An impressive number of studies have been conducted to improve the treatment response of patients receiving methadone substitution therapy. This work has become critically important because of the high rate of HIV transmission associated with drug abuse and the increasing number of patients responding poorly to standard methadone treatment. The trend toward poorer outcomes across methadone substitution programs parallels the epidemic of severe cocaine and other drug use problems in treatment seeking opioid abusers. Although studies now show that many forms of psychosocial treatments can enhance response to methadone pharmacotherapy, they also reveal limited interest and poor attendance when patients are offered these services. This problem illustrates the need for newer service delivery models that ensure participation in the psychosocial treatments necessary to maximize response to the pharmacotherapies. To be effective, these new models of treatment must also achieve success without doing harm to treatment retention. The approval of levo alpha acetyl methadol (LAAM) for opioid maintenance therapy raises yet another question that is important to evaluate- whether effective psychosocial treatments with one medication (i.e., methadone) will retain their efficacy across other pharmacotherapies. We previously demonstrated the effectiveness of a new treatment delivery model for opioid abusers that produced excellent clinical outcomes by making the continued availability of methadone ultimately contingent on counseling attendance and brief episodes of abstinence. In the proposed study, we will evaluate the efficacy of this treatment in a new group of opioid abusers inducted and maintained on LAAM, which has a very different clinical medication reporting schedule that might interact with the behavioral interventions driving out treatment approach. A total of 220 patients will be randomly assigned to our specialized treatment or a standard care comparison group and evaluated over a 10 month period, including a month baseline and a three month follow-up. Major outcome measures include rates of counseling attendance, self- reported and objectively measured drug use, rates of HIV risk behavior change, and treatment retention. The study will also provide information about the influence of individual differences (e.g., psychiatric co- morbidity, personality, stages of change) on response to LAAM substitution when it is administered either contingently with, or independently of, scheduled counseling services.
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