Effect of PTSD diagnosis and contingency management procedures on cocaine use in dually cocaine- and opioid-dependent individuals maintained on LAAM: a retrospective analysis

"I's" on the prize: A systematic review of individual differences in Contingency Management treatment response

Contingency Management is an evidence-based treatment for substance use disorders with strong potential for measurement-based customization. Previous work has examined individual difference factors in Contingency Management treatment response of potential relevance to treatment targeting and adaptive implementation; however, a systematic review of such factors has not yet been conducted. Here, we summarize and evaluate the existing literature on patient-level predictors, mediators, and moderators of Contingency Management treatment response in stimulant and/or opioid using outpatients - clinical populations most frequently targeted in Contingency Management research and clinical practice. Our search strategy identified 648 unique, peer-reviewed publications, of which 39 met full inclusion criteria for the current review. These publications considered a variety of individual difference factors, including (1) motivation to change and substance use before and during treatment (8/39 publications), (2) substance use comorbidity and chronicity (8/39 publications), (3) psychiatric comorbidity and severity (8/39 publications), (4) medical, legal, and sociodemographic considerations (15/39 publications), and (5) cognitive-behavioral variables (1/39 publications). Contingency Management was generally associated with improved treatment outcomes (e.g., longer periods of continuous abstinence, better retention), regardless of individual difference factors; however, specific patient-level characteristics were associated with either an enhanced (e.g., more previous treatment attempts, history of sexual abuse, diagnosis of antisocial personality disorder) or diminished (e.g., complex post-traumatic stress symptoms, pretreatment benzodiazepine use) response to Contingency Management. Overall, the current literature is limited but existing evidence generally supports greater benefits of Contingency Management in patients who would otherwise have a poorer prognosis in standard outpatient care. It was also identified that the majority of previous work represents a posteriori analysis of pre-existing clinical samples and has therefore rarely considered pre-specified, hypothesis-driven individual difference factors. We therefore additionally highlight patient-level factors that are currently understudied, as well as promising future directions for measurement-based treatment adaptations that may directly respond to patient traits and states to improve Contingency Management effectiveness across individuals and over time.

Contingency management treatment for substance use disorders: How far has it come, and where does it need to go?

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

No Wrong Doors: Findings from a Critical Review of Behavioral Randomized Clinical Trials for Individuals with Co-Occurring Alcohol/Drug Problems and Posttraumatic Stress Disorder

Prior reviews of behavioral treatments for individuals with comorbid alcohol and drug use disorders (substance use disorder SUD) and posttraumatic stress disorder (PTSD) have not systematically considered whether comparison conditions are matched to target treatments on time and attention. A systematic literature search using PubMed MESH terms for alcohol and substance use disorders, PTSD, and treatment identified relevant behavioral randomized clinical trials (RCTs) that evaluated PTSD-oriented exposure-based treatments, addiction-focused treatments, and coping-based treatments that do not involve exposure to trauma memories. Information pertaining to within-subject changes over time and between-subject differences, quality of control condition, recruitment efficiency, and assessment and treatment retention was synthesized. Alcohol and drug outcomes were described separately when possible. Twenty-four behavioral RCTs were identified: 7 exposure based, 6 addiction focused, and 11 coping based. Seven studies included SUD intervention comparison conditions matched to the target intervention on time and attention. Most of the 24 studies found that participants in both the experimental and control conditions improved significantly over time on SUD and PTSD outcomes. No study found significant between-group differences in both SUD and PTSD outcomes favoring the experimental treatment. Despite greater treatment dropout, there was greater improvement in some PTSD outcomes for exposure-based interventions than the control conditions, including when the control conditions were matched for time and attention. Addiction-focused and coping-based interventions did not generally show an advantage over comparably robust controls, although some coping-based interventions yielded better drug use outcomes than control conditions. When available, interventions that integrate exposure-based PTSD treatment and behavioral SUD treatment are recommended as they are associated with better PTSD outcomes than SUD care matched for time and attention. However, the results of this critical review also suggest that people with SUD/PTSD can benefit from a variety of treatment options, including standard SUD care.

The Prevalence of Posttraumatic Stress Disorder Symptoms among Addiction Treatment Patients with Cocaine Use Disorders

Co-occurring cocaine use and posttraumatic stress disorders are prevalent and associated with negative treatment, health and societal consequences. This study examined the relationships among PTSD symptoms, gender, and cocaine use problems. Within a cross-sectional design, we gathered archival point prevalence data on new admissions (n = 573) to three addiction treatment agencies. Demographic, substance use, and PTSD symptom information were collected across the three agencies. Logistic regression analyses revealed that patients with cocaine use disorders had a two-fold increased odds for a probable PTSD diagnosis, compared to patients without a cocaine use disorder (OR = 2.19, 95% CI = 1.49-3.22, p < 0.001). Among females with cocaine use disorder, multinomial regression yielded a significant increase in the risk of moderate (RRR = 2.12, 95% CI = 1.10-4.10, p < 0.05) and severe (RRR = 2.87, 95% CI = 1.33-6.21, p < 0.01) PTSD symptoms. Males with cocaine use disorders had a two-fold increase in the risk of moderate PTSD symptoms (RRR = 2.13, 95% CI = 1.23-3.68, p < 0.01), but had no increased risk of developing severe PTSD symptoms (RRR = 1.93, 95% CI = 0.85-4.39, p = 0.117). Cocaine use appears to impact the risk of PTSD symptoms, especially in females. Future research should explore the generalizability of these findings to more racially and ethnically diverse samples, as well as among persons with this comorbidity who are not engaged in treatment services.

Prize-based contingency management for the treatment of substance abusers: a meta-analysis

AIM

To review randomized controlled trials to assess efficacy of a prize-based contingency management procedure in reducing substance use (where a drug-free breath or urine sample provides a chance of winning a prize).

METHODS

A meta-analysis was conducted on papers published from January 2000 to February 2013 to determine the effect size of studies comparing prize-based contingency management to a treatment-as-usual control condition (k = 19 studies). Parallel analyses evaluated the efficacy of both short- (k = nine studies) and long-term outcomes (k = six studies) of prize-based contingency management.

RESULTS

The average end-of-treatment effect size (Cohen's d) was 0.46 [95% confidence interval (CI) = 0.37, 0.54]. This effect size decreased at the short-term (≤3-month) post-intervention follow-up to 0.33 (95% CI = 0.12, 0.54) and at the 6-month follow-up time-point there was no detectable effect [d = -0.09 (95% CI = -0.28, 0.10)].

CONCLUSION

Adding prize-based contingency management to behavioral support for substance use disorders can increase short-term abstinence, but the effect does not appear to persist to 6 months.

Treatment outcome in substance use disorder patients with and without comorbid posttraumatic stress disorder: A systematic review

We investigated the role of comorbid posttraumatic stress disorder (CO-PTSD) in substance use disorder (DSM-IV/ICD-10 substance abuse or dependence, SUD) treatment. We conducted a systematic review of treatment outcome studies in SUD patients with and without CO-PTSD from 2000 to 2011. The N = 22 studies found differed clearly with regard to methodology and the sufficiency of provided study information, limiting their comparability. Remarkably, no consistent indication of a negative effect of CO-PTSD on the reported SUD treatment outcome was found. In addition to CO-PTSD, we point out possible further effect modifiers which need to be better understood. Finally, we emphasize the requirements for future research such as methodological standardization and a focus on long-term studies.

Contingency Management Reduces Symptoms of Psychological and Emotional Distress among Homeless, Substance-dependent Men Who Have Sex with Men

BACKGROUND

This prospective analysis evaluated the efficacy of a contingency management (CM) intervention to improve the psychological health of non-treatment seeking, homeless, substance-dependent, men who have sex with men in Los Angeles. It was hypothesized that administration of CM would be associated with reductions in participants' symptoms of psychological and emotional distress.

METHODS

One hundred and thirty-one participants were randomized into either a voucher-based contingency management (CM; n = 64) condition reinforcing substance abstinence and prosocial/health-promoting behaviors, or to a control condition (n = 67). Participants' symptoms of psychological and emotional distress were assessed at intake and at 12-months post-randomization.

RESULTS

Participants randomized into the CM intervention exhibited significantly lower levels of psychological distress in all measured symptom domains up to one year post randomization, reductions not evidenced in the control arm. Omnibus tests resultant from seemingly unrelated regression analysis confirmed that CM was significantly associated with reductions in symptoms of psychological and emotional distress, even when controlling for biomarker-confirmed substance use outcomes (χ²₍₉₎ = 17.26; p < 0.05).

CONCLUSIONS

Findings demonstrate that a CM intervention reduced symptoms of psychological and emotional distress among a sample of non-treatment seeking, homeless, substance-dependent men who have sex with men.

Integrated treatment of substance use and psychiatric disorders

Epidemiological studies find that psychiatric disorders, including mental disorders and substance use disorders, are common among adults and highly comorbid. Integrated treatment refers to the focus of treatment on two or more conditions and to the use of multiple treatments such as the combination of psychotherapy and pharmacotherapy. Integrated treatment for comorbidity has been found to be consistently superior compared to treatment of individual disorders with separate treatment plans. This article focuses on a review of the risks for developing comorbid disorders and the combinations of treatments that appear to be most effective for clients with particular comorbid disorders.

Using incentives to reduce substance use and other health risk behaviors among people with serious mental illness

INTRODUCTION

Serious mental illness (SMI) is associated with high rates of tobacco and other drug dependence, poor treatment compliance, obesity and low levels of physical activity, which have severe medical and psychosocial consequences. Interventions that effectively reduce these health risk behaviors among people with SMI are urgently needed.

METHODS

Published reports from studies evaluating incentive-based treatments for promoting tobacco and other drug abstinence, treatment attendance, medication use and increased physical activity are reviewed.

RESULTS

Results of this review indicate the efficacy of incentive-based treatments for reducing tobacco and other drug use among people with SMI. Few studies have examined whether incentive-based treatments improve treatment attendance, medication use and physical activity levels in people with SMI; however, initial evidence is positive and indicates that further research in these areas is warranted.

CONCLUSION

Given the medical and psychosocial costs of tobacco and other drug use, treatment non-compliance and physical inactivity, and the efficacy of incentive-based treatments for improving these behaviors, such interventions should be further developed and integrated into behavioral health treatment programs for people with SMI.

Treatment of substance abusing patients with comorbid psychiatric disorders

OBJECTIVE

To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients.

METHOD

Articles were extracted from Pubmed using the search terms "dual diagnosis," "comorbidity" and "co-occurring" and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity.

RESULTS

Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions.

CONCLUSIONS

Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.