The section continues to investigate pharmacological and behavioral treatments of substance abuse and to explore combinations of treatments. NIDA/IRP treatment studies have already demonstrated the effectiveness of behavioral interventions (reinforcement of cocaine-negative urine samples) in large inner-city samples of intravenous polydrug abusers and has begun to evaluate the best way to apply the treatment. Promising intervention efforts to increase abstinence in cocaine-dependent patients ave focused on rearranging the drug user's environment through voucher-based contingency management alone or in combination with community reinforcement counseling procedures. A second promising approach is to improve the quality and quantity of coping skills through cognitive-behavior therapy (CBT) to address the maladaptive responses to internal and external stimuli so commonly found in cocaine-dependent patients. Contingency management rapidly reduces cocaine use, but its effects tend to subside after treatment discontinuation. In contrast, CBT produces enduring reductions in cocaine use that only emerge 6-12 months after treatment discontinuation. We hypothesized that in combination, the two treatments might produce benefits that would be both rapid and enduring. In a 2x2 design, 193 cocaine-using methadone-maintained outpatients were randomly assigned to 12 weeks of group therapy (CBT or a control condition) and voucher availability (contingency management with vouchers contingent on cocaine-negative urines, or noncontingent vouchers). Vouchers were exchangeable for goods and services. Standard methadone treatment continued for 12 more weeks; follow-up assessments occurred 3, 6, and 12 months after study exit. The primary outcome measure was cocaine-negative urine specimens (urinalysis thrice weekly during treatment, and once at each posttreatment visit). During treatment, the rapid benefit of contingency management (an increase in cocaine-negative urine specimens) was actually delayed by CBT. Twelve months posttreatment, the two treatments appeared to have had additive beneficial effects on cocaine abstinence, although group differences at 12 months were not statistically significant. Posttreatment effects of CBT did reach significance in exploratory contrasts of 3- versus 12-month follow-ups. Former CBT participants were also more likely to acknowledge their cocaine use and its deleterious effects, and to report more days of employment. Thus, when contingency management is augmented with cognitive-behavioral therapy, delayed posttreatment benefits may occur, including a reduction in cocaine use, a reduction in the tendency to minimize self-reports of use and problems, and an improvement in employment status. We are currently conducting a study to address the question of how a hypothetical methadone-maintenance clinic could best allocate its resources (both pharmacological and nonpharmacological) to reduce both heroin and cocaine abuse, if the clinic were to institute voucher-based contingency management. By combining an intervention primarily aimed at decreasing cocaine use through behavioral reinforcement (contingency management) with another intervention focused on decreasing illicit-opiate use through pharmacological treatment (high-dose methadone maintenance), we hypothesize that we will see greater abstinence from cocaine and illicit opiates than has been seen when either approach was applied separately.
Showing the most recent 10 out of 32 publications
