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Director's Report to the National Advisory Council on Drug Abuse - May, 2005

Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse

Abstinence Relates to Depression Symptoms in Methamphetamine Dependent Gay and Bisexual Men Undergoing Behavioral Substance Abuse Treatment

Dr. Peck and colleagues evaluated the relationship between symptoms of depression and drug abuse treatment among methamphetamine dependent gay and bisexual men undergoing treatment for substance abuse. Participants (N=162) were assigned to sixteen weeks of either standard cognitive behavioral therapy (CBT), contingency management (CM), or combined CBT+CM and a culturally tailored cognitive behavioral therapy (CCBT). Depression was measured using Beck Depression Inventory scores collected weekly. At intake 73.2% of participants endorsed symptoms consistent with mild to moderate depression. Reductions in methamphetamine use and depression generally were sustained for one year after treatment entry regardless of treatment condition. A secondary analysis revealed that urinalysis results positive for methamphetamine predicted depression symptoms. However, depression symptoms were not predictive of methamphetamine use. These post-hoc results suggest that abstinence, regardless of the behavioral intervention used to obtain it, is likely to improve symptoms of depression. Additionally, they suggest depression symptoms may not trigger relapse among gay or bisexual men in treatment as was previously supposed. Peck, J.A., Reback, C.J., Yang, X., Rotheram-Fuller, E., and Shoptaw, S. Journal of Urban Health. Mar 82(1 Suppl 1), i100-i108, 2005.

Drug Abusers and Therapists Perceive Sources of Reinforcement and Punishment in Clinics Differently

Dr. Roll and colleagues at UCLA evaluated provider and patient perceptions of the opportunities for reinforcement and punishment in a drug free clinic, to determine whether existing inexpensive methods might be available for impacting the behavior of drug users in treatment. Despite evidence for the efficacy of contingency management interventions, community based treatment providers often cite the cost of providing reinforcers as a primary reason why they do not adopt these approaches. Cost may be lower if naturalistic sources of reinforcement within a drug treatment environment could be used. Additionally, research suggests that withholding reinforcement in cases of non-compliance (punishment) may be more effective than simply reinforcing abstinence. In this study 93 patients and 18 clinical staff members at a drug free clinic were asked to rate 38 potential punishers and 44 potential reinforcers. Generally both clients and staff agreed about the order and magnitude of reinforcers. However clinic staff's ratings of potential punishers were generally higher than that of clients. Several low cost activities such as ceremonies recognizing treatment completion, attendance certificates, and assistance with finding employment were highly rated. Events rated as punishers included letters to the legal system indicating poor treatment compliance, withdrawal of smoking privileges, increase in the price of treatment, and premature treatment discharge. Future contingency management approaches may reduce costs by using naturally available services and consequences. Roll, J.M., Chudzynski, J.E. and Richardson, G. American Journal of Drug and Alcohol Abuse 31(1), pp. 21-33 2005.

A Meta-Analysis of Smoking Cessation Interventions with Individuals in Substance Abuse Treatment or Recovery

A systematic review was conducted to examine the effectiveness of smoking cessation interventions for individuals with substance abuse problems. An extensive literature search identified 19 randomized controlled trials of smoking cessation interventions with individuals in current addictions treatment (n=12) or recovery (n=7). Smoking and substance use outcomes at post-treatment and long-term follow up (6- to 12-months) were abstracted. Smoking cessation intervention effects for smokers in addictions treatment and recovery were significant at post-treatment. Effects were no longer significant at 6- to 12-months follow up. For participants in addictions treatment, smoking cessation interventions were associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs. The findings suggest short-term success with treating tobacco dependence among individuals in addictions treatment and recovery and the need for innovative strategies for long-term cessation. Contrary to previous concern, smoking cessation efforts delivered during addictions treatment appeared to enhance rather than compromise long-term sobriety. Prochaska, J.J., Delucchi, K. and Hall, S.M. Journal of Consulting and Clinical Psychology, 72(6), pp. 1144-1156, 2004.

A Pilot Study on Voucher-based Incentives to Promote Abstinence from Cigarette Smoking during Pregnancy and Postpartum

Dr. Higgins and colleagues from the University of Vermont report results from a pilot study examining the use of vouchers redeemable for retail items as incentives for smoking cessation during pregnancy and postpartum. Fifty-eight women who were still smoking upon entering prenatal care were assigned to either contingent or noncontingent voucher conditions. Vouchers were available throughout pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence; in the noncontingent condition, vouchers were earned independent of smoking status. Contingent vouchers significantly increased abstinence at the end-of-pregnancy (37% vs. 9%), and 12-week postpartum (33% vs. 0%) assessments. That effect remained significant at the 24-week postpartum assessment (27% vs. 0%), which was 12 weeks after discontinuation of the voucher program. The magnitude of these treatment effects exceeds levels typically observed with pregnant and recently postpartum smokers, and the maintenance of effects through 24 weeks postpartum extends the duration beyond those reported previously. Higgins, S.T., Heil, S.H., Solomon, L.J., Lussier, J.P. and Lynch, M.E. Nicotine and Tobacco Research, 6(6), pp. 1015-1020, 2004.

Perceived Risks and Benefits of Smoking Cessation: Gender-specific Predictors of Motivation and Treatment Outcome

The primary aim of this study was to examine gender differences in perceived risks and benefits of smoking cessation and their relationship to pretreatment motivation and treatment outcome. A self-report instrument was developed for this purpose. Findings are reported from a subsample of 93 participants out of 573 treatment seeking smokers entering a smoking cessation study. Females indicated greater likelihood ratings of perceived risks and benefits than males. For women and men, perceived benefits were positively associated with motivation, and perceived risks were negatively associated with motivation and treatment outcome. Women evidenced stronger associations between perceived risks and pretreatment motivation, and treatment outcome. Knowledge of perceived risks and benefits associated with smoking cessation is critical for public education campaigns and could inform intervention strategies designed to modify sex-specific beliefs associated with lowered behavioral intentions to quit smoking. McKee, S.A., O'Malley, S.S., Salovey, P., Krishnan-Sarin, S. and Mazure, C.M. Addictive Behaviors, 30, pp. 423-435, 2005.

Depressed Smokers and Stage of Change: Implications for Treatment Interventions

Dr. Prochaska and colleagues from the University of California, San Francisco examined depressed smokers' readiness to quit and the applicability of the Stages of Change framework to a psychiatric sample. Currently depressed smokers (N=322) from four outpatient psychiatric clinics participated. The majority (79%) reported intention to quit smoking with 24% ready to take action in the next 30 days. Individuals in the preparation stage reported more prior quit attempts, a greater commitment to abstinence, increased recognition of the cons of smoking, and greater use of the processes of change. Precontemplators were least likely to identify a goal related to their smoking behavior. Depressive symptom severity and history of recurrent depressive episodes were unrelated to readiness to quit. This study is one of the first to examine the smoking behaviors of currently depressed psychiatric outpatients. The level and longevity of their tobacco use underscore the need for cessation interventions. The consistency in hypothesized patterns among theoretical constructs of the Stages of Change model supports the transfer of stage-tailored interventions to this clinical population. Prochaska, J.J., Rossi, J.S., Redding, C.A., Rosen, A.B., Tsoh, J.Y., Humfleet, G.L., Eisendrath, S.J., Meisner, M.R., and Hall, S.M. Depressed Smokers and Stage of Change: Implications for Treatment Interventions. Drug Alcohol Depend. 76(2), pp. 143-151, November 11, 2004.

Acceptance-Based Treatment for Smoking Cessation

This pilot study applied a theoretically derived model of acceptance-based treatment process to smoking cessation, and compared it to a pharmacological treatment based on a medical dependence model. Seventy-six nicotine-dependent smokers were randomly assigned to one of two treatments: Nicotine Replacement Treatment (NRT), or a smoking-focused version of Acceptance and Commitment Therapy (ACT). There were no differences between conditions at posttreatment; however, participants in the ACT condition had better long-term smoking outcomes at 1-year follow-up. As predicted by the acceptance process model, ACT outcomes at 1 year were mediated by improvements in acceptance-related skills. Withdrawal symptoms and negative affect neither differed between conditions nor predicted outcomes. Gifford, E.V., Kohlenberg, B.S., Hayes, S.C., Antonuccio, D.O., Piasecki, M.M., Rasmussen-Hall, M.L. and Palm, K.M. Behavior Therapy, 35, pp. 689-705, 2004.

Methadone versus Buprenorphine with Contingency Management or Performance Feedback for Cocaine and Opioid Dependence

In this study Dr. Schottenfeld and colleagues at Yale University compared the effects of buprenorphine and methadone and evaluated the efficacy of combining contingency management with maintenance treatment for patients with co-occurring cocaine and opioid dependence. One hundred and sixty two subjects with cocaine and opioid dependence were provided manual-guided counseling and randomly assigned in a double-blind design to receive daily sublingual buprenorphine (12-16 mg) or methadone (65-85 mg, p.o.) and to contingency management or performance feedback. Contingency management subjects received monetary vouchers for opioid and cocaine negative urine tests, which were conducted three times per week; voucher value escalated during the first 12 weeks for consecutive drug free tests and was reduced to a nominal value in weeks 13-24. Performance feedback subjects received slips of paper indicating the urine test results. The primary outcome measures were the maximum number of consecutive weeks abstinent from illicit opioids and cocaine and the proportion of drug free tests. Analytic models included two-by-two analysis of variance and mixed-model repeated measures analysis of variance. In this study the methadone treated subjects remained in treatment significantly longer and achieved significantly longer periods of sustained abstinence and a greater proportion of drug free urine tests, compared with the subjects who received the buprenorphine. Subjects receiving contingency management achieved significantly longer periods of abstinence and a greater proportion of drug free tests during the period of escalating voucher value, compared with those who received performance feedback, but there were no significant differences between groups in these variables during the entire 24-week study. Contingency management improved outcomes during both buprenorphine and methadone maintenance, supporting the efficacy of combining opioid agonist maintenance with this behavioral treatment. Schottenfeld, R.S., Chawarski, M.C., Pakes, J.R., Pantalon, M.V., Carroll, K.M. and Kosten, TR. American Journal of Psychiatry 162(2), pp. 340-349, February 2005.

A Trial of Three Strategies of Training Clinicians in Cognitive-Behavioral Therapy

Until recently there has been little research on the effectiveness of different training strategies or the impact of exposure to treatment manuals alone on clinicians' ability to effectively implement empirically supported therapies. In this study 78 community-based clinicians were assigned to 1 of 3 training conditions: review of a cognitive-behavioral (CBT) manual only, review of the manual plus access to a CBT training Web site, or review of the manual plus a didactic seminar followed by supervised casework. The primary outcome measure was the clinicians' ability to demonstrate key CBT interventions, as assessed by independent ratings of structured role plays. Statistically significant differences favoring the seminar plus supervision over the manual only condition were found for adherence and skill ratings for 2 of the 3 role plays, with intermediate scores for the Web condition. Sholomskas, D.E., Syracuse-Siewert, G., Rounsaville, B.J., Ball, S.A., Nuro, K.F. and Carroll, K.M. Journal of Consulting and Clinical Psychology 73(1), pp. 106-115, February 2005.

The Effectiveness of Telephone-Based Continuing Care for Alcohol and Cocaine Dependence

Dr. James McKay of the University of Pennsylvania and colleagues tested an intervention delivered mostly by telephone to patients with cocaine or alcohol dependence after initial success in an intensive outpatient group treatment. A total of 359 patients were randomized to receive one of three 12-week interventions: the telephone-based continuing care treatment; once weekly individualized and group therapy based on a relapse prevention model; or standard continuing care involving twice weekly, disease-model group sessions. Results showed overall efficacy of the telephone-based intervention in supporting abstinence from cocaine and alcohol, with different measures of substance use outcomes showing different relative efficacy compared to the other treatment conditions. Of particular interest is the apparent superiority of the telephone-based intervention for participants with lower risk factors for relapse, as compared to standard continuing care which seemed to be superior for participants with higher risk of relapse. These results suggest that creative use of disease-management, telephone-based brief interventions can support continued abstinence after initial treatment. McKay, J.R., Lynch, K.G., Shepard, D.S. and Pettinati, H.M. Archives of General Psychiatry, 62, pp. 199-207, 2005.

Dual and Multiple Diagnosis among Runaway and Homeless Youth

Dr. Natasha Slesnick and Jillian Prestopnik report on the clinical presentations of 226 youth at two homeless shelters participating in a study of family treatment for substance abuse. Regarding substance use disorders, 81% met criteria for marijuana abuse or dependence, 64% met criteria for alcohol abuse or dependence, and about half (44%) met criteria for two substance use disorders. About 60% of youth met criteria for at least one substance use disorder and at least one psychiatric diagnosis. Of these youth, 60% met criteria for Oppositional Defiant Disorder or Conduct Disorder (ODD/CD); 34% met criteria for an Affective Disorder; and 54% met criteria for an Anxiety Disorder. Youth with ODD/CD were significantly more likely to use marijuana than other youth. Young men were significantly more likely than young women to meet criteria for ODD/CD, while young women were significantly more likely to meet criteria for Affective Disorders and Anxiety Disorders, and to have multiple diagnoses. These results highlight the large overlap between substance use disorders and psychiatric disorders found, and the need for appropriate treatment, among runaway youth. Slesnick, N. and Prestopnik, J.L. American Journal of Drug and Alcohol Abuse, 31, pp. 179-201, 2005.


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