The Community Reinforcement Approach (CRA) with contingency management is an efficacious drug abuse treatment. Unfortunately, efficacy alone is not sufficient for a treatment to be adopted by treatment programs. Adoption of CRA with contingency management may be facilitated if it could be delivered in ways that are less costly.
The aim of this proposal is to examine the efficacy of two modifications to CRA with contingency management that make it less costly to provide. The first method will consist of delivering CRA via computer-based interactive technology. Such technology may render the treatment less costly by decreasing counselor contact time. The second method will reduce costs by using an incentive system that employs buprenorphine privileges contingent on drug abstinence as opposed to monetary-based incentives. We propose to examine the efficacy of these cost-reducing methods in the context of buprenorphine maintenance treatment of opioid dependence. While opioid dependence is frequently acknowledged as a public health problem of urban areas, it is less frequently acknowledged as an issue for rural areas. Opioid dependence, however, can be a serious problem in rural areas, especially with the current threat of AIDS due to high-risk behavior by substance abusers.
The aims of this project are to address this serious public health concern by continuing the first and only outpatient clinic to provide pharmacotherapies for opioid dependence in the State of Vermont. While in treatment, patients will participate in two randomized clinical trials. In the first trial, patients will be randomly assigned to receive one of three treatments: (1) computer- delivery CRA with the voucher incentive system (e.g., provision of monetary vouchers contingent on drug abstinence), (2) therapist-delivered CRA with the voucher incentive systems, or (3) standard counseling. In the second treatment, patients will be randomly assigned to receive one of three treatments: (1) CRA with buprenorphine-related contingency management (alternative dose regimens and dose adjustment), (2) CRA with the voucher incentive program, or (3) standard counseling. Contingency management procedures in both trials will target both opioid and cocaine abstinence in this population. Primary outcome measures will include abstinence, retention and cost-effectiveness. Measures will also be taken of HIV-risk behavior. Overall, this research will contribute new empirical information by identifying the efficacy of two methods of reducing costs of CRA with contingency management treatment. Such information may contribute to the adoption of this efficacious treatment. This research will also examine the utility of computerizing substance abuse treatment. The computerization of some substance abuse treatment services is a novel approach that may positively impact the future of drug abuse treatment services. Finally, by providing the only outpatient pharmacotherapy services for opioid dependence in the State of Vermont, this project will contribute positively to this region's public health.
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