initial weeks of a quit attempt and provide a change in treatment when smoking is detected. Higgins, S.T., Heil, S.H., Dumeer, A.M., Thomas, C.S., Solomon, L.J., and Bernstein, I.M. Drug and Alcohol Dependence, 85, pp. 138-141, 2006.
Treatment for Cigarette Smoking Among Depressed Mental Health Outpatients: A Randomized Clinical Trial
Dr. Hall and colleagues at the University of California, San Francisco conducted this study to test the efficacy of a Stage Care Intervention (SCI) for cigarette smoking in psychiatric patients in outpatient treatment for depression. Three-hundred and twenty-two participants were randomized to one of two conditions. The SCI operationalized the recommendations of the AHCPR and the APA practice guidelines. It integrated a computerized feedback system based on the Transtheoretical Model that provided feedback about smoking with provision of face-to-face psychological individual counseling and pharmacological treatment at the appropriate stage of readiness. The control (CON) participants received a self-help guide and referral list. The control condition was designed to model current practices in mental health clinics. Participants were assessed at baseline and at months 3, 6, 12, and 18. As hypothesized, abstinence rates in SCI (12 months=14.1%; 18 months=18.4%) exceeded those in CON (12 months=9.4%; 18 months=13.2%). Significant differences favoring SCI were also found in occurrence of a quit attempt and stringency of abstinence goal. The authors conclude that individuals in psychiatric treatment for depression can be aided in quitting smoking by staged care interventions, and that smoking cessation interventions used in the general population can be implemented in psychiatric outpatient settings. Hall, S.M., Tsoh, J.Y., Prochaska, J.J., Eisendrath, S., Rossi, J.S., Redding, C.A., Rosen, A.B., Meisner, M., Humfleet, G.L., and Gorecki, J.A. American Journal of Public Health, 96, pp. 1808-1814, 2006.
Weight Concerns Affect Motivation to Remain Abstinent From Smoking Postpartum
This study assessed motivation for postpartum abstinence among pregnant women who had quit smoking and examined the relationship of weight concerns and mood to abstinence motivation. Participants (N=119) completed assessments of smoking, weight concerns, depressive symptoms, and perceived stress. Sixty-five percent were highly motivated to remain abstinent postpartum. Women who were and were not motivated were similar in age, race, and nicotine dependence. Motivated women reported more stress, greater self-efficacy for weight management, less hunger and less smoking for weight control than less motivated women. After controlling for intention to breast-feed, nicotine dependence, years of smoking, partner smoking, and race, self-efficacy for weight control was related to motivation to maintain postpartum abstinence. This study suggests that weight concerns are linked with motivation for postpartum smoking abstinence, and interventions designed to prevent postpartum smoking may need to target eating, weight and shape concerns. Levine, M.D., Marcus, M.D., Kalarchian, M.A., Weissfeld, L., and Qin, L. Annals of Behavioral Medicine, 32, pp. 147-153, 2006.
Relationship of DSM-IV-Based Depressive Disorders to Smoking Cessation and Smoking Reduction in Pregnant Smokers
Investigators at the University of Texas M.D. Anderson Cancer Center in Houston conducted this study to examine psychiatric disorders as predictors of smoking outcomes among pregnant smokers. Eighty-one pregnant women participating in a low-intensity smoking cessation trial were investigated. Thirty-two percent of the sample met criteria for current dysthymia, major depressive disorder in partial remission, or minor depression. The findings showed that no significant reduction in smoking among women with or without current depressive disorders was shown. Unexpectedly, compared to women without depressive disorders, women with dysthymia significantly increased the mean number of cigarettes smoked (from 8 to 23 cigarettes per day during the 2 to 30 days post-targeted quit date period) and were smoking significantly more at 30 days. A main effect approaching significance suggested that women with current depressive disorders were less likely to be abstinent than women without current depressive disorders. The current results add to previous findings indicating a correlation between depressive symptoms and continued smoking in pregnant women. These findings indicate that additional research is needed in evaluating the impact of depression on smoking outcomes in pregnant women and that investigation of mood-focused smoking cessation interventions may be warranted. Blalock, J.A., Robinson, J.D., Wetter, D.W., and Cinciripini, P.M. The American Journal on Addictions, 15, pp. 268-277, 2006.
Brief Motivational Interventions May Not Always Be Sufficient for Treating Teen Drug Abuse
Drs. Peggy Peterson, John Baer and colleagues at the University of Washington conducted a study of a brief motivational intervention for drug abusing, homeless teens. A sample of 285 teens was recruited via drop-in centers and street outreach, with high rates of self-reported and biologically-confirmed use of alcohol (87%), marijuana (94%), tobacco (93%), amphetamines (53%), hallucinogens (36%), heroin (27%), crack cocaine (28%), and other drugs in the past month. Guided interviews over 2 sessions assessed all teens' patterns of drug use and associated risk behaviors. Teens were randomly assigned to receive 1 session of personalized feedback in a motivational interviewing style, or to one of two assessment-only conditions (assessment at baseline and follow-up, or follow-up assessment only). Follow-up interviews were conducted at 1 month and 3 months after baseline. As a whole, there were no significant reductions in drug or alcohol use for any of the three conditions, and there were no significant differences in reductions in drug or alcohol use between any of the conditions. Looking separately at illicit drugs other than marijuana, the motivational intervention was associated with significantly larger reductions in use at 1-month follow-up than the assessment-only conditions, but this effect did not remain at the 3-month follow-up. Brief motivational-based interventions have been found to increase teen substance abuse treatment engagement and retention, and to reduce alcohol-related risk behaviors, but have not produced consistently positive results as stand-alone treatments. Future research may clarify for whom and for what purposes brief motivational-based interventions should be incorporated into a comprehensive treatment intervention. Peterson, P.L., Baer, J.S., Wells, E.A., Ginzler, J.A., and Garrett, S.B. Short-term Effects of a Brief Motivational Intervention to Reduce Alcohol and Drug Risk among Homeless Adolescents. Psychology of Addictive Behaviors, 20, pp. 254-264, 2006.
Twelve-Step Treatment for Drug Abuse Can Be Effective HIV Risk Reduction
Dr. Thomas Lyons and colleagues at the University of Illinois at Chicago conducted a study of 64 cocaine- and methamphetamine-using MSM participating in Crystal Meth Anonymous meetings as part of drug abuse recovery. Participants were recruited at 12-step venues, HIV treatment clinics, and through advertisements. Data were collected at a number of Crystal Meth Anonymous (CMA) meetings designated as "open", and consisted of standardized questionnaires, interviews, and investigator observations. Self-reports indicated almost all participants were polydrug users, with 76% using methamphetamine (18% intravenously), and 52% using cocaine or crack cocaine (also 18% intravenously). Among the 15 participants reporting injection drug use, 13 were HIV positive. Overall, participants reported significant declines in sexual risk behavior after starting CMA meetings, with percent of participants engaging in unprotected anal intercourse dropping from 70% to 24%, and number of sexual partners dropping from 7 to 1 per month. Declines in risk behaviors were even larger for HIV positive participants. Participants' interview responses and comments in meetings highlighted the connection between use of methamphetamine in particular and sexual concerns. Participants frequently reported complications in sexual relations during recovery, and attributed reductions in sexual risk behaviors due to fear of relapse to drug use. This observational study adds to the growing body of literature indicating that drug abuse treatment is, in itself, HIV risk reduction. Lyons, T., Chandra, G., and Goldstein, J. Stimulant Use and HIV Risk Behavior: The Influence of Peer Support Group Participation. AIDS Education and Prevention, 18, pp. 461-473, 2006.
Contingency Management, Motivational/Skills-Building, and 12-Step Drug Counseling for Treating Young Adult Marijuana Abuse and Dependence
Dr. Kathleen Carroll and colleagues at the Yale University School of Medicine compared the efficacy of four treatments for marijuana-using, young adult probationers referred by the criminal justice system. Of the 136 participants, 90% were male, 60% were African-American, and all were between 18 - 25 years old. Participants were randomly assigned to one of four 8-week treatment conditions: 1) Motivational Enhancement Therapy and Cognitive Behavioral Therapy (MET/CBT); 2) MET/CBT with contingency management (MET/CBT + CM); 3) Twelve-step based individual Drug Counseling (DC); or 4) DC with contingency management (DC + CM). Assessments were conducted at baseline before treatment began, weekly during treatment, and at 3 and 6 months after treatment termination, and included self-reports and biological verification of marijuana use. Overall, treatments including contingency management (CM) produced better abstinence results than those without CM, including longer periods of continuous absence from marijuana use, and more total negative urine samples. Retention rates were 60% overall, and were significantly better for treatments with CM, and were significantly better for MET/CBT than for DC treatments. On the whole, participants maintained treatment gains through 6-month follow-ups, with those participating in either MET/CBT treatment showing even greater improvements than those in either DC treatment. These results confirm the potency of adjunctive CM in boosting treatment retention and effectiveness, and add confirm existing data suggesting that skills-based interventions can produce continued improvements, even after treatment ends. Carroll, K.M., Easton, C.J., Nich, C., Hunkele, K.A., Neavins, T.M., Sinha, R., Ford, H.L., Vitolo, S.A., Doebrick, C.A., and Rounsaville, B.J. The Use of Contingency Management and Motivational/Skills-Building Therapy to Treat Young Adults with Marijuana Dependence. Journal of Consulting and Clinical Psychology, 74, pp. 955-966, 2006.
Clinical Trial of Abstinence-Based Vouchers and Cognitive-Behavioral Therapy for Cannabis Dependence
Ninety cannabis-dependent adults seeking treatment were randomly assigned to receive cognitive-behavioral therapy, abstinence-based voucher incentives, or their combination. Treatment duration was 14 weeks, and outcomes were assessed for 12 months posttreatment. Findings suggest that (a) abstinence-based vouchers were effective for engendering extended periods of continuous marijuana abstinence during treatment, (b) cognitive-behavioral therapy did not add to this during-treatment effect, and (c) cognitive-behavioral therapy enhanced the post-treatment maintenance of the initial positive effect of vouchers on abstinence. This study extends the literature on cannabis dependence, indicating that a program of abstinence-based vouchers is a potent treatment option. Discussion focuses on the strengths of each intervention, the clinical significance of the findings, and the need to continue efforts toward development of effective interventions. Budney, A.J., Moore, B.A., Rocha, H.L., and Higgins, S.T. J Consult Clin Psychol. 74(2), pp. 307-316, April 2006.