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Director's Report to the National Advisory Council on Drug Abuse - May, 2008

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

Coping Skills Training and Contingency Management Treatments for Marijuana Dependence: Exploring Mechanisms of Action

Dr. Kadden and colleagues at the University of Connecticut conducted this study to explore the mechanisms of behavior change from a marijuana treatment trial in which behavioral treatments for marijuana dependence were evaluated. Participants were 240 adult marijuana smokers from an out-patient treatment research facility located in the university medical center. The participants were assigned to one of four 9-week treatment conditions: 1) case management control condition; 2) Motivational Enhancement/Cognitive Behavioral Therapy; 3) Contingency Management; or 4) a combination of Motivational Enhancement/Cognitive Behavioral Therapy and Contingency Management. Results indicated that regardless of treatment condition, abstinence in near-term follow-ups was predicted most clearly by abstinence during treatment, but long-term abstinence was predicted by use of coping skills and especially by post-treatment self-efficacy for abstinence. It was concluded that the most efficacious treatments for marijuana dependence are likely to be those that increase self-efficacy. Litt, M.D., Kadden, R.M., Kabela, E.C., and Petry, N.M. Coping Skills Training and Contingency Management Treatments for Marijuana Dependence: Exploring Mechanisms of Behavior Change. Addiction, 103(4), pp. 638-648, 2008.

Treating Tobacco Dependence in Clinically Depressed Smokers: Effect of Smoking Cessation on Mental Health Functioning

Dr. Prochska and colleagues at the University of California, San Francisco, conducted this study to examine the effect of smoking cessation on mental health functioning among depressed smokers. Participants were 322 actively depressed smokers recruited from outpatient mental health clinics. All participants completed a computer-delivered expert system program that provided feedback matched to their stage of change for quitting. Participants interested in quitting smoking could receive 6 sessions of individual cognitive-behavioral counseling combined with a nicotine patch. The control group received brief cessation advice. Ten indicators of mental health functioning were obtained at baseline and at 4 follow-up assessment periods. Of 40 comparisons, only one was significant: successful quitters were less likely to report alcohol use at 6-months compared with smokers. There were no group differences for depressive symptoms, which declined significantly over time for participants who stopped smoking as well as for those who continued to smoke. No indication of worse outcomes were found among successful quitters. The authors conclude that individuals who have clinical depression can be helped to stop smoking without adversely affecting their mental health recovery and should be offered concurrent tobacco dependence and depression treatment rather than delaying smoking cessation until the depression resolves. Prochaska, J.J., Hall, S.M., Tsoh, J.Y., Eisendrath, S., Rossi, J.S., Redding, C.A., Rosen, A.B., Meisner, M., Humfleet, G.L. and Gorecki, J.A. Treating Tobacco Dependence in Clinically Depressed Smokers: Effect of Smoking Cessation on Mental Health Functioning. American Journal of Public Health, 98, pp. 446-448, 2008.

Tobacco Use among Individuals with Schizophrenia: What Role has the Tobacco Industry Played?

This study examined the role the tobacco industry has played in promoting and maintaining cigarette use among individuals diagnosed with schizophrenia. Previously secret tobacco industry documents were analyzed and it was determined that the tobacco industry monitored or directly funded research supporting the idea that individuals with schizophrenia were less susceptible to the harms of tobacco and that they needed tobacco as self-medication. The tobacco industry promoted smoking in psychiatric settings by providing cigarettes and supporting efforts to block hospital smoking bans. Findings from the documents indicate that the tobacco industry engaged in a variety of direct and indirect efforts that likely contributed to the slowed decline in smoking prevalence in schizophrenia via slowing nicotine dependence treatment development for this population and slowing the rate of policy implementation on psychiatric units. The authors conclude that an awareness of the tobacco industry's efforts to preserve smoking among individuals with schizophrenia is needed to better inform treatment and policy strategies. Prochaska, J.J., Hall, S.M. and Bero, L.A. Tobacco Use among Individuals with Schizophrenia: What Role has the Tobacco Industry Played? Schizophrenia Bulletin, Feb. pp. 1-13, 2008.

Craving, Withdrawal, and Smoking Urges on Days Immediately Prior to Smoking Relapse

Dr. Allen and colleagues at the University of Minnesota conducted this study to identify temporal patterns of standardized symptom scores (for craving, withdrawal, and smoking urges) that would either refute or support the assumption that these factors are key contributors to relapse in smokers. Data were analyzed from 137 female smokers, aged 18-40 years, who completed 30 days of a protocol for a longitudinal smoking cessation trial. All subjects were followed post quit date, regardless of their subsequent smoking status. Measures of craving, withdrawal and smoking urges were completed at baseline and daily for 30 days, beginning on their quit date. A total of 26 women quit smoking and 11 relapsed. A consistent symptom severity pattern was observed, in which craving, withdrawal, and smoking urges increased leading up to the day of relapse and then subsided quickly. These findings suggest an association between patterns of symptom intensity and relapse. The authors conclude that frequent symptom monitoring might be clinically important for relapse prevention. Allen, S.S., Bade, T., Hatsukami, D., and Center, B. Craving, Withdrawal, and Smoking Urges on Days Immediately Prior to Smoking Relapse. Nicotine & Tobacco Research, 10(1), pp. 35-45, 2008.

Motivational Enhancement Therapy for High-Risk Adolescent Smokers

Dr. Helstrom and colleagues conducted this study to test the effectiveness of Motivational Enhancement Therapy (MET) in a sample of delinquent adolescent smokers and to examine how comorbid problems (alcohol use) and intrapersonal factors (impulsivity) moderated treatment outcome. Eighty-one adjudicated adolescent smokers were randomly assigned to receive either one session of MET or tobacco education control. Assessment was conducted at baseline and at one and six months post treatment. Results suggest that although between-group differences on outcome measures were not significant at follow-up, smoking behavior decreased in both groups with approximately 10% achieving 1-month smoking abstinence at 6-month follow-up. The brief MET was better than standard educational material with respect to decreasing smoking behavior for a subset of adolescents. Adolescents who consumed less alcohol and were less impulsive responded relatively well to MET in terms of self-reported decreases in smoking rates. However, for adolescents who endorsed higher rates of alcohol, or who were higher in impulsivity, MET generally performed worse than the control treatment. In fact, this subset of adolescents responded better to the control condition. The authors conclude that MET may be an effective intervention for some adolescent smokers but may be contraindicated for adolescents who have concomitant problems with alcohol use or impulsivity. Helstrom, A., Hutchison, K., and Bryan, A. Motivational Enhancement Therapy for High-Risk Adolescent Smokers. Addictive Behaviors, 32(10), pp. 2404-2410, 2007.

Cigarette Smoking in Opioid-Using Patients Presenting for Hospital-Based Medical Services

The authors examined cigarette smoking practices in 126 out-of-treatment opioid users presenting at a hospital for non-psychiatric medical services. In general, the study found the prevalence of smoking (92%) to be comparable to that reported in methadone treatment samples. Nineteen percent preferred unfiltered cigarettes. Women were more likely to smoke menthol cigarettes; men were more likely to smoke unfiltered cigarettes. Caucasians tended to smoke more than other ethnicities and exhibited greater dependence. The authors conclude that opioid users are a particularly high-risk group for continued smoking and they highlight the need for treatment programs to include smoking cessation interventions. Haas, A.L., Sorensen, J.L., Hall, S.M., Lin, C., Delucchi, D., Sporer, K., and Chen, T. Cigarette Smoking in Opioid-Using Patients Presenting for Hospital-Based Medical Services. The American Journal on Addictions, 17, pp. 65-69, 2008.

Combining Cognitive Behavioral Therapy with Contingency Management for Smoking Cessation in Adolescent Smokers

Investigators at Yale University conducted this study to evaluate the optimal format of cognitive behavioral therapy (CBT) to combine with contingency management (CM) in a four-week, high school-based smoking cessation program. In this pilot study, two different formats of CBT were compared. Thirty-four adolescent smokers were randomly assigned to receive either a standard weekly version of longer duration CBT or a more frequent brief behavioral intervention. Results indicated a trend toward a higher seven-day point prevalence end-of-treatment abstinence rate and percent days abstinent during treatment in the CBT condition. In addition, significantly more participants in the CBT group completed treatment. These preliminary results suggest that when combined with CM, the standard weekly format of CBT is more acceptable to adolescents. Cavallo, D.A., Cooney, J.L., Duhig, A.M., Smith, A.E., Liss, T.B., Fetridge A.K., Babuscio, T., Nich, C., Carroll, K.M., Rounsaville, B.J., and Krishnan-Sarin, S. Combining Cognitive Behavioral Therapy with Contingency Management for Smoking Cessation in Adolescent Smokers: A Preliminary Comparison of Two Different CBT Formats. The American Journal on Addictions, 16, pp. 468-474, 2007.

A Test of Motivational Plus Nicotine Replacement Interventions for HIV Positive Smokers

The authors conducted this study to test the acceptability, feasibility and preliminary effectiveness of two delivery formats of a combination of interventions that included motivational and pharmacological components for smoking cessation among HIV positive smokers. Forty adult daily smokers receiving HIV care were randomly assigned to one of two treatment conditions: 1) a single session of motivational interviewing plus nicotine patch, or 2) self-guided reading plus nicotine patch. The motivational interviewing included personalized feedback, consequences of smoking, and readiness to change components. The self-guided reading contained self-assessment of smoking habits, recommendations about setting a quit date, seeking help, substituting habits, self-monitoring and other tips. Participants in both groups set a quit date and were given a 1-month supply of nicotine patches. Both interventions led to significant reductions in cigarettes smoked per day and CO expiration at the 3-month follow-up, with no differences between groups. Compliance with the nicotine patch was poor and declined over time. The authors conclude that smoking cessation interventions for people with HIV can be helpful and should include components that encourage some smoke-free days, increase self-efficacy, and attend to adherence to nicotine replacement treatment. Ingersoll, K.S., Cropsey, K.L., and Heckman, C.J. A Test of Motivational Plus Nicotine Replacement Interventions for HIV Positive Smokers. AIDS Behavior, December 8, 2007 (Epub ahead of print).

The Impact of an Integrated Treatment on HIV Risk Behavior among Homeless Youth: A Randomized Controlled Trial

Drs. Slesnick and Kang conducted this study to examine an integrated individual intervention that included cognitive-behavioral treatment and HIV prevention as compared to treatment as usual on self-reported HIV risk behaviors among homeless youth. The integrated intervention focused on skills building and education. The treatment as usual condition included a place to rest during the day, food, showers, clothing, and case management that linked youth with community resources at the youth's request. Participants were 180 adolescents who were recruited from a drop-in center and were assessed at entry into the program and at 3 and 6 month follow-ups. Findings showed an interaction between treatment condition, age and time. In the interaction, youth assigned to the integrated treatment reported greater condom use than youth assigned to treatment as usual, with younger youth assigned to treatment as usual showing no change in condom use. The number of sexual partners reported by youth in both treatment conditions was also reduced over time. However, youth in both conditions continued to engage in other high-risk behaviors. The integrated treatment findings are promising and suggest that interventions which target both HIV risk behavior in addition to other life areas (substance use, mental health, and housing) among homeless youth may be necessary in order to significantly impact high-risk behaviors among this unique group. Slesnick, N. and Kang, M.J. The Impact of an Integrated Treatment on HIV Risk Behavior among Homeless Youth: A Randomized Controlled Trial. Journal of Behavioral Medicine, October 2007 (Epub ahead of print).

Older Versus Younger Treatment-Seeking Smokers

The purpose of this study was to describe treatment seeking smokers aged 50 years or older and compare them with younger smokers (aged<50) presenting to the same smoking treatment facility during the same time period. The subjects (n=810) were participating in one of two studies: one was limited to smokers aged 50 years or older; the other was open to smokers aged 18 years or older. As predicted, smokers aged 50+ were more tobacco dependent, had better psychological functioning, and had poorer physical functioning than those aged <50. Contrary to predictions, no differences were found in motivation to quit cigarette smoking or in alcohol use. Women aged 50+ were less likely to report marijuana use than women aged <50, and less likely than men to receive a positive diagnosis for alcohol abuse. Despite higher scores on measures of tobacco dependence, older smokers were less likely to be diagnosed as tobacco dependent or as having tobacco withdrawal using DSM-IV criteria. Rates of alcohol abuse and dependence were high in both age groups, but were higher for smokers aged <50. Hall, S.M., Humflet, G.L., Gorecki, J.A., Munoz, R.F., Reus, V.I., and Prochaska, J.J. Older Versus Younger Treatment-Seeking Smokers: Differences in Smoking Behavior, Drug and Alcohol Use, and Psychosocial and Physical Functioning. Nicotine & Tobacco Research, 10(3), pp. 463-470, 2008.

Nicotine Interventions with Comorbid Populations

Dr. Sharon Hall wrote this article to selectively review research on smoking treatment for individuals with comorbid psychiatric or non-nicotine substance abuse disorders. With the exception of research on those with a history of major depressive disorder, research on smoking cessation in these populations is sparse. However, the prevalence of smoking is very high in these populations and individuals express an interest in quitting. Multiple barriers to implementation of interventions exist. Research findings to date indicate that provision of cigarette smoking interventions in substance abuse treatment patients is efficacious and does not appear to interfere with abstinence from alcohol or illicit drugs. The data available on smoking cessation in populations with psychiatric disorders suggest at least moderate efficacy and little evidence of exacerbation of these disorders. Integration of interventions into existing treatment clinics appears desirable. Further research is recommended in both the treatment and prevention of cigarette smoking in individuals with psychiatric and substance abuse disorders. It is reasonable to offer existing treatments to these subgroups of smokers, since there is some evidence of efficacy and little evidence of harm. Hall, S.M. Nicotine Interventions with Comorbid Populations. American Journal of Preventive Medicine, 33(6S), pp. S406-S412, 2007.

Posttraumatic Stress Disorder and Smoking Relapse

This paper addresses the gap in the literature regarding factors potentially influencing smoking relapse among individuals with Posttraumatic Stress Disorder (PTSD). PTSD is associated with high prevalence of cigarette smoking, heavy cigarette consumption, and low cessation rates. To date little is known about mechanisms impeding smoking cessation among this recalcitrant group of smokers. The assessment of mechanisms related to relapse would be an important first step in improving smoking cessation treatment efficacy. Such knowledge would aid in the development of tailored relapse prevention strategies for this population. Mechanisms reviewed that may be particularly relevant to smoking relapse among PTSD smokers include negative affect, positive affect, attention, anxiety sensitivity, distress tolerance, and self-efficacy. Cook, J.W., McFall, M.M. Calhoun, P.S. and Beckham, J.C. Posttraumatic Stress Disorder and Smoking Relapse. Journal of Traumatic Stress, 20(6), pp. 989-998, 2007.

Message Framing for Smoking Cessation

Research on message framing tests whether or not gain-framed messages (i.e., emphasizing the benefits of quitting smoking) are more persuasive in promoting cessation than loss-framed messages (i.e., emphasizing the costs of continuing to smoke). The authors conducted this study to examine how gender differences in perceptions of risk of quitting smoking influence the effects of framed interventions. Participants were 249 adult smokers (129 females, 120 males) in a clinical trial of message framing for smoking cessation with bupropion. The results showed that women reported a higher perceived risk of cessation than men. Participants who anticipated high risks associated with quitting smoking reported fewer days to relapse. Further, females in the gain-framed condition who reported low perceived risks of cessation had a greater number of days to relapse, as opposed to females in the loss-framed condition. These findings suggest that message framing interventions for smoking cessation should consider the influence of gender and risk perceptions associated with quitting on the effectiveness of framed interventions. Toll, B.A., O'Malley, S.S., Mazure, C.M., Latimer, A., McKee, S.A. Message Framing for Smoking Cessation: The Interaction of Risk Perceptions and Gender. Nicotine & Tobacco Research, 10(1), pp. 195-200, 2008.

Dimensions of Depressive Symptoms and Smoking Cessation

Dr. Leventhal and colleagues conducted this study to evaluate whether certain dimensions of depressive symptoms have a greater influence on smoking cessation than others. Certain psychopathologic components of depressive symptoms [negative affect (NA), somatic features (SF), low positive affect/anhedonia (PA), and interpersonal disturbance (IP)] were examined in a sample of 157 non-clinically depressed social drinkers enrolled in a clinical trial for smoking cessation. The subscales of the Center for Epidemiologic Studies Depression Scale (CESD) were used to predict (a) baseline tobacco dependence severity and motives for smoking, (b) abstinence-provoked nicotine withdrawal, and (c) smoking abstinence over the follow-up period. From a clinical standpoint, the findings suggest that interventions targeting anhedonia and low positive affect may be useful for smokers trying to quit. Leventhal, A.M., Ramsey, S.E., Brown, R.A., LaChance, H.R., and Kahler, C.W. Dimensions of Depressive Symptoms and Smoking Cessation. Nicotine & Tobacco Research, 10(3), pp. 507-517, 2008.

Promising Results from Behavioral and HIV Risk Reduction with Buprenorphine

Dr. Schottenfeld and colleagues conducted this study to see if behavioral drug and HIV risk reduction counseling (BRDC) and abstinent contingent buprenorphine reduced HIV risk and drug abuse in opioid dependent patients in Malaysia. Following a two-week induction onto buprenorphine, twenty-four participants were randomized in this pilot trial to either standard treatment (physician managed buprenorphine administered non-contingently) or enhanced treatment. The enhanced treatment included behavioral drug and HIV risk reduction counseling and abstinent contingent buprenorphine. Buprenorphine ingestion was observed by staff and only administered following submission of a drug negative urine specimen. Both groups decreased use of opioids significantly over time. However, participants assigned to the enhanced treatment had longer consecutive periods of abstinence and a higher proportion of drug negative urines during treatment. Both groups reduced HIV risk behaviors from baseline. Although preliminary, these findings are significant because this short term community friendly intervention can be delivered by nurses in regular medical settings. Therefore, it is likely to be useful in many developing countries that are setting up an infrastructure to treat opioid abuse but which lack counselors or therapists with advanced training. Chawarski, M.C., Mazlan, M., Schottenfeld, R.S. Behavioral Drug and HIV Risk Reduction Counseling (BDRC) with Abstinence-Contingent Take-Home Buprenorphine: A Pilot Randomized Clinical Trial. Drug and Alcohol Dependence, 94(1-3), pp. 281-284, 2008.

Buprenorphine and Brief Medical Management In Primary Care Reduces HIV Risk

Dr. Sullivan and colleagues examined HIV risk behavior participants (N=166) enrolled in a 24-week clinical trial who were receiving either standard or intensive medical management and either once weekly or thrice weekly medication management (buprenorphine) administered in primary care. Medical management was conducted by nurses and lasted 20 minutes for the standard and 45 minutes for the intensive conditions. None of the study conditions specifically targeted HIV sexual risk behavior. HIV risk was assessed at baseline, 12 and 24 weeks. None of the conditions showed any difference in abstinence (results reported elsewhere) although all participants reduced opioid use. Results showed a significant decrease in injection drug use from baseline across conditions. Additionally, the percentage of people endorsing "having sex with a steady partner while 'high'" decreased as well. Infrequent condom use did not change significantly. These results are important because they show that buprenorphine plus brief medical management approaches delivered in a primary care setting can reduce HIV risk. Additionally, they suggest the effect of these interventions are primarily through reducing drug use as well as certain risky behavior while under the influence of opioids. However, the results also indicate changes to the intervention are needed to directly address infrequent condom use which continues to put patients and their partners at risk. Sullivan L.E., Moore, B.A., Chawarski, M.C., Pantalon, M.V., Barry, D., O'Connor, P.G., and Schottenfeld, R.S., Fiellin, D.A. Buprenorphine/Naloxone Treatment in Primary Care is Associated with Decreased Human Immunodeficiency Virus Risk Behaviors. Journal of Substance Abuse Treatment, 2007. (Epub ahead of print).

Live Teleconferencing Improves Therapist Motivational Interviewing Skills

Dr. Nunes and colleagues conducted this study to determine whether live teleconferencing could be used to help therapists learn motivational interviewing (MI) skills following a workshop training session. Currently, workshop training is the dominant method of training therapists in MI. However, studies show most therapists do not become proficient in MI skills following a single workshop. During Teleconferencing Supervision (TCS) the trainer watches a live video of the student conducting therapy and listens to the session over the telephone. Supervisors then provide immediate feedback over the phone via a microphone in the student therapist's ear. In this study, thirteen clinicians from community substance abuse treatment programs were recruited and trained in a workshop by an expert MI trainer. Twelve of thirteen participants completed all of the training which included the workshop and 5 teleconference supervision sessions and separate in depth supervision sessions in between sessions with patients. Initial trainee skillfulness was examined through a role play MI session following the workshop rated by expert MI coders using a standardized rating instrument. These were then compared to tapes of actual sessions with substance using clients at 8 and 20 weeks to examine the impact of the telesupervision. Initial skill levels were low. At the study end points motivational interviewing skills including open ended questions had improved to expert level. However, most advanced skills typically did not improve beyond beginner proficiency. These findings are important because they demonstrate the feasibility of a novel approach to provide community therapists with access to expert training in research based behavioral treatment. Additionally they suggest that long-term sustained monitoring and feedback (supervision) is likely to be necessary for community treatment providers to adeptly administer the treatments NIDA seeks to disseminate. Smith, J.L, Amrhein, P.C., Brooks, A.C., Carpenter, K.M., Levin, D., Schreiber, E.A., Travaglini, L.A., and Nunes, E.V. Providing Live Supervision via Teleconferencing Improves Acquisition of Motivational Interviewing Skills after Workshop Attendance. Am. J. Drug Alcohol Abuse, 33(1), pp. 163-168, 2007.

Longest Abstinence Length Predicts Incentive Treatment Outcome for Cocaine

Dr. Petry and colleagues conducted this study to determine whether there was a difference in outcome between standard contingency management "incentive" treatment that reinforces abstinence with escalating voucher values for drug negative urines and a novel prize based approach where participants submitting drug negative urines draw for prizes. In the prize condition prizes ranged from verbal reinforcement (slips of paper that say good "job" to small prizes worth about $1 up to jumbo prizes worth $100. Under this prize system the probability of winning a prize is inversely proportional to the size of that prize and the number of chances to draw increase with each consecutive drug negative urine sample a participant provides. Across 12 weeks of treatment and the number of chances the maximal expected earnings for a participant in this trial was $300. Seventy-six drug users were assigned at random to either standard drug treatment or standard drug treatment plus voucher contingencies (V) or standard drug treatment plus prizes (P). The median number of weeks of consecutive abstinence was 0 in the standard treatment and 6 in both contingent conditions. At 6 and 12 weeks post-treatment no difference existed between the groups. However, regardless of group assignment, the longest duration of abstinence predicted long term abstinence. Overall, the total earnings of both contingency groups did not differ significantly. Results are significant because community treatment providers wishing to use this alternate method can be assured it is as effective as the standard method. Additionally, findings indicate that many methods which enable a drug user to achieve a long period of abstinence may be effective for establishing a trajectory of abstinence. Petry, N.M., Alessi, S.M., Hanson, T., and Sierra S. Randomized Trial of Contingent Prizes versus Vouchers in Cocaine-Using Methadone Patients. Journal of Consulting and Clinical Psychology, 75(6), pp. 983-991, 2007.

Dually Diagnosed Veterans in Vocational Rehabilitation Benefit from Incentives

Dr. Rounsaville and colleagues examined whether adding incentives exchangeable for goods and services contingent on submitting a drug free urine would improve abstinence and vocational rehabilitation in veterans with a substance use and mental health disorder. One hundred participants were randomly assigned to standard vocational rehabilitation (VR) or vocational rehabilitation plus the opportunity to earn up to $1170 in incentives for completing tasks related to abstinence, job searches and employment maintenance (VR+). Relative to VR, Veterans in VR+ transitioned more quickly to competitive employment and at higher rates and had more abstinence during the first 16 weeks of the program. These results are significant because obtaining employment may be difficult for dually diagnosed veterans, but it is crucial for successful rehabilitation. Additionally, these findings suggest that restructuring traditional work for pay contingencies to include direct financial reimbursement for clinical goal achievement may increase abstinence in this difficult to treat population. Drebing, C.E., Van Ormer, E.A., Mueller, L., Hebert, M., Penk, W.E., Petry, N.M., Rosenheck, R., and Rounsaville, B. Adding Contingency Management Intervention to Vocational Rehabilitation: Outcomes for Dually Diagnosed Veterans. Journal of Rehabilitation Research Development, 44(6), pp. 851-866, 2007.

Dose Response for Cash Incentives but not Goods-Based Incentives

Dr. Stitzer and colleagues examined whether providing goods in exchange for abstinence or money in exchange for abstinence resulted in either better abstinence outcomes or more cocaine use in methadone-maintained cocaine-dependent people attempting to abstain from cocaine. In a 16-week study with 12 participants, incentives (both goods based and checks) worth $0.00, $25, $50 and $100 were compared in a case-controlled randomized design with a nine day washout period between each incentive condition. Checks worth $50 and $100 produced greater abstinence rates than control checks ($0). However, this effect was not observed for goods-based incentives. Additionally, the cash conditions did not produce more cocaine use. These results are important for two reasons. First, most incentive programs give goods rather than cash because of the perception that goods are safer for patients. However, this study suggests that providing money directly may be more effective. Additionally, the reason why most incentive programs use prize or voucher programs that require a great deal of staff effort to shop for and monitor prizes is out of concern that providing money in exchange for abstinence might trigger relapse. These preliminary results suggest that in the face of ongoing money incentives to become abstinent, drug users are actually unlikely to relapse and costly extra voucher and prize components may not be essential. Vandrey, R., Bigelow, G.E., and Stitzer, M.L. Contingency Management in Cocaine Abusers: A Dose-Effect Comparison of Goods-Based versus Cash-Based Incentives. Experimental Clinical Psychopharmacology, 15(4), pp. 338-343, 2007.

Drop-In Centers Help Homeless Youth Substance Users but do not Affect Education or Permanent Housing

Dr. Slesnick and colleagues conducted this study to examine the impact of drop-in centers where homeless youth in an urban community could receive case management, substance abuse treatment and access to essential basic survival services such as meals, clothing and daytime shelter. Youth were assessed at baseline, 6 months, and 12 months via semi-structured interviews and questionnaires conducted over 3 years. Significant improvements were found in mental health, substance abuse and days housed up to 12 months after baseline. Additionally, decreased substance use was associated with improvements in housing status. However, most youth did not acquire permanent housing even if substance use decreased. Additionally, education, employment and medical service utilization remained low and did not improve over time. These findings are significant because they suggest that while drop-in centers can impact high risk behaviors, reducing substance use does not translate into ending homelessness for youth. To rehabilitate homeless youth, additional measures are needed. Many youth avoid shelters and foster care due to fear of exploitation by adults. Additionally, local laws that forbid minors from leasing apartments appear to be a barrier to stability that make education and employment possible. Adult homeless treatment programs have shown housing to be essential for effective care. This study corroborates findings from other researchers that suggest the homeless adolescent care system would likely benefit from independent living programs that integrate housing, substance abuse and mental health services similar to those afforded to adults. Slesnick, N., Kang, M.J., Bonomi, A.E., and Prestopnik, J.L. Six- and Twelve-Month Outcomes among Homeless Youth Accessing Therapy and Case Management Services Through an Urban Drop-In Center. Health Services Research, 43(1), pp. 211-229, 2007.

Behavioral Treatment for Drug Abuse Comparable in Efficacy to Other Interventions in Psychiatry

Dr. Otto and colleagues conducted a meta-analysis of psychosocial treatments for substance use disorders examining thirty-four well controlled treatments. Contingency management (CM), relapse prevention, cognitive behavioral therapy (CBT) and combinations of CM and CBT were included. Overall results of the meta-analysis showed these interventions had a moderate effect size, comparable to that yielded by other psychiatric interventions. They showed the most efficacy for marijuana users and the least for polysubstance users. Drop out was significantly greater in control group participants than in the experimental conditions. CM, particularly when combined with CBT, produced the largest effect sizes. Results are significant because they suggest the average participant in these psychosocial interventions achieves better outcomes than 67% of control group participants. Finally, additional work is need related to improving treatment efficacy for polysubstance uses. Dutra, L., Stathopoulou, G., Basden, S.L., Leyro, T.M., Powers, M.B., and Otto, M.W. A Meta-Analytic Review of Psychosocial Interventions for Substance Use Disorders. Am J Psychiatry, 165(2), pp. 179-87, 2008. (Epub ahead of print).

Motivational Enhancement Therapy Reduces Viral Load in HIV+ Youth

Dr. Naar King and colleagues adapted a motivational enhancement therapy for use with youth and conducted a pilot test to determine whether it would reduce HIV risk behaviors and viral load in HIV+ youth and maintain those improvements over time. Thirty-two HIV+ participants between ages 16-25 were assigned either to treatment as usual or to the four session experimental motivational enhancement treatment (MET) adapted from a similar intervention geared at addressing substance use and HIV medication in adults called Healthy Choices. Youth assigned to MET received individual counseling sessions where information was feedback from their assessment and they could chose to work on 2 of 3 problem behaviors including sexual risk, health behavior including HIV medication taking, and substance use behaviors. The goals for the first two sessions (weeks 1 & 2) were to motivate and help establish a self-directed change plan. In follow-up sessions weeks 6 and 10, counselors reviewed progress, problem solved barriers, and helped youth think of strategies to prevent relapse. The treatment group showed greater reductions in viral load and alcohol use compared with the control group at 6-month follow-up but none in marijuana use or unprotected sex. Reductions for the treatment group in marijuana use, alcohol use and viral load were maintained at 9 months. This is significant because MET treatments have not previously been shown to have an impact on this population. It is especially noteworthy that four sessions of therapy could effect reductions in viral load. More research is needed on how this treatment impacts viral load as well as how it can be improved to affect more risk behaviors. Naar-King, S., Lam, P., Wang, B., Wright, K., Parsons, J.T., and Frey, M.A. Brief Report: Maintenance of Effects of Motivational Enhancement Therapy to Improve Risk Behaviors and HIV-Related Health in a Randomized Controlled Trial of Youth Living with HIV. J. Pediatr. Psychology, 33(4), pp. 441-445, 2008.


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