Continuing care for cocaine dependence: comprehensive 2-year outcomes

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review

Introduction: The prevalence of substance use disorders in forensic populations is high. They are an important factor linked to negative outcomes in mentally ill offenders and are detrimental to forensic or non-forensic outcome measures. In contrast, substance use disorders are often underdiagnosed and undertreated, especially in forensic settings. Forensic Assertive Community Treatment is a forensic adaptation of regular assertive community treatment, combined with essential elements of forensic rehabilitation theories. Little is known however on the effectivity of forensic assertive community treatment when it comes to substance use disorders or what their exact role is on the outcome measures. In this paper, we explore how SUD is treated in Forensic assertive community treatment and how it relates to the forensic and non-forensic outcome measures. Methods: We performed a systematic review (PRISMA) of forensic Assertive community treatment teams that followed the main evidence-based principles of regular assertive community treatment and added basic elements of forensic rehabilitation. We analyzed articles the Psychinfo and Medline databases dating from 2005 to 2020. Fifteen studies fit the search criteria and were included in the analysis. The Quality of the studies was assessed using the Newcastle-Ottawa scale. Results: SUD was highly prevalent in all studies. Patients entered FACT through two pathways, either from a care continuum or directly from prison. The severity of SUD at intake emerges as a critical element when deciding which pathway to choose, as a high severity-score at the start of FACT follow-up was linked to recidivism. While differing in method all studies offered integrated SUD treatment. These included evidence-based techniques like CBT, therapeutic communities, and Substance Abuse Management Module. Though results on SUD outcomes were mixed 4 studies mentioned abstinence in 50-75%. The severity of SUD tended to increase initially and to stabilize afterwards. Conclusion: Severity of SUD at intake emerges as a decisive element in decision-making on entering FACT teams directly from prison or through a care-continuum. The ways to provide SUD treatment varied and outcomes for SUD were mixed. SUD was found to be detrimental to forensic and non-forensic outcome measures, such as recidivism or hospitalizations during FACT treatment.

A review of research-supported group treatments for drug use disorders

This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women's recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.

Psychosocial interventions for psychostimulant misuse

BACKGROUND

Psychostimulant misuse is a continuously growing medical and social burden. There is no evidence proving the efficacy of pharmacotherapy. Psychosocial interventions could be a valid approach to help patients in reducing or ceasing drug consumption.

OBJECTIVES

To assess the effects of psychosocial interventions for psychostimulant misuse in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive); Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science and PsycINFO, from inception to November 2015. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any psychosocial intervention with no intervention, treatment as usual (TAU) or a different intervention in adults with psychostimulant misuse or dependence.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 52 trials (6923 participants).The psychosocial interventions considered in the studies were: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study), 12-step facilitation (4 studies).We judged most of the studies to be at unclear risk of selection bias; blinding of personnel and participants was not possible for the type of intervention, so all the studies were at high risk of performance bias with regard to subjective outcomes; the majority of studies did not specify whether the outcome assessors were blind. We did not consider it likely that the objective outcomes were influenced by lack of blinding.The comparisons made were: any psychosocial intervention versus no intervention (32 studies), any psychosocial intervention versus TAU (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of included studies did not provide any useful data for inclusion in statistical synthesis.We found that, when compared to no intervention, any psychosocial treatment: reduced the dropout rate (risk ratio (RR): 0.83, 95% confidence interval (CI) 0.76 to -0.91, 24 studies, 3393 participants, moderate quality evidence); increased continuous abstinence at the end of treatment (RR: 2.14, 95% CI 1.27 to -3.59, 8 studies, 1241 participants, low quality evidence); did not significantly increase continuous abstinence at the longest follow-up (RR: 2.12, 95% CI 0.77 to -5.86, 4 studies, 324 participants, low quality evidence); significantly increased the longest period of abstinence: (standardised mean difference (SMD): 0.48, 95% CI 0.34 to 0.63, 10 studies, 1354 participants, high quality evidence). However, it should be noted that the in the vast majority of the studies in this comparison the specific psychosocial treatment assessed in the experimental arm was given in add on to treatment as usual or to another specific psychosocial or pharmacological treatment which was received by both groups. So, many of the control groups in this comparison were not really untreated. Receiving some amount of treatment is not the same as not receiving any intervention, so we could argue that the overall effect of the experimental psychosocial treatment could be smaller if given in add on to TAU or to another intervention than if given to participants not receiving any intervention; this could translate to a smaller magnitude of the effect of the psychosocial intervention when it is given in add on.When compared to TAU, any psychosocial treatment reduced dropout rate (RR: 0.72, 95% CI 0.59 to 0.89, 6 studies, 516 participants, moderate quality evidence), did not increase continuous abstinence at the end of treatment (RR: 1.27, 95% CI 0.94 to 1.72, 2 studies, 224 participants, low quality evidence), did not increase longest period of abstinence (MD -3.15 days, 95% CI -10.35 to 4.05, 1 study, 110 participants, low quality evidence). No studies in this comparison assessed the outcome of continuous abstinence at longest follow-up.There were few studies comparing two or more psychosocial interventions, with small sample sizes and considerable heterogeneity in terms of the types of interventions assessed. None reported significant results.None of the studies reported harms related to psychosocial interventions.

AUTHORS' CONCLUSIONS

The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces the dropout rate and increases the longest period of abstinence. It may increase the number of people achieving continuous abstinence at the end of treatment, although this might not be maintained at longest follow-up. The most studied and the most promising psychosocial approach to be added to treatment as usual is probably contingency management. However, the other approaches were only analysed in a few small studies, so we cannot rule out the possibility that the results were not significant because of imprecision. When compared to TAU, any psychosocial treatment may improve adherence, but it may not improve abstinence at the end of treatment or the longest period of abstinence.The majority of the studies took place in the United States, and this could limit the generalisability of the findings, because the effects of psychosocial treatments could be strongly influenced by the social context and ethnicity. The results of our review do not answer the most relevant clinical question, demonstrating which is the most effective type of psychosocial approach.Further studies should directly compare contingency management with the other psychosocial approaches.

WITHDRAWN: Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders

Review withdrawn as the Cochrane Funding Arbitration Panel found this review non‐compliant with the Cochrane’s commercial sponsorship policy. The new author team will update and replace this review.

The editorial group responsible for this previously published document have withdrawn it from publication.

The continuing care model of substance use treatment: what works, and when is "enough," "enough?"

There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.

Who benefits from extended continuing care for cocaine dependence?

The goal of this study was to determine which cocaine dependent patients engaged in an intensive outpatient program (IOP) were most likely to benefit from extended continuing care (24 months). Participants (N=321) were randomized to: IOP treatment as usual (TAU), TAU plus Telephone Monitoring and Counseling (TMC), or TAU plus TMC plus incentives for session attendance (TMC+). Potential moderators examined were gender, stay in a controlled environment prior to IOP, number of prior drug treatments, and seven measures of progress toward IOP goals. Outcomes were: (1) abstinence from all drugs and heavy alcohol use, and (2) cocaine urine toxicology. Follow-ups were conducted at 3, 6, 9, 12, 18, and 24 months post-baseline. Results indicated that there were significant effects favoring TMC+ over TAU on the cocaine urine toxicology outcome for participants in a controlled environment prior to IOP and for those with no days of depression early in IOP. Trends were obtained favoring TMC over TAU for those in a controlled environment (cocaine urine toxicology outcome) or with high family/social problem severity (abstinence composite outcome), and TMC+ over TAU for those with high family/social problem severity or high self-efficacy (cocaine urine toxicology outcome). None of the other potential moderator effects examined reached the level of a trend. These results generally do not suggest that patients with greater problem severity or poorer performance early in treatment on the measures considered in this report will benefit to a greater degree from extended continuing care.

How effective is continuing care for substance use disorders? A meta-analytic review

Given the often chronic nature of substance use disorders, patients sometimes receive less intensive continuing care following an initial period of more intensive treatment. This meta-analysis estimated the effect of continuing care and formally tested several proposed moderators (intervention duration, intensity, modality, and setting) of that effect. A systematic search identified 33 controlled trials of continuing care; 19 included a no/minimal treatment condition and were analyzed to assess the overall effect of continuing care versus control. Continuing care had a small, but significant, positive effect size, both at the end of the continuing care interventions (g=0.187, p<0.001) and at follow-up (g=0.271, p<0.01). Limited by a small number of studies, analyses did not identify any significant moderators of overall effects. These results show that continuing care can provide at least modest benefit after initial treatment. We discuss study characteristics that may have reduced the magnitude of the overall continuing care effect estimate.

Factors in sustained recovery from cocaine dependence

The goal was to identify factors that predicted sustained cocaine abstinence and transitions from cocaine use to abstinence over 24 months. Data from baseline assessments and multiple follow-ups were obtained from three studies of continuing care for patients in intensive outpatient programs (IOPs). In the combined sample, remaining cocaine abstinent and transitioning into abstinence at the next follow-up were predicted by older age, less education, and less cocaine and alcohol use at baseline, and by higher self-efficacy, commitment to abstinence, better social support, lower depression, and lower scores on other problem severity measures assessed during the follow-up. In addition, higher self-help participation, self-help beliefs, readiness to change, and coping assessed during the follow-up predicted transitions from cocaine use to abstinence. These results were stable over 24 months. Commitment to abstinence, self-help behaviors and beliefs, and self-efficacy contributed independently to the prediction of cocaine use transitions. Implications for treatment are discussed.

Personalized treatment of alcohol dependence

Pharmacogenetic and adaptive treatment approaches can be used to personalize care for alcohol-dependent patients. Preliminary evidence shows that variation in the gene encoding the μ-opioid receptor moderates the response to naltrexone when used to treat alcohol dependence. Studies have also shown moderating effects of variation in the gene encoding the serotonin transporter on response to serotonergic treatment of alcohol dependence. Adaptive algorithms that modify alcohol treatment based on patients' progress have also shown promise. Initial response to outpatient treatment appears to be a particularly important in the selection of optimal continuing care interventions. In addition, stepped-care algorithms can reduce the cost and burden of treatment while maintaining good outcomes. Finally, matching treatment to specific problems present at intake or that emerge during treatment can also improve outcomes. Although all of these effects require replication and further refinement, the future of personalized care for alcohol dependence appears bright.

Treatment outcomes of a stage 1 cognitive-behavioral trial to reduce alcohol use among human immunodeficiency virus-infected out-patients in western Kenya

AIMS

Dual epidemics of human immunodeficiency virus (HIV) and alcohol use disorders, and a dearth of professional resources for behavioral treatment in sub-Saharan Africa, suggest the need for development of culturally relevant and feasible interventions. The purpose of this study was to test the preliminary efficacy of a culturally adapted six-session gender-stratified group cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use among HIV-infected out-patients in Eldoret, Kenya.

DESIGN

Randomized clinical trial comparing CBT against a usual care assessment-only control.

SETTING

A large HIV out-patient clinic in Eldoret, Kenya, part of the Academic Model for Providing Access to Healthcare collaboration.

PARTICIPANTS

Seventy-five HIV-infected out-patients who were antiretroviral (ARV)-initiated or ARV-eligible and who reported hazardous or binge drinking.

MEASUREMENTS

Percentage of drinking days (PDD) and mean drinks per drinking days (DDD) measured continuously using the Time line Follow back method.

FINDINGS

There were 299 ineligible and 102 eligible out-patients with 12 refusals. Effect sizes of the change in alcohol use since baseline between the two conditions at the 30-day follow-up were large [d=0.95, P=0.0002, mean difference=24.93, 95% confidence interval (CI): 12.43, 37.43 PDD; d=0.76, P=0.002, mean difference=2.88, 95% CI: 1.05, 4.70 DDD]. Randomized participants attended 93% of the six CBT sessions offered. Reported alcohol abstinence at the 90-day follow-up was 69% (CBT) and 38% (usual care). Paraprofessional counselors achieved independent ratings of adherence and competence equivalent to college-educated therapists in the United States. Treatment effect sizes were comparable to alcohol intervention studies conducted in the United States.

CONCLUSIONS

Cognitive-behavioral therapy can be adapted successfully to group paraprofessional delivery in Kenya and may be effective in reducing alcohol use among HIV-infected Kenyan out-patients.

Primary outcomes in two randomized controlled trials of treatments for cannabis use disorders

BACKGROUND

While several randomized controlled trials evaluating a range of treatments for cannabis use disorders have appeared in recent years, these have been marked by inconsistency in selection of primary outcomes, making it difficult to compare outcomes across studies.

METHOD

With the aim of identifying meaningful and reliable outcome domains in treatment studies of cannabis use disorders, we evaluated multiple indicators of marijuana use, marijuana problems, and psychosocial functioning from two independent randomized controlled trials of behavioral treatments for cannabis use disorders (Ns=450 and 136).

RESULTS

Confirmatory factor analysis indicated that the best-fitting model of outcomes in both trials encompassed three distinct factors: frequency of marijuana use, severity of marijuana use, and psychosocial functioning. In both trials, frequency of marijuana use and longest period of abstinence during treatment were most strongly associated with outcome during follow-up. Using two categorical definitions of "clinically significant improvement," individuals who demonstrated improvement differed on most end-of-treatment and long-term outcomes from those who did not improve.

CONCLUSIONS

Results may guide future randomized controlled trials of treatments for cannabis use disorders in the collection of relevant end-of-treatment outcomes and encourage consistency in the reporting of outcomes across trials.

Enabling or Engaging? The Role of Recovery Support Services in Addiction Recovery

Recovery capital-the quantity and quality of internal and external resources to initiate and maintain recovery-is explored with suggestions for how recovery support services (RSS) (nontraditional, and often nonprofessional support) can be utilized within a context of comprehensive addiction services. This article includes a brief history of RSS, conceptual and operational definitions of RSS, a framework for evaluating RSS, along with a review of recent empirical evidence that suggests that rather than enabling continued addiction, recovery supports are effective at engaging people into care, especially those who have little recovery capital, and/or who otherwise would likely have little to no "access to recovery."

The efficacy of diversion and aftercare strategies for adult drug-involved offenders: a summary and methodological review of the outcome literature

Diversion strategies aim to redirect drug-involved offenders away from the criminal justice system and into treatment. Despite the interest in diversionary practices, the emergence of an empirical evaluation literature has been slow. A methodological review of published outcome studies was conducted to investigate the current strength of evidence for the efficacy of diversion and aftercare practices for criminal offenders. Twenty outcome studies were identified for review: 19 on diversion and one on aftercare. The vast majority of studies were non-randomised evaluations, reflecting the paucity of rigorous evaluation work in this area. Although most studies were prospective, very few reported on long-term outcomes following treatment. Detail was lacking with regard to basic study characteristics, such as eligibility criteria and outcomes. Despite these methodological shortcomings, results provide some tentative evidence that diversion and aftercare programmes could be effective. Best practice elements of diversion and aftercare programmes are identified and feasible strategies to improve the methodological quality of future evaluations are considered.

Continuing care research: what we have learned and where we are going

In the field of addiction treatment, the term continuing care has been used to indicate the stage of treatment that follows an initial episode of more intensive care. This article reviews controlled studies of continuing care conducted over the prior 20 years. The results indicate that continuing care interventions were more likely to produce positive treatment effects when they had a longer planned duration, made more active efforts to deliver treatment to patients, and were studied more recently. However, there was considerable variability in patient response and room for improvements in participation rates and effectiveness. It is possible that the effectiveness of continuing care interventions could be further improved by the use of adaptive algorithms, which adjust treatment over time based on changes in patients' symptoms and status. The use of alternative service delivery methods and care settings may also lead to greater engagement and retention in continuing care, particularly among the large numbers of individuals who do not want traditional, clinic-based specialty care.

Criminality and Addiction: Selected Issues for Future Policies, Practice, & Research

The high cost of incarceration and a general confidence in the effectiveness of drug abuse treatment have led many states to adopt community-based drug abuse treatment as part of, or as an alternative to, incarceration. Community re-entry and aftercare have therefore received increasing attention from both practitioners and researchers. This article examines possibilities for encouraging change in both adult and juvenile justice treatment. Four issues are highlighted: (1) relapse and aftercare, (2) co-occurring disorder, (3) juvenile justice programming, and (4) women's treatment. The success of U.S. drug treatment policy depends on a capacity to resolve these and related issues.

Perfil dos usuários do serviço de teleatendimento sobre drogas de abuso VIVAVOZ

INTRODUÇÃO: O abuso de drogas é um problema importante de saúde pública, e intervenções telefônicas são utilizadas como uma modalidade de tratamento. Objetivou-se descrever o perfil sociodemográfico, o padrão de consumo e a dependência de substâncias psicoativas dos usuários que buscaram auxílio em um serviço de teleatendimento para drogas de abuso. MÉTODOS: Foram utilizados os dados do 1º ano de funcionamento do serviço, coletados por consultores previamente capacitados, através de protocolo informatizado. Foram aplicados instrumentos para caracterização sociodemográfica, padrão de consumo e dependência dos usuários. Utilizou-se estatística descritiva para estimar a distribuição das variáveis, e os dados apresentam-se em freqüências. RESULTADOS: No período, foram atendidas 28.257 ligações, sendo 7.956 incluídas no estudo. No total, foi encontrada maior prevalência de mulheres, estudantes, solteiros, maiores de 35 anos, com ensino fundamental incompleto e renda familiar menor que cinco salários mínimos procurando o teleatendimento. Dentre os usuários de drogas, predominaram homens, de 18 a 25 anos. As drogas mais utilizadas foram tabaco, maconha, álcool e cocaína. O uso de tabaco foi semelhante para ambos os sexos. Indivíduos do sexo masculino usaram mais drogas ilícitas. A maioria dos usuários era dependente, sendo que os homens apresentaram maiores índices de dependência para tabaco e solventes. CONCLUSÕES: Esses resultados traçam o perfil do usuário que procura auxílio telefônico para a questão de drogas, e revelam a importância desses serviços à população, auxiliando no direcionamento de ações preventivas.

Extending residential care through telephone counseling: initial results from the Betty Ford Center Focused Continuing Care protocol

There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the "real world". This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described.

Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders

BACKGROUND

The consumption of psychostimulants for non-medical reasons probably occurs because of their euphoriant and psychomotor-stimulating properties. Chronic consumption of these agents results in development of stereotyped behaviour, paranoia, and possibly aggressive behaviour. Psychosocial treatments for psychostimulant use disorder are supposed to improve compliance, and to promote abstinence. Evidence from randomised controlled trials in this subject needs to be summarised.

OBJECTIVES

To conduct a systematic review of all RCTs on psychosocial interventions for treating psychostimulant use disorder.

SEARCH STRATEGY

Electronic searches of Cochrane Library, EMBASE, MEDLINE, and LILACS (to may 2006); reference searching; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of psychostimulants abuse/ dependence.

SELECTION CRITERIA

All randomised-controlled trials focusing on psychosocial interventions for treating psychostimulants abuse/ dependence.

DATA COLLECTION AND ANALYSIS

Three authors extracted the data independently and Relative Risks, weighted mean difference and number needed to treat were estimated, when possible. The reviewers assumed that people who died or dropped out had no improvement (intention to treat analysis) and tested the sensitivity of the final results to this assumption.

MAIN RESULTS

Twenty-seven randomised controlled studies (3663 participants) fulfilled inclusion criteria and had data that could be used for at least one of the main comparisons. There was a wide heterogeneity in the interventions evaluated: this did not allow to provide a summary estimate of effect and results cannot be summarised in a clear cut way. The comparisons between different type of Behavioural Interventions showed results in favour of treatments with some form of Contingency management in respect to both reducing drop outs and lowering cocaine use..

AUTHORS' CONCLUSIONS

Overall this review reports little significant behavioural changes with reductions in rates of drug consumption following an intervention. Moreover, with the evidence currently available, there are no data supporting a single treatment approach that is able to comprise the multidimensional facets of addiction patterns and to significantly yield better outcomes to resolve the chronic, relapsing nature of addiction, with all its correlates and consequences.

Psychosocial approaches to psychostimulant dependence: A systematic review

This review examines the nature and evidence for the effectiveness of psychosocial interventions for psychostimulant dependence. Psychostimulant dependence and related harms continue to increase in many parts of the world, while treatment responses are predominantly limited to psychosocial interventions. The effectiveness of psychosocial interventions is compromised by poor rates of treatment induction and retention. As with other substance use disorders, increasing the diversity of treatment options is likely to improve treatment coverage and outcomes across a broader range of users. Identifying medications that might enhance treatment induction and retention would also enhance the effectiveness of psychosocial programs. It is concluded that psychosocial interventions are moderately effective in reducing psychostimulant use and related harms among psychostimulant-dependent persons.

Is there a case for extended interventions for alcohol and drug use disorders?

AIMS

To determine whether there is evidence to support the implementation of extended interventions (i.e. longer than 6 months) for individuals with alcohol or other drug use disorders.

METHODS

Literature on extended behavioral and pharmacotherapy interventions was reviewed, along with findings from studies of extended monitoring and monitoring paired with adjunctive counseling. Studies were identified through database searches, citations in prior reviews and examinations of recent volumes of relevant journals. Key terms were defined, and a theoretical rationale was presented for extended treatment. Several adaptive treatment studies that made use of stepped care or continuation protocols were also described.

MEASUREMENTS

The primary outcomes that were considered were alcohol and drug use during the intervention and post-intervention follow-ups. Other outcomes were examined when they were included in the articles reviewed.

FINDINGS

Most of the studies in the review provided support for the effectiveness of extended interventions for alcohol and drug abusers, whether the extended care was delivered through face-to-face contact or via the telephone. These findings held across all types of interventions that were examined (e.g. behavioral treatment, pharmacotherapy and monitoring). However, only a few studies directly compared extended and standard length version of the same intervention. New developments in addiction treatment with implications for extended care models were also described and discussed.

CONCLUSIONS

The findings of the review indicate that maintaining therapeutic contact for extended periods of time with individuals with alcohol and other drug disorders appears to promote better long-term outcomes than 'treatment as usual', although more studies are needed that compare extended and standard versions of interventions. Achieving good compliance and successful disease management with extended interventions will probably require adaptive protocols in which the intensity of treatment can be adjusted up or down in response to changes in symptoms and functioning over time. Future directions in research on extended interventions were discussed.

Reconsidering the evaluation of addiction treatment: from retrospective follow-up to concurrent recovery monitoring

Historically, addiction treatments have been delivered and evaluated under an acute-care format. Fixed amounts or durations of treatment have been provided and their effects evaluated 6-12 months after completion of care. The explicit expectation of treatment has been enduring reductions in substance use, improved personal health and social function, generally referred to as 'recovery'. In contrast, treatments for chronic illnesses such as diabetes, hypertension and asthma have been provided for indeterminate periods and their effects evaluated during the course of those treatments. Here the expectations are for most of the same results, but only during the course of continuing care and monitoring. The many similarities between addiction and mainstream chronic illnesses stand in contrast to the differences in the ways addiction is conceptualized, treated and evaluated. This paper builds upon established methods of during-treatment evaluation developed for the treatment of other chronic illnesses and suggests a parallel evaluation system for out-patient, continuing-care forms of addiction treatment. The suggested system retains traditional patient-level, behavioral outcome measures of recovery, but suggests that these outcomes should be collected and reported immediately and regularly by clinicians at the beginning of addiction treatment sessions, as a way of evaluating recovery progress and making decisions about continuing care. We refer to this paradigm as 'concurrent recovery monitoring' and discuss its potential for producing more timely, efficient, clinically relevant and accountable evaluations.

Do patient characteristics and initial progress in treatment moderate the effectiveness of telephone-based continuing care for substance use disorders?

AIMS

To determine whether substance use severity, psychiatric severity, social support, self-help attendance or motivation moderated substance use outcomes in a telephone-based continuing care intervention.

DESIGN

A randomized study comparing three 12-week continuing care interventions: weekly telephone monitoring and counseling combined with a support group in the first 4 weeks (TEL), twice-weekly individualized relapse prevention (RP) and twice-weekly standard group counseling (STND).

METHODS

Following completion of 4-week intensive out-patient programs (IOP), 359 patients with alcohol and/or cocaine dependence were assigned randomly to a continuing care condition and followed quarterly for 12 months. Ten potential moderator variables were examined in separate analyses. Two of these variables reflected pretreatment status, whereas the other variables were focused on performance while in the IOP. A composite risk measure was also constructed from dichotomized versions of seven of these variables, with higher scores indicating greater potential for relapse. The dependent measures were total abstinence and percentage of days abstinent from alcohol and cocaine in each quarter.

FINDINGS

Of 40 interaction contrasts that were examined with individual risk indicator measures, only one reached the 0.05 level of significance. Patients with any alcohol use in IOP had a higher percentage of days abstinence in STND than in TEL. In addition, high scores on the composite risk indicator predicted higher total abstinence rates in STND than in TEL, whereas low to moderate scores predicted higher abstinence rates in TEL than in STND.

CONCLUSION

For most graduates of IOPs, the combination of brief weekly telephone therapeutic contacts and a support group in the first month produced outcomes that are as good as those obtained in more intensive face-to-face continuing care interventions. However, patients with current dependence on both alcohol and cocaine who make little progress towards achieving the central goals of IOP may have better outcomes if they receive twice-weekly group counseling following IOP.

The Effectiveness of Telephone-Based Continuing Care in the Clinical Management of Alcohol and Cocaine Use Disorders: 12-Month Outcomes

This study of continuing care for substance dependent patients compared a telephone-based monitoring and brief counseling intervention (TEL) with 2 face-to-face interventions, relapse prevention (RP) and standard 12-step group counseling (STND). The participants were graduates of intensive outpatient programs who had current dependence on alcohol and/or cocaine. Self-report, collateral, and biological measures of alcohol and cocaine use were obtained over a 12-month follow-up. The treatment groups did not differ on abstinence-related outcomes in the complete sample (N = 359) or on cocaine use outcomes in participants with cocaine dependence (n = 268). However, in participants with alcohol dependence only (n = 91), TEL produced better alcohol use outcomes than STND on all measures examined and better outcomes than RP on some of the measures.

Psychological distress and return to substance use two years following treatment

This study examined client background characteristics, substance use severity, and psychological distress in relation to return to alcohol and drug use among men and women 2 years following substance user treatment. Participants (n = 180) completed a baseline interview within their first month of substance user treatment (conducted in 1995/1996) and follow-up interview 2 years following the baseline interview (conducted in 1997/1998). Structural equation modeling analyses were used to examine the relationship among client background characteristics and problem severity indicators, measured during treatment, in relation to alcohol and illicit drug use 2 years posttreatment. Psychological distress directly predicted alcohol and illicit drug use during follow-up and appeared to mediate the relationship between client background characteristics (such as gender, race, and marital status) and substance use consequences on posttreatment substance use. Income directly predicted alcohol use and age directly predicted illicit drug use, regardless of problem severity (including psychological distress and substance use consequences). Results support long-term clinical monitoring of psychological distress as a marker for return to drug or alcohol use.

Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: a randomized placebo-controlled trial

CONTEXT

Disulfiram has emerged as a promising treatment for cocaine dependence, but it has not yet been evaluated in general populations of cocaine users.

OBJECTIVES

To compare the effectiveness of disulfiram therapy with that of a placebo condition in reducing cocaine use and to compare the effectiveness of 2 active behavioral therapies-cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT)-in reducing cocaine use.

DESIGN

Randomized, placebo-controlled, double-masked (for medication condition), factorial (2 x 2) trial with 4 treatment conditions: disulfiram plus CBT, disulfiram plus IPT, placebo plus CBT, and placebo plus IPT.

SETTING

A community-based outpatient substance abuse treatment program.

PATIENTS

A total of 121 individuals meeting the criteria for current cocaine dependence.

INTERVENTIONS

Patients received either disulfiram (250 mg/d) or placebo in identical capsules. Medication compliance was monitored using a riboflavin marker procedure. Both behavioral therapies (CBT and IPT) were manual guided and were delivered in individual sessions for 12 weeks.

MAIN OUTCOME MEASURES

Random regression analyses of self-reported frequency of cocaine use and results of urine toxicology screens.

RESULTS

Participants assigned to disulfiram reduced their cocaine use significantly more than those assigned to placebo, and those assigned to CBT reduced their cocaine use significantly more than those assigned to IPT (P<.01 for both). Findings were consistent across all study samples (eg, intention to treat, treatment initiators, and treatment completers). Benefits of disulfiram use and CBT were most pronounced for participants who were not alcohol dependent at baseline or who fully abstained from drinking alcohol during treatment. Adverse effects experienced by participants who received disulfiram were mild and were not considerably different from those experienced by participants who received placebo.

CONCLUSIONS

Disulfiram and CBT are effective therapies for general populations of cocaine-dependent individuals. Disulfiram seems to exert a direct effect on cocaine use rather than through reducing concurrent alcohol use.

Relapse in outpatient treatment for marijuana dependence

The current study provides an initial examination of lapse and relapse to marijuana use among 82 individuals who achieved at least 2 weeks of abstinence during outpatient treatment for marijuana dependence. Seventy-one percent used marijuana at least once (i.e., lapsed) within 6 months of initial abstinence, averaging 73 days (SD = 50) till lapsing. Similarly, 71% of those who lapsed, relapsed to heavier use defined as at least 4 days of marijuana use in any 7-day period. Early lapses were more strongly associated with consequent relapse. Previous studies have noted that marijuana-dependent outpatients experience difficulty initiating abstinence from marijuana much as do those dependent on other substances. The present data suggest that these similarities extend to difficulty maintaining abstinence.

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

Predictors of drug treatment re-entry following relapse to cocaine use in DATOS

Many drug abusers have repeated exposure to treatment, yet little is known about the reasons some individuals re-enter treatment following relapse to drug use. This paper examines the predictors of treatment re-entry among cocaine abusers who relapsed to cocaine use (N = 347) within 5 years following their index treatment episode. In-depth assessments were conducted at treatment intake in 1991-93 and at 1 and 5 years following treatment discharge. About 44% of the sample returned to treatment, at an average of 2.6 years following discharge. A logistic regression analysis demonstrated that individuals who were African American, were previously married, used cocaine at least weekly after treatment discharge, and had more service needs at the time of index treatment were more likely to re-enter treatment. The findings suggest that a longer-term perspective on treatment utilization is needed to more fully address chronic substance abuse and the problems typically associated with it.

Outcome predictors in substance use disorders

Given the heterogeneous nature of substance abuse, it is notable that several predictors of response are independent of the primary drug of abuse or the treatment setting [208]. Although the strength of the relationship of predictor to outcome varies, the following factors have been identified consistently: severity of dependence or withdrawal; psychiatric comorbidity; substance-related problems; motivation (abstinence commitment); length of treatment; negative affective states; cognitive factors; personality traits and disorders; coping skills; multiple substance abuse; contingency contracting or coercion; genetic factors; sleep architecture; urges and craving; self-efficacy; and economic and social factors. Although it is well known that severity of dependence (including polysubstance abuse), serious psychiatric comorbidity, and social problems are associated with poor treatment response, only recently has research examined the efficacy of intervention strategies that specifically address these problems. Adequate treatment of psychiatric comorbidity and improvement in social, economic, and family functioning lead to better treatment outcomes. The development of specific techniques to enhance self-efficacy, motivation, coping skills, and functioning in the community are concrete examples of how the identification of factors associated with positive outcomes has led to the development of new treatments. Despite significant accomplishments, the field is left with many unanswered questions. Although several biologic markers, such as neuroendocrine response and sleep architecture, show promise as outcome predictors, it is not known whether these are critical factors in the initiation of substance use or its progression to dependence. Determining whether biologic markers are epiphenomena reflecting the amount and duration of substance abuse or are fundamental to the pathophysiology of dependence is a matter of urgent concern. With some exceptions, identification of biologic predictors has not led to innovative therapies. One of these exceptions is the development of naltrexone for the treatment of alcoholism, which was based in a solid theoretical rationale and followed by hypothesis-driven experiments. Similar opportunities should emerge from current basic science and clinical research. The application of pharmacogenetic techniques to the field of addiction also holds great promise. As future studies are undertaken, researchers and clinicians must be mindful that differences in outcome predictors across drugs of abuse and treatments may emerge as subgroups of individuals with addictive disorders and new therapies are identified. There is already evidence that early onset alcoholism is associated with poor response under some circumstances, yet may be a predictor of response to targeted pharmacotherapy with ondansetron [64, 112]. As the ability to subtype disorders based on meaningful biologic differences grows, it is anticipated that several relevant outcome predictors that are specific for pharmacotherapy will emerge.

Mediators of effectiveness in dual-focus self-help groups

Although research on the effectiveness of 12-step group participation has been increasing, there has been little examination of the processes by which such participation leads to positive outcomes. Two kinds of factors have been proposed as mediating between 12-step group affiliation and outcomes for members, common process factors that have been identified in a range of behavioral treatments and factors that are relatively unique to the 12-step model. The study tested the hypotheses that two common process factors (internal locus of control and sociability) and two unique factors (spirituality and installation of hope) mediate the effects of 12-step group affiliation on drug/alcohol abstinence and health promoting behavior. The study respondents were members of a dual focus 12-step-based fellowship, Double Trouble in Recovery (DTR), designed to address issues of both substance use and mental health. Members of 24 DTR groups in New York City were recruited and followed-up for 1 year. The degree of 12-step group affiliation during the study period was associated with more positive outcomes at follow-up. Internal locus of control and sociability mediated the effects of 12-step group affiliation on both outcomes, whereas spirituality and hope acted as mediators only for health promoting behavior. Understanding that the therapeutic factors inherent in 12-step are not mysterious, but appear to capitalize on well-documented social learning principles, may increase the acceptance of 12-step programs among addiction and mental health professionals.

Correlates of received and expressed violence persistence following substance abuse treatment

This study examined different types of violence (i.e. 'expressed' towards others and 'received' from others) across different relationship types (i.e. 'partners' and 'non-partners') among men and women in substance abuse treatment, and during a 2-year follow-up period. For received violence, participants were divided into three groups: no-violence before or after treatment, violence before treatment only, and violence both before and after treatment. Similarly, participants also were divided into three groups based on expressed violence: no-violence before or after treatment, violence before treatment only, and violence both before and after treatment. Both expressed and received violence (either before or after treatment) was associated with younger age. Unique demographic markers of received violence included being female, reporting less income and greater unemployment. For both received and expressed violence, several problem severity indicators (e.g. drug consequences, psychological distress) and psychosocial relapse risk indicators (e.g. resource needs, substance-using leisure activities) differentiated those who reported violence (either before or after treatment) and those who did not report violence. In addition, received violence was related to greater exposure to substances whereas expressed violence was related to greater cocaine use and craving. Continued received and expressed violence post-treatment was related to substance use during the follow-up, recruitment from inpatient treatment, and baseline psychological distress (expressed violence only). The results are consistent with contemporary models of violence specifying the impact of substance use, social/contextual and individual difference factors, and highlight risk factors that could be targeted during treatment to potentially reduce post-treatment substance use and violence.

The role of continuing care in outpatient alcohol treatment programs

Substance-abusing patients are frequently urged to participate in continuing care, or "after-care," following an initial phase of treatment. However, there has been relatively little research on the effectiveness of continuing care, particularly in the context of outpatient service delivery systems. Since 1988, 12 controlled studies of continuing care for alcohol use disorders have been published. Only three of these studies were conducted exclusively within outpatient service delivery systems; in the other studies, all patients (six studies) or at least half of the patients (three studies) were first treated in inpatient or residential facilities. Four of the 12 studies yielded positive findings (two of six studies with minimal/no continuing care control conditions and two of six studies with active control conditions). It is suggested that continuing care treatment might be improved by placing greater emphasis on addressing co-occurring problems and facilitating the identification and strengthening of patients' skills, interests, and talents, although additional research would be needed to evaluate the impact of these modifications. Further research is also needed to establish guidelines for when patients are ready to enter continuing care and to develop performance indicators to monitor progress.

Effectiveness of continuing care interventions for substance abusers. Implications for the study of long-term treatment effects

Substance-abusing patients are frequently urged to participate in lower intensity continuing care interventions, also known as "stepdown care" or "aftercare," following an initial phase of treatment. Since 1988, 15 controlled studies of continuing care for alcohol or drug abuse have been published, with follow-up data on substance use presented in 14 of these studies. In the studies that featured an active control condition, only 1 of 7 yielded positive findings. In the studies that featured a minimal- or no-treatment control, 3 of 7 studies yielded positive findings. The relative paucity of continuing care studies, coupled with the lack of stronger evidence of clinical effectiveness, provides a convincing rationale for conducting evaluations of continuing interventions, as well as evaluations of combinations of various primary and continuing interventions. Methodological issues in the evaluation of continuing care and potential research questions that could be addressed in long-term follow-up studies are outlined and discussed.

A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-ups. Preliminary results and methodological issues

This article is an initial report from a review of alcohol and drug treatment studies with follow-ups of 2 years or more. The goals of the review are to examine the stability of substance use outcomes and the factors that moderate or mediate these outcomes. Results from 12 studies that generated multiple research reports are presented, and methodological problems encountered in the review are discussed. Substance use outcomes at the group level were generally stable, although moderate within-subject variation in substance use status over time was observed. Of factors assessed at baseline, psychiatric severity was a significant predictor of outcome in the highest percentage of reports, although the nature of the relationship varied. Stronger motivation and coping at baseline also consistently predicted better drinking outcomes. Better progress while in treatment, and the performance of pro-recovery behaviors and low problem severity in associated areas following treatment, consistently predicted better substance use outcomes.

Continuous, categorical, and time to event cocaine use outcome variables: degree of intercorrelation and sensitivity to treatment group differences

Although a number of cocaine use variables are available for use in treatment outcome studies, there is little information on how strongly these variables are related or their relative sensitivity for detecting treatment group differences. Eight continuous and categorical variables of cocaine use obtained at 6-, 12-, 18-, and 24-month follow-ups, four event history variables, and one summary measure of cocaine use over the 24-month follow-up period were examined. The variables were generally correlated 0.30--0.50 or greater. An exploratory factor analysis in which the repeated measures were averaged across follow-up points yielded two factors, one made up of incidence of use variables (e.g. percent days cocaine use, monetary value of cocaine, abstinence status, time to relapse, urine toxicology) and a second consisting of perceived severity of use variables (e.g. drug and cocaine composites, craving). This factor solution was supported by confirmatory factor analyses conducted at each follow-up point. None of the variables yielded significant differences between the two treatment conditions in the study, standard group and individualized relapse prevention continuing care. However, monetary value of cocaine used and urine toxicology variables yielded the largest effect sizes (eta(2)=0.020 and 0.010, respectively).

Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence

Sixty individuals seeking outpatient treatment for marijuana dependence were randomly assigned to 1 of 3 treatments: motivational enhancement (M), M plus behavioral coping skills therapy (MBT), or MBT plus voucher-based incentives (MBTV). In the voucher-based incentive program, participants earned vouchers exchangeable for retail items contingent on them submitting cannabinoid-negative urine specimens. MBTV engendered significantly greater durations of documented marijuana abstinence during treatment compared with MBT and M, and a greater percentage of participants in the MBTV group compared with the MBT or M groups were abstinent at the end of treatment. No significant differences in marijuana abstinence were observed between the MBT and M groups. The positive effects of the voucher program in this study support the utility of incentive-based interventions for the treatment of substance dependence disorders including marijuana dependence.