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Director's Report to the National Advisory Council on Drug Abuse - September, 2004

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

Adherence to Treatment of Depression in Active Injection Drug Users

Investigators at Brown University School of Medicine recruited injection drug users for a randomized study of combined psychotherapy and pharmacotherapy for the treatment of depression. Among the 53 SCID diagnosed depressed subjects assigned to the combined treatment group, 43.4% were "fully adherent" to treatment (75% or greater attendance at cognitive-behavioral therapy sessions or 75% or greater adherence to the pharmacotherapy regimen). The correlation between cognitive-behavioral therapy attendance and pharmacotherapy use was high (r(s)=.74). Persons with major depression and dysthmia were most likely to be fully adherent (p=.01); frequency of heroin use was inversely associated with adherence. The impact of depression on drug users is extensive, serving as a trigger for high-risk injection practices and continued drug use. Stein, M.D., Herman, D.S., Solomon, D.A., Anthony, J.L., Anderson, B.J., Ramsey, S.E., and Miller, I.W. Journal of Substance Abuse Treatment, 26(2), pp. 87-93, 2004.

Network Therapy Decreased Secondary Opioid Use During Buprenorphine Maintenance Treatment

Network therapy utilizes family members and/or friends to support compliance with an addiction treatment carried out in office practice. Investigators at New York University conducted a study to examine whether Network Therapy is a useful psychosocial adjunct, relative to a control treatment, for achieving diminished illicit heroin use for patients on buprenorphine maintenance. Patients agreeing to randomization to either Network Therapy (N=33) or Medication Management (N=33) were inducted onto short-term buprenorphine maintenance and then tapered to zero dose at the end of the 18-week study. Network Therapy resulted in significantly more urine toxicologies negative for opioids than Medication Management (65% vs. 45%), and more Network Therapy than Medication Management patients ( 50% vs. 23%) experienced a positive outcome relative to secondary heroin use by the end of treatment. The use of Network Therapy in office practice may improve the effectiveness of eliminating secondary heroin use during buprenorphine maintenance. Galanter, M., Dermatis, H., Glickman, L., Maslansky, R., Sellers, M., Neumann, E., and Rahman-Dujarric, C. Journal of Substance Abuse Treatment, 26(4), pp. 313-318, June 2004.

Choosing a Behavioral Therapy Platform for Pharmacotherapy of Substance Users: A Review of Empirically Supported Manual Guided Behavioral Therapies

Behavioral therapy platforms have become requirements in pharmacotherapy trials due to their utility in reducing noise variability, preventing differential medication adherence and protocol attrition, enhancing statistical power and addressing ethical issues in placebo-controlled trials. Selecting an appropriate behavioral platform for a particular trial requires study-specific tailoring, taking into account both the stage of development of the medication being evaluated, as well as the specific strengths and weaknesses of a broad array of available empirically supported behavioral therapies and the range of their possible targets (e.g., enhancing medication adherence, preventing attrition, addressing co-morbid problems, fostering abstinence, and targeting specific weaknesses of the pharmacologic agent). Choosing a suitable behavioral platform also requires consideration of the characteristics of the population to be treated, stage of scientific knowledge regarding the medication's effects, appropriate balance of internal and external validity, and consideration of potential ceiling effects. In this paper researchers at Yale University reviewed the available manualized behavioral treatments, noting the strengths and limitations of these empirically supported treatments for use as behavioral therapy platforms for pharmacotherapy trials. Carroll, K.M., Kosten, T.R., and Rounsaville, B.J. Drug and Alcohol Dependence, 75, pp. 123-134, 2004.

Funding Contingency Management Programs Via Community Donations

Researchers at Friends Research Institute have shown that direct mail solicitations can be used to finance donations to a community store through which contingent reinforcement opportunities may be provided for drug abusers who maintain abstinence. Over a two month period in Toronto over $8,000 worth of goods and services were donated. In Los Angeles over a 34 month period over $160,000 worth of goods and services were donated. Contributions were received from 19% and 26% of those contacted respectively. Cost is believed to be one of the main barriers to implementing contingency management programs for drug abuse. This method of financing a contingency management program may eliminate this barrier to providing efficacious treatment. Amass, L. and Kamien, J. Experimental and Clinical Psychopharmacology, 12(2), pp. 147-155, 2004.

Method to Improve Work Performance in Cocaine Abusers Attending Therapeutic Workplace

Researchers at Johns Hopkins University have shown a therapeutic workplace business in which drug abusers work as paid data entry operators contingent on abstinence can be an efficacious intervention for drug abuse. However, many data entry operators in the business failed to work the maximal amount they could work and earn maximal pay even though they were abstinent and eligible to work. In focus groups many participants reported that strict work schedules posed difficulties for adherence. Thus, participants often skipped work even when abstinent from drugs. Using an ABA reversal design researchers implemented a contingency in which participants who completed a full shift of work earned the opportunity to arrive to work at a flexible start time. Preliminary results show that overall attendance at the therapeutic workplace including number of full day shifts participants worked increase when the contingency is in place. This modification may be important for improving adherence to this behavioral intervention and ultimately may improve its efficacy. Wong, C.J., Dillon, E.M, Sylvest, C. and Silverman, K. Drug and Alcohol Dependence, 74(3), pp. 319-323, 2004.

Scales Used to Judge Therapist Adherence and Competence Effectively Differentiate Behavioral Treatments in Cocaine Collaborative Study

The NIDA Cocaine Collaborative Treatment Study was the first large scale clinical trial of behavioral treatments for addiction to measure therapist competence using scales administered by expert raters with experience in psychotherapy. Investigators at the University of Pennsylvania demonstrated that the scales used were reliable and internally consistent. Additionally, findings show that therapists administered the four therapies tested, Cognitive Therapy, Supportive Expressive Therapy, Individual Drug Counseling, and Individual and Group Drug Counseling combined, according to the manual instructions and training guidelines. Results showed that most of the time therapists administered the prescribed elements of the treatment to which the client was assigned rather than the elements of an intervention to which the client was not assigned. These results suggest that distinct therapies were administered each of which had an impact on drug abuse. Thus this study provides further support for the efficacy of the study treatments when administered with strict adherence to the treatment manual. Barber, J.P., Foltz, C., Crits-Christoph, P. and Chittams, J. Journal of Clinical Psychology, 60(1), pp. 29-41, 2004.

How to Word Effective Messages About Smoking and Oral Health: Emphasize the Benefits of Quitting

Investigators at Yale examined whether smokers differentially responded to messages about oral health that emphasized either the benefits of quitting smoking (gain-framed) or the risks of continued smoking (loss-framed). These messages were embedded in recruitment brochures for smoking cessation trials, which were placed in 20 dental office waiting rooms for a six-month period. The number of brochures taken from the waiting rooms was tracked, as well as calls to inquire about smoking cessation studies. As hypothesized, dental patients were more likely to acquire gain-framed brochures. Out of 271 brochures taken from the dental office waiting rooms, significantly more brochures contained gain-framed messages compared to loss-framed messages (59% vs. 41%, p<.05). There were an equal number of calls to inquire about smoking cessation studies for each message type. This study found that smokers are more receptive to information that emphasizes the benefits of quitting. McKee, S.A., O'Malley, S., Steward, W.T., Neveu, S., Land, M. and Salovey, P.J. Dent. Educ., 68(5), pp. 569-573, 2004.

Bupropion SR in Adolescents with Comorbid ADHD and Nicotine Dependence: A Pilot Study

Investigators at the Medical University of South Carolina conducted an open-label pilot study designed to examine the feasibility and preliminary tolerability of bupropion SR in adolescents with nicotine dependence. Sixteen adolescents were enrolled in the study. Eleven of the 16 participants also had comorbid ADHD. Two brief smoking cessation counseling sessions were also delivered. Over the course of treatment, a significant decrease in the average number of cigarettes smoked and carbon monoxide levels was found. There was no significant change in ADHD symptoms during the study. The investigators conclude that bupropion SR along with brief counseling may be safe and potentially efficacious for adolescents with nicotine dependence with and without ADHD. Smoking cessation trials in adolescents need to focus on strategies to increase retention for optimal effects. Upadhyaya, H.P., Brady, K.T. and Wang, W. J. Am. Acad. Child Adolesc. Psychiatry, 43(2), pp.199-205, 2004.

Training Support Persons to Help Smokers Quit: A Pilot Study

Mayo Clinic investigators evaluated the feasibility, acceptability, and potential efficacy of a skills-training intervention for adults interested in helping someone to stop smoking (i.e., support persons). Sixty adult support persons (77% female) were directly recruited from the community and randomly assigned to this intervention (manual plus five weekly group-based sessions) or a control condition (one-page leaflet). All intervention and outcome assessments occurred through the support persons. Assessments occurred at weeks 0 (baseline), 6 (end of treatment), 12, and 24. Outcomes were ratings of treatment acceptability, recruitment and retention rates, supportive behaviors provided to the smoker, and smoking behavior change in the smoker as reported by the support person. Support persons in skills training showed significant increases in their supportive behavior scores compared with control subjects at weeks 6 and 12. Although not statistically significant, the skills-training intervention was associated with more quit attempts, greater improvement in stage of change, and higher 7-day point prevalence abstinence rates in the smokers than the control condition. A skills training intervention for support persons is feasible and acceptable. Further studies are needed to test the efficacy of this approach for smoking cessation. Patten, C.A., Offord, K.P., Hurt, R.D., Sanderson Cox, L., Thomas, J.L. Quigg, S. M., Croghan, I.T., Wolter, T.D. and Decker, P.A. Am J Prev Med., 26(5), pp. 386-390, 2004.

An Experimental Test of the Influence of Prior Cigarette Smoking Abstinence on Future Abstinence

The present study was conducted to examine experimentally whether prior smoking abstinence histories can directly facilitate later abstinence, using a contingency management procedure to manipulate prior abstinence. A total of 40 adult cigarette smokers who were not trying to quit were randomly assigned to one of two conditions: Contingent ALL (C-ALL), who earned monetary incentives contingent on smoking abstinence during three 5 day experimental periods; or Contingent LAST (C-LAST), who earned incentives independent of abstinence during the first two periods (i.e., noncontingent payments) and contingent on abstinence during the final period. The contingency management procedure was effective in establishing different abstinence histories in the two conditions during the first two periods. Comparison of abstinence levels between the C-ALL and C-LAST conditions during the third period showed significantly greater abstinence in the C-ALL condition, although nicotine withdrawal and other subject ratings generally did not differ significantly between the two conditions. These results provide experimental evidence that prior abstinence histories can directly influence subsequent efforts to abstain from smoking. Heil, S.H., Alessi, S.M., Plebani Lussier, J., Badger, G.J., and Higgins, S.T. Nicotine & Tobacco Research, 3(3), pp. 471-479, 2004.

Do Changes in Mood and Concerns About Weight Relate to Smoking Relapse in the Postpartum Period?

The majority of women who quit smoking during pregnancy will resume smoking during the postpartum period. Little is known about the predictors of postpartum relapses to smoking. Changes in mood and increases in concerns about weight are common during the postpartum period, and these factors may affect women's postpartum smoking behavior. Investigators at the University of Pittsburgh reviewed the literature on postpartum relapse prevention trials and present evidence of a connection between changes in mood and weight concerns to postpartum relapse. Directions for future research on the prevention of smoking relapses during the postpartum period, and the roles of mood and weight concerns in smoking relapse are presented. Levine, M.D. and Marcus, M.D. Archives of Women's Mental Health, 7(3), pp. 155-166, 2004.

Aggressive Juvenile Offenders Transitioning into Emerging Adulthood: Factors Discriminating Persistors and Desistors

As part of a randomized clinical trial comparing Multisystemic Therapy to usual community services, researchers tracked juvenile offenders through early adulthood to assess psychosocial factors that were associated with success in treatment. Of the 115 adolescents participating in the original study, 80 completed multiple assessments in young adulthood, about 5 years later. Of these 80 participants, 55 were classified as "persistors", having engaged in crimes related to property or aggression in young adulthood based on self-reports and official law enforcement records; 25 were classified as "desistors", having no such self-reported or officially reported criminal behavior. In adolescence, those who became desistors in young adulthood showed less aggressive behavior than persistors, and behaved more positively toward peers. At young adulthood, desistors reported better psychosocial adjustment overall, including more emotional support, higher job satisfaction, closer peer relationships, and fewer psychiatric problems. Differences between desistors and persistors at young adulthood remained significant even after controlling for initial differences during adolescence. These results identify several targets for prevention and treatment interventions that could impact the long-term functioning of juvenile offenders as they transition to adulthood. Clingempeel, W.G. and Henggeler, S.W. American Journal of Orthopsychiatry, 73, pp. 310-323, 2003.


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