People disabled by psychiatric illness often use cocaine and because of their vulnerability, are harmed by it, but there are few evidence-based treatments for them. We seek a renewal and extension of our Stage 2 grant to test the efficacy of a money management-based therapy targeting cocaine use called Advisor-Teller Money Manager (the acronym is ATM). ATM involves re-directing the tendency to spend cash on cocaine to spending on basic needs and abstinence-related activities by 1) storage of client funds;2) training around money management and around achieving abstinence and;3) allocating money for specified plans and goals. ATM therapists in the proposed study will offer clients two additional tools to help them prevent diversion of money to drugs-first, the option of requesting a representative payee to help restrain misspending and second, exercises developed to help dually diagnosed people avoid relapsing. In our studies to date of participants who used cocaine and/or alcohol, participants assigned to ATM showed significantly greater reductions in some measures of cocaine use and attended more substance abuse treatment groups than participants assigned to the control intervention. Despite early evidence of efficacy, ATM's dissemination has been limited by the requirement that sites offering ATM have the accounting expertise to handle client checks and dispense their funds -- in the proposed study, a more exportable form of ATM will be utilized in which a central accountant manages accounts for therapists at three satellite sites. Enrollment of recent cocaine users from multiple sites will address another limitation of previous studies of ATM and other interventions for the dually diagnosed, namely, the enrollment of heterogeneous samples. Enrollment of a more homogeneous population at several sites will provide sufficient power to conclusively determine ATM's efficacy for cocaine use and conduct secondary analyses of mediation and moderator effects. In a 36-week, three-site trial, 120 people who receive SSI or SSDI, have used cocaine within 60 days and are enrolled in outpatient psychiatric treatment will be randomly assigned to either ATM or Drug Counseling, one of the standardized cocaine abuse treatments tested in the Cocaine Collaborative Study. Follow-up assessments will be conducted until week 52. The primary sub- stance abuse outcome will be the proportion of weeks with urine toxicology tests negative for cocaine metabolite and the primary money management outcome will be self-rated money mismanagement. Further analyses will determine whether a reduction in cocaine use is mediated by balance saved, days attending outpatient treatment or assignment of a representative payee. Moderator analyses will examine the role of psychiatric diagnosis, site and concurrent use of alcohol and/or cannabis. ATM has the potential to be a widely-applied addition to standard psychiatric care for these hard-to-treat clients and is, more broadly, a money management-based therapy that can be applied to other situations such as representative payee arrangements.
People who use cocaine and have disabling mental illnesses may benefit from a therapy that helps them manage their money better so it is not spent for cocaine. This clinical trial will determine whether a money management-based therapy is more effective in reducing cocaine use than standard drug counseling.
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