The goal of this proposal is to develop a behavioral therapy to be used in conjunction with naltrexone maintenance for the treatment of heroin addiction. Agonist maintenance, primarily with methadone, has been effective for many patients but has numerous limitations. Antagonist maintenance with naltrexone is an alternative, which has not, to date, lived up to its potential. An ideal pharmacotherapy in many respects, it blocks the intoxicating and reinforcing effects of heroin and other opiates, but itself has no opiate-like addictive effects. The clinical usefulness of naltrexone has been limited by at least four factors: l) Difficulty transitioning patients from opiates to naltrexone; 2) Poor compliance; 3) Possible dysphoric effects; and 4) The psycho-therapeutic context. Proposed is a Stage I developmental program (NIDA Behavioral Therapies Development Program PA-94-078), which will design and pilot test a therapeutic approach to address these limitations. Patients will be engaged in treatment together with one or more significant others who will agree to attend sessions and monitor naltrexone compliance. Patients will then be hospitalized for rapid transition from opiates to naltrexone, and discharged to outpatient naltrexone maintenance. Therapy sessions, twice-weekly thereafter, will draw elements from Network Therapy and the Community Reinforcement Approach. Compliance with naltrexone, and abstinence will be reinforced with tokens exchangeable for goods and services. Baseline and ongoing psychiatric assessment will monitor patients for development of dysphoria related either to naltrexone or underlying psychopathology.
Specific aims over the three year proposal are:
Specific Aim #1 : To develop a preliminary treatment manual for the combination of behavior therapy and naltrexone through completion of 20 patients through treatment in an uncontrolled pilot trial.
Specific Aim #2 : To explore the effectiveness and patient acceptability of the combination of behavior therapy and naltrexone through a randomized pilot trial with an attentional control. Based on the outcome of this trial, the therapy and manual will be refined and readied for larger-scale trials.
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