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

Prize-based Contingency Management Does Not Increase Gambling Behavior

Dr. Petry and colleagues at the University of Connecticut Health Center have shown that a treatment which awards chances to draw for prizes in exchange for treatment relevant behaviors such as providing drug free urines or attendance is efficacious (Prize-based CM). However this intervention has been criticized because of concerns that participating in this type of raffle or lottery like program might increase gambling behavior. Dr Petry randomly enrolled stimulant users in a multi-site trial to twelve weeks of either usual care or usual care plus Prize-based CM. People with prior gambling problems were not admitted to the study. She found that during the study period, 26% of people in the traditional outpatient programs and 37% of people in the methadone maintenance programs engaged in gambling. However, participation in the con- tingency management intervention did not significantly alter rates of gambling behavior, indicating that increasing gambling is likely not a risk for stimulant users without a prior gambling problem. This is significant because the possibility of increasing gambling risk, is no longer a barrier to adoption of this procedure by community providers. Petry, N.M., Kolodner, K.B., Li, R., Peirce, J.M., Roll, J.M., Stitzer, M.L. and Hamilton, J.A. Drug and Alcohol Dependence, available online 10 January 2006.

Voucher-Based Reinforcement Therapy (VBRT) Better than Control Treatments

Dr. Higgins and others at University of Vermont examined thirty studies of Voucher Based Reinforcement Therapy in a meta-analysis. Of these, twenty studies provided clients with vouchers redeemable for goods and services in exchange for client provided drug abstinent urine tests, six provided them in exchange for treatment attendance and four provided them in exchange for medication compliance. Control treatments included Effect sizes were d=.32, d=.15, and d=.32, respectively suggesting that VBRT is effective particularly for increasing abstinence and medication taking behaviors. The study showed that effects were enhanced by increasing the speed of voucher delivery and by increasing the magnitude of voucher delivery. Studies offering on average greater than $5.00 per day were associated with a moderate effect size. Studies delivering immediate vouchers had double the effect of studies in which the participants had to wait to receive their voucher. This is the first meta-analysis showing that VBRT is robust with myriad outcome measures and in numerous populations, and suggesting that the effect can be improved by following certain guidelines with respect to voucher magnitude and delivery. Lussier, J.P., Heil, S.H., Mongeon, J.A., Badger G.J. and Higgins, S.T. Addiction, pp. 192-203, February 2006.

Cognitive Deficits Predict Low Treatment Retention in Cocaine Dependent Patients

Dr. Aharonovich and colleagues at Columbia University conducted this study to investigate the association between cognitive abilities at treatment entry and retention and outcome in treatment seeking cocaine dependent patients. Fifty-six cocaine dependent patients receiving CBT in outpatient clinical trials were assessed for cognitive performance at treatment entry with the computerized MicroCog (MC) and the Wisconsin Card Sort Test (WCST). Treatment completion was defined as 12 or more weeks. Results demonstrated that treatment dropouts had significantly lower MC scores than completers, indicating poorer cognitive functioning. Significant differences were found in the following domains: attention, memory, spatial ability, speed, accuracy, global cognitive functioning and global proficiency. Mental reasoning demonstrated a trend toward significance. In contrast, performance on the WCST was at average or near average range, and completers and dropouts did not differ significantly on any measures. The authors speculate that the tasks on the WCST may not have been complex enough to tap into deficits in executive functioning. The findings from this study show that general level of cognitive functioning and specific cognitive deficits at treatment entry predict retention in outpatient CBT treatment for cocaine dependent patients. Knowledge of the presence of cognitive impairments at treatment entry may help tailor psychological and pharmacological interventions for cognitively impaired patients. Aharonovich, A., Hasin, D.S., Brooks, A.C., Liu, X., Bisaga, A. and Nunes, E.V. Drug and Alcohol Dependence, 81, pp. 313-322, 2006.

Predicting Smoking Stage of Change among Emergency Department Patients and Visitors

Dr. Boudreaux and colleagues from the Robert Wood Johnson Medical School conducted this study to determine if emergency department (ED) patients or their visitors are interested in smoking cessation. Patients and visitors aged 18 years and older presenting to four Boston EDs over two 24-hour periods, were interviewed. Twenty-three percent of those screened were current smokers. The interview showed some heterogeneity in stage of change of the smokers: 57% were in precontemplation stage, 31% in contemplation, and 12% in preparation. The variables most strongly associated with stage of change were self-efficacy, anticipated cessation-related health improvement, and having a smoking-related health problem. The authors conclude that the ED is a major source of health care in the U.S., especially among the uninsured and economically disadvantaged, and increased attention to smoking in the ED setting holds tremendous public health potential. The heterogeneity of smokers suggests that different strategies should be used to assist smokers on the basis of their stage. More research is needed to assess the efficacy and feasibility of different strategies of cessation promotion within the ED setting. Boudreaux, E.D., Hunter, G.C., Bos, K., Clark, S., Camargo Jr., C.A. Academic Emergency Medicine, 13, pp. 39-34, 2006.

Experimental Evidence for a Causal Relationship between Smoking Lapse and Relapse

This study evaluated the impact of smoking lapse on relapse probability. Smokers (N=87) who were not seeking cessation treatment participated in a 10-day study that involved a temporary quit attempt during which a smoking-lapse episode was experimentally manipulated. Participants who demonstrated abstinence until day four were randomly assigned to one of three experimental manipulations: (a) smoke five nicotine-containing cigarettes; (b) smoke five denicontinized-containing cigarettes; (c) or remain abstinent (no lapse) during a four-hour period. Subsequently, smokers were asked to remain abstinent for the remaining six days. The percentage of participants abstinent at the end of the 6-day follow-up period was 70% for the no-lapse group, relative to 45% and 40% among those who smoked nicotine-containing and denicotinized cigarettes, respectively. That is, those receiving the lapse exposure manipulation, returned to smoking more rapidly than those who remained abstinent. Smoking outcomes did not differ between nicotine-containing and denicotinized cigarettes. This data suggests that stimulus factors may play an important role in the lapse to relapse processes. In summary, this study demonstrates under controlled conditions that smoking lapse has a direct detrimental effect on subsequent abstinence outcomes. Juliano, L.M., Donny, E.C., Houtsmuller, E.J. and Stitzer, M.L. Journal of Abnormal Psychology, 115(1), pp. 166-173, 2006.

Tobacco Cessation in Dental Settings: Research Findings and Future Directions

Dr. Judith Gordon and colleagues at the Oregon Research Institute reviewed the literature on smoking cessation interventions conducted in dental office-based settings. The dental office visit represents a clinical opportunity during which patients may be receptive to cessation advice and assistance. Data from seven randomized clinical trials indicate there is ample evidence for the efficacy of dental office-based interventions, but adoption of tobacco cessation activities into practice has been slow. Currently, there are several studies underway that may help to increase the effectiveness of dental office-based tobacco cessation programs, and to further efforts to encourage adoption of empirically proven interventions into routine dental care. The public health impact would be enormous if dental practitioners provided cessation assistance routinely to their patients. The authors suggest that researchers and clinicians continue to work together towards universal adoption of effective tobacco cessation interventions at each clinical encounter. Gordon, J.S., Lichtenstein, E., Severson, H.H. and Andrews, J.A. Drug and Alcohol Review, 25, pp. 27-37, 2006.

Cardiovascular Risk Behavior Among Sedentary Female Smokers and Smoking Cessation Outcomes

Researchers from the Harvard School of Dental Medicine conducted this study to determine if female sedentary smokers with additional cardiovascular disease (CVD) health risk behaviors, like diet and alcohol use, predict abstinence from tobacco use. This study was part of a randomized controlled trial testing the effectiveness of exercise and nicotine gum in smoking cessation. Included in the analysis were 148 participates. This study suggested that high alcohol consumption alone and accumulation of two added risk behaviors predicted poorer smoking cessation outcome in a quit attempt. Dietary behavior alone was not related to cessation outcome. However, the high-fat diet interacted with depression, suggesting that depressed women engaging in high-fat diet are significantly more likely to relapse in their quit attempt compared to other subgroups. The authors conclude that non-moderate alcohol use alone and accumulation of multiple CVD risk behaviors seem to be associated with lower success in smoking cessation. Korhonen, T., Kinnunen, T., Quiles, Z., Leeman, R.F., Terwal, D.M. and Garvey, A.J. Tobacco Induced Diseases, 3, pp. 7-26, 2005.

Clinical Trial of Abstinence-Based Vouchers and Cognitive-Behavioral Therapy for Cannabis Dependence

Dr. Budney and colleagues at the University of Vermont conducted a study to test behavioral treatments for marijuana dependent persons. Ninety adults seeking treatment for marijuana dependence 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 post-treatment. 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 abstinence-based vouchers is a potent treatment option. Budney, A.J., Moore, B.A., Rocha, H.L. and Higgins, S.T. Journal of Consulting and Clinical Psychology, 74(2), pp. 307-316, 2006.

A Controlled Trial of Naltrexone Augmentation of Nicotine Replacement Therapy for Smoking Cessation

Dr. O'Malley and colleagues at Yale University conducted this study to evaluate whether naltrexone hydrochloride augmentation of nicotine patch therapy improves smoking abstinence and reduces postcessation weight gain more than nicotine patch therapy alone. In an outpatient research center, four hundred individuals who smoked more than 20 cigarettes per day participated in a six-week, double-blind, placebo-controlled trial. The patients were randomly assigned to a treatment of a 21-mg nicotine patch and various doses of naltrexone hydrochloride (0, 25, 50, or 100 mg/d). All patients received behavioral counseling. Among the 295 treatment completers, the 100-mg/d was associated with higher continuous abstinence rates (71.6%) compared with the placebo (48%). Also, the 25-mg/d naltrexone hydrochloride group gained significantly less weight than the placebo group. The authors conclude that the 100-mg dose of naltrexone hydrochloride shows the most potential to enhance the efficacy of nicotine patch therapy for smoking cessation outcomes and the low-dose naltrexone hydrochloride may help control weight gain in weight-concerned smokers, however further research is required. O'Malley, S., Cooney, J.L., Krishnan-Sarin, S., Dubin, J.A., McKee, S., Cooney, N.L., Blakeslee, A., Meandzija, B., Romano-Dahlgard, D., Wu, R., Makuch, R. and Jatlow, M.D.P. Arch Intern Med, 166, pp. 667-674, 2006.

Comprehensive Treatment Including Provision of Housing Reduced Drug Use for Homeless, Dually-Diagnosed Cocaine Abusers

Drs. Jesse Milby and Joseph Schumacher and colleagues at the University of Alabama delivered a cognitive behaviorally-based day treatment and work therapy platform to 196 homeless cocaine abusers, along with one of 3 randomly-assigned housing conditions: 1) provision of housing contingent upon abstinence from drugs; 2) provision of housing without an abstinence contingency; and 3) no provision of housing. Treatment occurred in phases, beginning with a skills-based day treatment and free housing for those receiving housing (months 1 - 2), followed by work therapy, group treatment, and low-cost rent for those receiving housing (months 3 - 6), and finally less intensive support group meetings (months 7 - 12). Participants who were provided housing had significantly better abstinence rates and retention rates than did those who were not provided housing, and there were few significant differences in outcomes between the two housing groups. However, among participants who were engaged into the day-treatment phase, those with abstinent-contingent housing had better abstinence than the other groups. Also, all housing recipients were successful in earning and paying rent during the work therapy phase of treatment. Sex/gender did not appear to moderate the relationships between interventions and outcomes. This study contributes to a line of related research highlight the value of housing in recovery, and suggests several methods for successfully integrating provisions of housing and work skills into substance abuse treatment. Milby, J.B., Schumacher, J.E., Wallace, D., Freedman, M.J. and Vuchinich, R.E. To House or Not to House: The Effects of Providing Housing to Homeless Substance Abusers in Treatment. American Journal of Public Health, 95, pp. 1259-1265, July 2005.