Community reinforcement approach plus vouchers among cocaine-dependent outpatients: twelve-month outcomes

The aims of this study were to assess the effectiveness of the Community Reinforcement Approach (CRA) plus vouchers treatment in a cohort of Spanish cocaine-dependent outpatients, and to examine the maintenance of treatment effects after the voucher intervention was discontinued. Sixty-four adult outpatients were randomly assigned to one of two treatment conditions, CRA plus vouchers or standard care. The vouchers program was implemented from weeks 1 to 24. Among patients assigned to the CRA plus vouchers condition, 65.5% completed 12 months of treatment versus 28.6% of those assigned to the standard care condition (p = .003). At the 12-month assessment, 58.6% of patients assigned to the CRA plus vouchers condition were abstinent, compared with 25.7% in the standard care condition (p = .008); furthermore, 34.5% of patients assigned to the CRA plus vouchers condition achieved twelve months of continuous cocaine abstinence, versus 17.1% in the standard care condition. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the standard care condition. Overall, these results reveal an extension of the effectiveness of the CRA plus vouchers treatment to a community sample of cocaine-dependent outpatients, while also supporting the maintenance of treatment effects for 6 months after completion of the voucher program.

Adding voucher-based incentives to community reinforcement approach improves outcomes during treatment for cocaine dependence

This study compares the efficacy of the Community Reinforcement Approach (CRA) with and without an incentive program for cocaine-dependent patients in Spain. A total of 58 patients were randomly assigned to the CRA or CRA plus vouchers condition. In the CRA plus vouchers group, mean percentage of cocaine-negative samples was 97.07%, versus 79.76% in the no-voucher group. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the CRA condition. The present results show that treatment outcome is better if incentives are delivered contingent upon the submission of cocaine-free urine specimens. 

Pattern of craving response among smokers exposed to virtual reality

Introduction

Tobacco craving is an intense desire to smoke. Cue-induced craving is considered the main responsible for relapse after smoking cessation. Cue Exposure Treatment (CET) consists of controlled and repeated exposure to stimuli associated with substance use in order to reduce craving associated.

Objective

To analyze the pattern of craving response of smokers exposed to Virtual Reality environments.

Methods

Forty-six smokers were exposed randomly to complex virtual scenes of 6 minutes long duration with smoking related cues that reproduce typical situations where people use to smokes. Craving was assessed before each exposure and 6 times during navigation with a visual analogic scale. For this secondary analysis the evolution of craving response were explored for the environments that produced the most and the least craving responses.

Results

In the environment that produced the highest craving level, the pattern of response remains similar after the second assessment during the exposure, that is, after two minutes. For the environment that trigger the lowest levels, the responses gradually increased during the exposure and the highest level appeared in the last craving assessment, after 6 minutes.

Conclusions

This study has several implications. In the first place, virtual reality environments are able to elicit craving. In the second, we found that differents patterns of craving response exist in response to VR environments. Furthermore, the results obtained in the present study may be useful for cessation programs that include CET, in which is it necessary to know the pattern of desire during the exposure.

Individual characteristics and response to Contingency Management treatment for cocaine addiction

Voucher-based contingency management (CM) research has demonstrated efficacy for treating cocaine addiction, but few studies have examined associations between individual baseline characteristics and response to CM treatments. The aim of this study, involving 50 cocaine outpatients receiving CM for cocaine addiction, was to assess the impact of baseline characteristics on abstinence outcomes after six months of treatment. Patients who were abstinent after six months of treatment accounted for 58% of the sample. Patients with higher scores on the Alcohol area of the EuropASI and patients that were non-abstinent during the first month of treatment were less likely to achieve abstinence. These outcome predictors have implications both for treatment research and for clinical practice. Patients who do not respond early to treatment may need a more intensive intervention, and concomitant problematic alcohol use should be detected and treated. The remaining baseline variables examined were not statistically significant predictors of abstinence. This finding is important for the generalizability of CM across the range of individual characteristics of treatment-seeking cocaine abusers.

Long-term benefits of adding incentives to the community reinforcement approach for cocaine dependence

BACKGROUND

The community reinforcement approach (CRA) with vouchers is a well-established program developed for the treatment of cocaine addiction. It involves an incentive program in which patients earn vouchers that can be exchanged for goods or services contingent upon abstinence from cocaine use.

AIM

To examine the contributions of incentives to retention, abstinence, and psychosocial outcomes in the CRA+vouchers program at the 12-month follow-up.

METHODS

58 cocaine addicts were randomly assigned to CRA treatment with or without an added incentive program in a community setting for cocaine dependence in Spain.

RESULTS

65.5% of patients in the group with vouchers completed 12 months of treatment, versus 48.3% in the no-voucher group. In the CRA+vouchers group, mean percentage of cocaine-negative samples was 95.76%, versus 79.31% in the group without vouchers. There were significant improvements in psychosocial functioning in both treatments, but when differences were observed, they supported CRA with vouchers over CRA alone.

CONCLUSION

Combining CRA with incentives improves treatment outcomes in cocaine-dependent outpatients. Additive benefits of vouchers remain 6 months after the incentive program ends.

Evolution of smoking urge during exposure through virtual reality

The use of Virtual Reality (VR) could be a useful tool for the improvement of Cue Exposure Therapy (CET) for smoking cessation. Nevertheless, it is necessary to know the appropriate parameters of exposure in order to develop efficacious treatment programs. This study was conducted to analyze the pattern of tobacco desire in a sample of smokers exposed to VR. Results showed that the environments were able to generate two different patterns of craving response. These results could contribute to determine exposure parameters when using VR technology in CET.

Urine testing during treatment predicts cocaine abstinence

The objective of this study was to analyze the influence of the variables that predict cocaine abstinence on an outpatient program for the treatment of addiction to this substance. Participants were 80 patients (85% men and 15% women) selected at random from those receiving treatment at a Spanish health service outpatient unit. For detecting the predictor variables the authors carried out a chi-square automatic interaction detection (CHAID) analysis. Logistic regression analysis and discriminant analysis were performed to estimate the probability of abstinence according to/using the predictor variables detected by CHAID analysis. Abstinence rate after six months of treatment was 37.5%. The variable that best predicted abstinence was number of urine tests carried out over the course of treatment. The rest of the variables used did not have statistically significant influence. The mathematical model used correctly classified 80% of cases. A total of 31 tests were necessary for a probability of over 0.75 of being abstinent at six months. Regular screening for abstinence by means of objective tests helps to improve abstinence rates on cocaine-addiction treatment programs.

Community Reinforcement Approach (CRA) for cocaine dependence in the Spanish public health system: 1 year outcome

INTRODUCTION AND AIMS

The development and dissemination of effective treatments for cocaine dependence is an important public health priority in Europe, and especially in Spain, given the increase in treatment demand over recent years. The aim of this study was to determine the effectiveness of the Community Reinforcement Approach (CRA) for cocaine dependents at an outpatient clinic within the Spanish public health system.

DESIGN AND METHODS

A total of 82 cocaine-dependent patients were randomly assigned to one of two treatment conditions: Standard Treatment (n = 35) or CRA (n = 47). Dependent variables were treatment retention, cocaine abstinence and composite scores from the European version of the Addiction Severity Index at 12 month follow up.

RESULTS

Of the patients who received CRA, 55% completed 6 months of treatment, versus 40% who received Standard Treatment. At the 12 month follow up, patients assigned to the CRA condition achieved higher rates of abstinence (95.2%) by comparison with Standard Treatment (69.2%). In the CRA group, 27% of the patients achieved continuous cocaine abstinence, versus 21% in the Standard Treatment group. The CRA group also obtained lower scores than the Standard Treatment group in all Addiction Severity Index composite scores.

DISCUSSION AND CONCLUSIONS

This study showed that CRA is a feasible treatment for cocaine addiction in a public community setting in Spain.

Identifying specific cues and contexts related to smoking craving for the development of effective virtual environments

Craving is considered the main variable associated with relapse after smoking cessation. Cue Exposure Therapy (CET) consists of controlled and repeated exposure to drug-related cues with the aim of extinguishing craving responses. Some virtual reality (VR) environments, such as virtual bars or parties, have previously shown their efficacy as tools for eliciting smoking craving. However, in order to adapt this technology to smoking cessation interventions, there is a need for more diverse environments that enhance the probability of generalization of extinction in real life. The main objective of this study was to identify frequent situations that produce smoking craving, as well as detecting specific craving cues in those contexts. Participants were 154 smokers who responded to an ad hoc self-administered inventory for assessing craving level in 12 different situations. Results showed that having a drink in a bar/pub at night, after having lunch/dinner in a restaurant and having a coffee in a cafe or after lunch/dinner at home were reported as the most craving-inducing scenarios. Some differences were found with regard to participants' gender, age, and number of cigarettes smoked per day. Females, younger people, and heavier smokers reported higher levels of craving in most situations. In general, the most widely cited specific cues across the contexts were people smoking, having a coffee, being with friends, and having finished eating. These results are discussed with a view to their consideration in the design of valid and reliable VR environments that could be used in the treatment of nicotine addicts who wish to give up smoking.

Effectiveness of three intensities of smoking cessation treatment in primary care

The purpose of this study was to compare the effectiveness of three smoking cessation programs of varying intensity applied in a primary care setting. Participants were 89 individuals randomly assigned to one of three treatment groups: brief counseling plus information pamphlet, self-help program with telephone follow-up, and intensive behavioral treatment. At the 12-mo. follow-up, intensive behavioral treatment (42.8% abstinence) was more effective than the self-help program (27.5%), which was in turn more effective than counseling (12.9%). Continued abstinence was also higher in the intensive treatment group (37.9%) than in the self-help (17.2%) and the counseling groups (9.7%), although these differences only reached statistical significance in the first and third of these groups. Treatment adherence was higher in the intensive behavioral group (82.8% of participants attended all the sessions) than in the self-help group (61.8% completed the program). The results appear to confirm a dose-response effect in the treatment of smokers and indicate satisfactory acceptability of intensive behavioral programs applied in primary care.

Efficacy of virtual reality in triggering the craving to smoke: its relation to level of presence and nicotine dependence

Virtual Reality environments that reproduce typical contexts associated with tobacco use may be useful for aiding smoking cessation. The main objective of this study was to assess the capacity of eight environments to produce the craving to smoke and determine the relation of craving to nicotine dependence and level of presence. The results show that all the environments were able to generate the desire to smoke; a direct relation was found between sense of presence and craving.

[Treatment dropout in cocaine addicts]

The high rate of dropout from treatment programs is one of the most serious problems in the field of drug dependence. Early identification of predictors of dropout risk can provide useful information on the specific treatment needs of these types of patient. The aim of this study was to identify predictors of premature cessation of an outpatient treatment program for cocaine addicts. The study was carried out at public healthcare units in a Spanish city. Participants were 91 cocaine addicts admitted for treatment for their addiction, assessed by means of interview and various self-report measures. For identifying predictive variables the researchers used a factor analysis, a cluster analysis and a CHAID analysis. The variables that obtained predictive capacity were the MAST scores and the combined alcohol and drugs scores on the EuropASI. These three variables were grouped in a single factor which was called addictive severity. The predictive analysis showed that this factor had some degree of capacity for the prediction of dropout, but that it was not completely determinant. The results suggest the advantage of detecting at the admission stage those patients who might require more attention to their motivational aspects, greater treatment control and intensity, or the provision of complementary interventions.

Smoking risk factors and gender differences among Spanish high school students

The objectives of the present study were to analyze the pattern of tobacco use among Spanish adolescents, as well as to determine gender differences in specific risk factors of cigarette use. The study sample was made up of 1,483 boys and 1,358 girls, aged 12-16 (M = 14). Participants were asked to answer an ad-hoc instrument to evaluate the pattern of use, perceived availability, risk of harm, family- and peer-use, engagement in leisure activities, drive for thinness, and self-esteem. Results showed no gender differences in the pattern of use. With regard to risk and protector factors, a predictive analysis showed that peer-related variables were the most determinant for tobacco use both for boys and girls. Some gender differences were also detected: Playing sports was protective for boys only, and listening to music for girls only. Drive for thinness and self-esteem were not related to tobacco use for either boys or girls. These findings help increase our understanding of smoking risk factors in adolescence and to pay special attention to the group of friends when planning prevention programs to reduce risk factors.

Self-change strategies in smokers and former smokers: Spanish adaptation of the SCS-CS and SCS-FS

The purpose of this study was to validate and adapt the Self-Change Strategies in Current Smokers (SCS-CS) and the Self-Change Strategies in Former Smokers (SCS-FS) (Christie & Etter, 2005) to the Spanish population. We also wished to analyze the differences in the self-change strategies used as a function of gender. Participants were 370 subjects (190 smokers and 180 former smokers) who were recruited by means of the "snowball" method. The alpha coefficients for the SCS-CS and the SCS-FS were .86 and .87, respectively. Both scales present satisfactory psychometric properties, so they are shown to be useful instruments to use in the Spanish population. The SCS-CS score showed that male smokers used more self-change strategies than females (46.6 vs. 11.9, p < .01), specifically, more cognitive strategies. In the SCS-CS, men scored higher than women (49 vs. 12.08, p < .01), in both the group of cognitive and behavioral strategies. The psychological mechanisms used to control the smoking habit are the same in men as in women, but the men tend to use a larger number of strategies. Treatments to quit smoking do not need to be substantially different, but they should be more intensive in the case of women smokers.

Family predictors of parent participation in an adolescent drug abuse prevention program

Low participation rates constitute a serious problem faced by family drug abuse prevention programs. In this study we analyse the factors related to participation in a Life Skills Training program implemented in three schools in Spain. Participants in the study were 485 pupils aged 12 - 14 years and their respective parents. The variables that predicted participation in the program were: number of children and educational level of parents, children's drug use, family conflict, parental rearing style, relationships between parents and children and family communication. The results from Spain are similar to those found in international studies, and indicate that the families most at risk of drug use are those least likely to participate in prevention programs. There is a need for strategies to increase participation in prevention programs of the families most at risk.

Financing a voucher program for cocaine abusers through community donations in Spain

This study analyzed the viability of financing a voucher program for cocaine addicts in Spain through public and private donations. Of the 136 companies contacted, 52 (38%) provided donations. The difference between the benefits (15,670 Euro/ $20,371) and the costs (3734 Euro/ $4854) was 11,936 Euro/ $15,517. The type of reinforcer a company can offer, the size of the company, and the time elapsed before responding may be determining variables in a company's decision whether to collaborate.

[Family-based drug use prevention: the "Familias que Funcionan" ["Families that Work"] program]

Family-based drug use prevention: The <<Familias que Funcionan [Families that work]>> program.. <<Familias que Funcionan>>[Families that work] is a family-based drug-use prevention program resulting from the adaptation to the Spanish context of the prestigious North-American <<Strengthening Families Program 10-14>>. The program was applied at four secondary schools (N = 380 pupils) in Asturias (northern Spain). This article presents the results of the assessment of this application after a two-year follow-up, regarding its effectiveness in the reduction of drug use among adolescents and its effects on certain family risk factors. Consistent attendance in the <<Familias que Funcionan>> program proved effective for reducing both rates (t= -2.73, p<.05 and t= -4.58, p<.005, for the 1- and 2-year follow-ups, respectively) of increase in adolescent drug use and some family risk factors.

Differences among substance abusers in Spain who recovered with treatment or on their own

This exploratory study compared the differences among substance abusers in Spain who recovered with treatment or on their own. Advertisements were used to recruit 58 individuals (29 self-changers and 29 treatment-changers) who had had problems with alcohol or drugs, and who had been recovered for at least one year. The groups differed significantly in severity of dependence, psychiatric treatment prior to recovery, and coping strategies to maintain recovery. Consistent with previous studies, those who had recovered through treatment had a more serious substance use history than those who changed on their own. In addition, social support was associated with maintenance of change for both groups. These findings parallel those for English-speaking populations.

[Determinants of recovery from alcohol problems in treated and untreated individuals in a Spanish sample]

This study compared the recovery process of two groups of alcohol abusers in Spain, one that had recovered with treatment and one that had recovered without treatment. Using advertisements and other recruitment strategies, 32 Spanish participants (16 treatment-seekers and 16 self-changers) were recruited, all of whom had had problems with alcohol consumption and had recovered 1 year or more previously. Participants were interviewed on a single occasion about their alcohol use history and recovery. Results showed that the two groups differed significantly in variables such as degree of dependence, type of recovery, and coping strategies used in the maintenance of recovery. As in previous research, pressure and support from the person's family and social circle played an important role in recovery and maintenance, especially for the treatment-seekers. These results are highly similar to those found in studies with English-speaking populations.

Community reinforcement approach plus vouchers for cocaine dependence in a community setting in Spain: six-month outcomes

The aim of this study was to assess the efficacy of the community reinforcement approach (CRA) plus vouchers treatment in achieving cocaine abstinence and treatment retention among patients enrolled in an outpatient program for cocaine dependence in Spain. Forty-three patients were randomly assigned to one of two treatment conditions in a community setting: CRA plus vouchers or standard care. Of the patients who received the CRA plus vouchers program, 73% completed 24 weeks of treatment, as compared with 42% of the patients who received standard care who did. In the CRA plus vouchers group, 40% of the patients achieved 24 weeks of continuous cocaine abstinence, as compared with 21% of the patients in the standard care group who did. These results support the effectiveness and generalizability of the CRA plus vouchers treatment in a community setting outside of the United States. Further follow-up is required to confirm the long-term maintenance of the results.

[Effect of incentives on retention in an outpatient treatment for cocaine addicts]

The high drop-out rate in treatment programs is one of the most important problems in the area of drug addictions. This study evaluated the effect of the use of incentives on retention in an outpatient program for cocaine addicts. The effect of individual variables on program drop-out was also analysed. Participants were 66 subjects who were randomly assigned to one of three treatment groups: standard treatment, treatment with incentives I, and treatment with incentives II. The patients of these two groups received incentives contingent on cocaine abstinence with two different magnitudes. Retention rate at six months was 35% in the standard treatment, 78.6% in the treatment with incentives I, and 53.3% in the treatment with incentives II. The global prognostic capacity of the individual variables (sociodemographic, history and consumption pattern, psychopathological variables, and EuropASI scores) was 85.7%, with the psychopathological variables being more closely related to retention. These results suggest that the use of incentives may be an effective strategy to improve retention in outpatient treatments for cocaine addiction.