Cocaine dependence remains a major U.S. public health problem for which effective treatments are sorely needed. Towards that end, our group has been researching a multicomponent, outpatient treatment for cocaine dependence. The treatment integrates two key components: a voucher-based incentive program and Community Reinforcement Approach therapy. This treatment is one of the few reliably efficacious interventions for retaining cocaine-dependent adults in outpatient treatment and for engendering cocaine abstinence. The studies proposed in this competing continuation programmatically extend this treatment approach. Our current focus is on understanding how to increase post-treatment cocaine abstinence. Interestingly, evidence from us and others indicates that increasing during-treatment abstinence may be the most effective strategy for improving longer-term abstinence in cocaine-dependent outpatients. Experimental and correlational data from our clinic, for example, indicate that sustaining three or months of continuous cocaine abstinence during treatment increases greater than 3-fold the odds of cocaine abstinence at follow-up. Our prior trials also indicate clearly that the voucher-based incentive program is the most effective element in this multicomponent treatment for increasing during-treatment abstinence. Hence, the proposed studies will experimentally analyze how changes in the value of the voucher-based incentive program as well as length of treatment with it affects during-treatment and post-treatment cocaine abstinence. Additionally, while strong evidence exists supporting the efficacy of this voucher program, there is a striking dearth of information available on how alterations in its basic parameters affect outcome. Thus, the proposed trials also will provide practically important new parametric information on this intervention. We have proposed two trials. Trial 1 will use a randomized, parallel-groups design to examine the during- and post-treatment effects of this multicomponent treatment with the vouchers set at one-half, full, and twice their usual monetary value. Trial 2 will use the same design, but instead of manipulating the value of the vouchers, the length of time that patients receive them will be set at one-half, full, and twice the usual duration. Overall, these clinical trials will further understanding of cocaine-dependence treatment in at least two ways: First, they will rigorously evaluate the hypothesis that increasing during-treatment abstinence increases longer-term cocaine abstinence. If that hypothesis is supported, it will provide a concrete target for facilitating longer-term cocaine abstinence in future treatment efforts. Secondly, the trials will provide rigorous, experimental analyses of the relationships between the value of voucher-based incentives and length of treatment with them and treatment outcome. Such information is essential to a thorough evaluation of this emerging treatment technology.
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