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

Doubling Voucher Incentive Amount during Initial Weeks of Treatment Produces Greater During Treatment and Longer-Term Cocaine Abstinence

Cocaine dependent outpatients were randomly assigned to receive Community Reinforcement Approach Behavioral Treatment with either a high value ($1995) or low value ($499) of voucher incentives available during the first twelve weeks of a twenty-four week treatment period. The voucher incentives were contingent upon providing drug negative urine specimens and could be exchanged for non-drug related goods or services. Results show that duration of continuous abstinence was higher across the entire 24 week treatment period in the higher condition. Additionally, the point prevalence rates of abstinence assessed every three weeks across an eighteen month follow-up period showed higher rates in the high than the low condition. Additional analyses indicate that few people in the low voucher value condition achieved 1 month or more of continuous abstinence. These results are significant because they indicate that larger voucher values early in treatment may maximize outcomes for cocaine dependent people receiving a comprehensive behavioral intervention. Higgins, S.T., Heil, S.H., Dantona, R., Matthews, M., and Badger, G. Addiction, 102 (2), pp. 271-281, 2007.

Contingency Management Improves Adherence to HIV Medication and Reduces Viral Load

Individuals with poor compliance to antiretroviral medication were randomized to either sixteen weeks of supportive counseling or sixteen weeks of a contingency management (CM) intervention. In the contingency management condition, bottle caps that monitored pill opening, a Medication Event Monitoring System (MEMS), were placed on up to three bottles of participants HIV medications for four weeks. Participants MEMS data was reviewed weekly and those whose data indicted that medication was taken in a timely manner were given the opportunity to draw cards from a bowl. Cards were printed with values ranging as follows: $1.00 (26% of cards), $20.00 (7.6% of cards) and $100.00 (0.2% of cards). The remaining cards did not have a value associated with them but had the words "good job" printed on them. Participants drawing winning cards had the opportunity to exchange these cards for goods worth the winning denomination in an on-site prize closet. Participants in the CM group attended significantly more counseling sessions than those assigned to supportive counseling. On average CM participants earned approximately $24.00/week of the intervention. Adherence in the CM group grew significantly higher over time while the control group drifted lower. At week 16 viral load had significantly improved for CM group participant indicating that review and contingent reinforcement of MEMS data likely resulted in better adherence. Rosen, M.I., Dieckhaus, K., McMahon, T.J., Valdes, B., Petry, N.M., Cramer, J., and Rounsaville, B. AIDS Patient Care STDS, 21(1), pp. 30-40, 2007.

Adding MEMS Feedback to Behavioral Smoking Cessation Therapy Increases Compliance with Bupropion: A Replication and Extension Study

This study was conducted to replicate and extend initial positive findings on the usefulness of a Medication Event Monitoring System (MEMS) to assess pill-taking behavior and enhance compliance with Bupropion for smoking cessation. Participants were 55 women aged 20-65, smoking a minimum of 10 cigarettes per day. All participants received MEMS bottles containing Bupropion-SR (150 mg) to be taken twice daily for 7 weeks, then randomized into one of two conditions, Usual Care (UC) or Enhanced Therapy (ET). In the UC condition, participants received individual cognitive behavioral therapy for smoking cessation. In the ET condition, weekly smoking cessation therapy sessions included additional 10 min of MEMS feedback and counseling using CBT techniques. Compliance outcomes included total doses taken and number of doses taken within the prescribed time interval. Results indicated significantly higher compliance over time for the Enhanced Therapy group. Smoking abstinence rates did not differ between the two groups, but pooled sample analysis showed a significant association between level of medication compliance and abstinence status at treatment weeks 3 and 6. Findings recommend incorporating MEMS-based compliance interventions into smoking pharmacotherapy trials. Mooney, M.E., Sayre, S.L., Hokanson, P.S., Stotts, A.L., and Schmitz, J.M., Addictive Behaviors, 32, pp. 875-880, 2007.

An Internet-based Abstinence Reinforcement Treatment for Cigarette Smoking

Dr. Jesse Dallery and colleagues at the University of Florida conducted this study to test a practical method of providing abstinent reinforcement treatment to smokers. Using a within-subject reversal design, the present study tested an Internet-based method to obtain objective evidence of smoking status and to deliver voucher incentives for evidence of abstinence. Twenty heavy smokers completed this 4-week study. Twice a day, participants made video recording of themselves providing a breath carbon monoxide sample with a web-camera. The video was made at home and sent electronically to the smoking clinic. Participants could earn vouchers for gradual reductions in breath CO during a 4-day shaping condition, and then for achieving abstinence (CO

Abstinence Rates Following Behavioral Treatments for Marijuana Dependence

Dr. Kadden and colleagues at the University of Connecticut conducted this dismantling study to determine whether adding contingency management (ContM) to motivational enhancement therapy plus cognitive behavioral therapy (MET+CBT), an intervention used in previous studies, would enhance abstinence outcomes in marijuana-dependent subjects. Two-hundred forty marijuana dependent participants were randomly assigned to one of four treatments, all of which lasted nine sessions: 1) MET+CBT, 2) ContM only, 3) MET+CBT+ContM, or 3) to a case-management control condition (CaseM). All interventions involved 1-hour individual sessions, except for the ContM-only condition whose sessions were about 15 minutes. ContM provided reinforcement for marijuana-free urine specimens, in the form of vouchers redeemable for goods or services. Follow-up data were collected at post treatment and at 3-month intervals for 1 year. The two ContM conditions had superior outcomes: ContM- only had the highest abstinence rates at post treatment, and the MET+CBT+ContM combination had the highest rates at later follow-ups and the longest periods of continuous abstinence. These findings support the prediction that maintenance of abstinence over the course of the follow-up year would require the coping skills development offered by CBT. Kadden, R.M., Litt, M.D., Kebela-Cormier, E., and Petry, N.M., Addictive Behaviors, 32(6), pp. 1220-1236, 2007.

Does Smoking Reduction Increase Future Cessation and Decrease Disease Risk? A Qualitative Review

Drs. Hughes and Carpenter conducted this qualitative review to determine whether smoking reduction in smokers not currently interested in quitting (a) will undermine motivation to quit smoking in the future and (b) produce a clinically-significantly decrease in risks of smoking-related diseases. Systematic computer searches and other methods located 19 studies examining reduction and subsequent cessation and ten studies examining reduction and disease risk. Across 19 studies reviewed, none found that reduction decreased later cessation in smokers not currently trying to quit. In fact, 16 found reduction was associated with greater future cessation including two randomized trials of reduction versus non-reduction. The ten trials of disease risk found conflicting results and none was an adequate test. The authors concluded that (a) smoking reduction increases probability of future cessation and (b) whether smoking reduction decreases the risks of smoking-related diseases has not been adequately tested. Hughes, J.R., and Carpenter, M.J., Nicotine & Tobacco Research, 8, pp. 739-749, 2006.

Developmental Course(s) of Lifetime Cigarette Use and Panic Attack Comorbidity: An Equifinal Phenomenon?

The primary objective of this investigation was to better understand the developmental course(s) of lifetime cigarette use and panic attacks. Specifically, the ages of onset and temporal patterns of onset between daily cigarette smoking and panic attacks was examined. A second objective was to evaluate the developmental features of smoking-panic comorbidity in relation to other comorbid psychiatric and substance outcomes. Participants included 4,409 adults, ages 15-54 years from the National Comorbidity Survey. One key finding was that among those with lifetime history of comorbid daily smoking and panic attacks, the onset of daily smoking preceded the onset of panic attacks in 64% of cases. In a large minority of cases (33%) panic attacks preceded the onset of daily smoking. Another finding indicates that whereas daily smoking demonstrates a relatively consistent mean age of onset in mid- to late adolescence, the mean ages of onset of panic attacks differ markedly between the comorbid subsamples (age 27.8 years among the smoking-to-panic subsample and age 11.4 years among the panic-to-smoking subsample). A third finding indicates that comorbidity of smoking and panic attacks, relative to unimorbid smoking or unimorbid panic attacks, was significantly associated with greater risk for substance abuse and/or dependence. The observed findings underscore the importance of delineating the developmental course(s) of smoking and panic comorbidity as well as specific course-related variables in understanding the nature of smoking-panic attack comorbidity. Bernstein, A., Zvolensky, M.J., Schmidt, N.B., and Sachs-Ericcson, N. Behavior Modification, 31, pp. 117-135, 2007.

Attrition in a Multi-Component Smoking Cessation Study for Females

Attrition is a major challenge faced by researchers when implementing clinical trials. Investigators conducted this study to determine which baseline smoking-related, demographic and psychological participant characteristics were associated with attrition. Data were from a clinical trial evaluating exercise as an adjunctive treatment for nicotine gum among female smokers (N=246). There were a number of significant demographic predictors of attrition. Participants with at least one child living at home were at increased risk of both early and late dropout. Non-Whites were at increased risk of early dropout, while not having a college degree put one at increased risk of late dropout. Age was found to be a protective factor in that the older a participant was, the less likely she was to drop out in the early stages of the trial. With respect to psychological variables, weight concerns and guilt increased risk of attrition. In terms of smoking-related variables, mean cigarettes per day was not a significant predictor of attrition, although length of longest prior quit attempt was a significant predictor of early dropout when age was removed from the regression. Leeman, R.F., Quiles, Z.N., Molinelli, L.A., Medaglia Terwal, D., Nordstrom, B.L., Garvey, A.J. and Kinnunen, T. Tobacco Induced Diseases, 3, pp. 59-71, 2006.

Challenges and Potential Benefits of Using Email Communication to Treat Drug Abuse

Dr. Susanna Nemes of Social Solutions, Incorporated, and colleagues review the ethical, legal, logistical and clinical challenges and potential benefits in using email communication as a form of drug abuse treatment. A growing body of literature supports the potential efficacy of online communication (interactive internet-based support groups, web-based self-help, computerized medicine, etc.) for managing health-related problems. Email communication between counselors and patients in drug abuse treatment might be another application with potential benefits. Such communication brings with it concerns about generating a permanent written record of discussions, breeches of privacy, lag time in responses, and generally providing an appropriate level of care for patients. Professional organizations such as the American Medical Association and the American Psychological Association have offered guidelines for appropriate use of email communication. Dr. Nemes and colleagues stress the importance of the content of emails, and provide some guidance about the appropriate content and components of a therapeutic email intervention. Among the key elements of a therapeutic email intervention for drug abuse treatment are: 1) establishing contact; 2) assessing the patient's status; 3) identifying the consequences of drug use; 4) developing a plan for recovery; 5) mobilizing support for change; 6) identifying problematic interpersonal relationships; 7) adjusting daily routines through group action; 8) creating a sense of spirituality and/or community through group action; 9) identifying substitute routines through group action; 10) sharing success with others; 11) addressing the cycle of relapse; and 12) making amends and offering help to others. Research is underway to develop and test therapeutic email interventions to optimize the benefits of this technology to patients and the health care system. Alemi, F., Haack, M.R., Nemes, S., Aughburns, R., Sinkule, J., and Neuhauser, D. Substance Abuse Treatment, Prevention, and Policy, 2, pp. 1-18, 2007.