Contingency management for substance use disorders in Spain: Implications for research and practice

OBJECTIVE

We provide a narrative review of published studies evaluating voucher-based contingency management (CM) treatment for cocaine, nicotine and cannabis use disorders in Spain and discuss the concerns and future challenges.

METHOD

Published studies between 2008 and 2015 that evaluated the impact of incentives for SUD in Spain and included an appropriate control or comparison condition were identified and reviewed.

RESULTS

Adding voucher-based CM to standard treatments obtained better treatment retention and cocaine abstinence than standard care alone. CM also improved psychosocial functioning. Economic status or depressive symptoms did not affect the results of CM treatment for cocaine dependence. The addition of a CM protocol to cognitive behavioral treatment (CBT) also improved treatment effectiveness for smoking cessation. Available data on the effect of CM on cannabis use disorders (CUD) with young people did not allow confirmation of its superiority to date.

CONCLUSION

The research conducted to date in Spain confirms and expands the findings of studies conducted in the US supporting the effectiveness of CM in the context of community settings with cocaine- and nicotine-dependents. However, CM has not yet been readily adopted into general clinical practice in Spain or the rest of Europe. The limited effectiveness of CM for CUD is likely due to the scarcity of data and may change with more studies, taking into account recent research on this topic in the US. Continued efforts are warranted to further develop and disseminate incentive-based treatments for SUD across clinical settings and populations in Spain.

Interaction effect of contingency management and sex on delay-discounting changes among treatment-seeking smokers

Despite the potential influence of sex on delay-discounting rates, there is no previous evidence with regard to the effect of this variable on the clinical interventions aimed at modifying delay-discounting rates. This study assessed the effect of sex on the association between the type of treatment received (either cognitive-behavioral treatment [CBT] alone or combined with contingency management [CM + CBT]) and delay-discounting changes at end of treatment and 6-month follow-up. This aim was addressed after controlling for the influence of baseline delay discounting. Treatment-seeking smokers (N = 116) were randomly assigned to either CM + CBT (n = 69) or CBT alone (n = 47). Participants completed delay-discounting assessments at intake, at end of treatment, and at 6-month follow-up. Results showed that there was a significant interaction effect of treatment type and sex, such that women who received CM decreased their discounting more than women who did not. However, this effect was not found among men. Participants who discounted most at intake showed the greatest delay-discounting decreases. Lastly, smoking abstinence did not affect changes in delay discounting. The current results suggest that CM intervention may have a differential effect on delay-discounting changes as a function of sex. This finding supports the relevance of considering the effect of individual variables when assessing changes in delay discounting due to clinical interventions.

Individual variables related to craving reduction in cue exposure treatment

INTRODUCTION

Although extensive research has demonstrated that cigarette craving can be effectively attenuated, very few studies have explored associations between individual variables and craving reduction. This study explored whether individual characteristics predict craving decreases during virtual reality cue exposure treatment (VR-CET).

METHOD

Participants were 41 treatment-seeking smokers (73% women) with a mean age of 39.4 (SD=13.2), who had been smoking 15.0 (SD=7.1) cigarettes per day for 20.0 (SD=10.7) years. Their mean score on the Fagerström Test of Nicotine Dependence (FTND) was 4.8 (SD=2.3). Participants completed five cue exposure sessions using virtual reality for smoking cessation over a five-week period. The percentage of reduction in craving was calculated by comparing self-reported craving after the first and last exposure sessions. Sociodemographic characteristics (gender, age, years of education and marital status), tobacco-related [duration of daily smoking, cigarettes per day, FTND and Nicotine Dependence Syndrome Scale (NDSS)] and psychological characteristics [depressive symptoms (Beck's Depression Inventory-Second Edition, BDI-II), impulsiveness (delay discounting) and anxiety (State-Trait Anxiety Inventory, STAI)] were examined as possible predictors for craving reductions.

RESULTS

Multiple regression revealed that greater decreases in craving were associated with younger age (β=-.30, p=.043), cigarettes smoked per day (β=.30, p=.042), higher values on delay discounting (β=.34, p=.020) and higher BDI-II scores (β=.30, p=.035).

CONCLUSION

These findings suggest that smokers with certain individual characteristics may benefit most from interventions aimed at reducing craving through VR-CET.

Contingency management for cigarette smokers with depressive symptoms

Despite depressive symptoms being very common among smokers from the general population, few studies have examined the effects of depressive symptoms on smoking treatment outcomes, and even less research has been carried out in the context of contingency management (CM). The authors conducted a secondary analysis to assess the interrelation between treatment condition, depressive symptoms and treatment outcomes among treatment-seeking smokers. The sample was made up of 147 treatment-seeking smokers who were randomly allocated 2 treatment conditions: cognitive behavioral treatment (CBT; n = 74), or CBT + CM (n = 73). CBT was applied in 1-hr group-based sessions over 6 weeks. The CM protocol was voucher-based with maximum earnings of €300 (US$339). Depressive symptoms were assessed using the Beck Depression Inventory-II. Smoking abstinence was verified though cotinine and carbon monoxide. Several analyses were conducted to explore the effect of treatment condition and baseline depressive symptoms on treatment outcomes, as well as the effect of treatment condition and smoking status on depressive symptoms. The CBT + CM condition was more effective than CBT, independent of depressive symptoms. The presence of depressive symptoms decreased the number of days of continuous smoking abstinence. Participants with a greater number of days of continuous smoking abstinence had fewer depressive symptoms than those with fewer days of continuous smoking abstinence. Findings suggest that health care providers should consider encouraging their patients with depressive symptoms to seek smoking cessation services that include both smoking cessation protocols and behavioral activation for mood management, thus maximizing both smoking and depressive outcomes.

Spanish adaptation and validation of the Barratt Impulsiveness Scale for early adolescents (BIS-11-A)

Impulsivity has been associated with several psychiatric disorders such as substance abuse. The Barratt Impulsiveness Scale (BIS-11) is one of the most commonly administered self-reports for the assessment of impulsiveness in both research and clinical settings. There is a version for adolescents called BIS-11-A, which has not been yet properly adapted to Spanish population. The goal of this study is to offer an alternative and more adequate Spanish version of the BIS-1-A, as well as to assess its psychometric properties including factor structure, reliability and predictive validity regarding substance use (last month alcohol, tobacco and cannabis use, presence of last month intoxication, binge drinking and problem drinking). The BIS-11-A and items from the European School Survey Project on Alcohol and other Drugs (ESPAD) were applied to1,183 students (aged 12-14) at 16 Spanish secondary schools. The BIS-11-A showed a bidimensional factor structure, high reliability (Cronbach's alpha = .87) and good capacity for identifying substance use, binge drinking and problem drinking (sensitivity = 67.3-75%; specificity = 83.4-85.4%). The BIS-11-A Spanish version is a reliable and valid instrument for be used among early adolescents.

Interaction of depressive symptoms and smoking abstinence on delay discounting rates

Delay discounting and depressive symptomatology have strong connections with smoking. However, few studies have examined interactions across delay discounting, depressive symptoms, and smoking status. The primary goal of this secondary analysis was to assess the interrelations across these 3 variables among treatment-seeking smokers. Delay discounting and depressive symptoms were assessed in 95 smokers enrolled in a clinical trial for smoking cessation at intake and 6-month follow-up. Participants with and without depressive symptoms did not differ in their discounting rates neither at intake nor at 6-month follow-up. However, delay discounting was significantly lower among abstainers at 6-month follow-up, and changes in discounting associated with smoking status were more pronounced among participants with depressive symptoms. These results clarify the relationship between delay discounting and depressive symptoms among current and former smokers and suggest that the association between smoking abstinence and lower delay discounting is significantly greater among individuals with depressive symptoms versus those who do not have depressive symptomatology.

Effects of systematic cue exposure through virtual reality on cigarette craving

INTRODUCTION

Cigarette cravings have been associated with less successful attempts to quit smoking and a greater likelihood of relapse after smoking cessation. Background craving refers to a relatively steady and continuous experience of craving, while cue-induced craving refers to phases of intense craving triggered by cues associated with smoking. Cue exposure treatment (CET) involves repeated exposure to stimuli associated with substance use in order to reduce craving responses. However, mixed results have been found regarding the effect of CET on both types of craving. The aim of this study was to assess the effect of systematic virtual reality cue exposure treatment (VR-CET) on background and cue-induced cravings.

METHODS

Participants were 48 treatment-seeking smokers. The VR-CET consisted of prolonged exposure sessions to several interactive virtual environments. The VR-CET was applied once a week over 5 weeks. An individualized hierarchy of exposure was drawn up for each patient starting from the easiest virtual environment. Background and cue-induced cravings were recorded in each session.

RESULTS

Cue-induced craving decreased over each session as a result of prolonged exposure. VR-CET also reduced cue-induced and background cravings across the 5 sessions, showing a cumulative effect across the exposure sessions.

CONCLUSIONS

Our results evidenced the utility of VR-CET in reducing both types of cigarette craving. A combination of CET through VR with psychological treatments may improve current treatments for smoking cessation.

Toward a comprehensive developmental model of smoking initiation and nicotine dependence

BACKGROUND

This study aims to identify predictors of smoking initiation and nicotine dependence (ND) to develop a comprehensive risk-factor model based on Kendler's development model for major depression.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Wave 2 (n=34,653). Risk factors were divided into five developmental tiers according to Kendler's model (childhood, early adolescence, late adolescence, adulthood, past-year). Hierarchical logistic regression models were built to predict the risk of smoking initiation and the risk of ND, given initiation. The continuation ratio (CR) was tested by ordinal logistic regression to examine whether the impact of the predictors was the same on smoking initiation or ND.

RESULTS

The final models highlighted the importance of different tiers for each outcome. The CR identified substantial differences in the predictors of smoking initiation versus ND. Childhood tier appears to be more determinant for smoking initiation while the effect of more distal tiers (i.e. childhood and early adolescence) was tempered by more proximal ones (i.e. late adolescence, adulthood and past-year) in ND, with few sex differences.

CONCLUSIONS

The differential effect of some predictors on each outcome shows the complexity of pathways from smoking initiation to ND. While some risk factors may be shared, others impact only at one stage or have even an inverse effect. An adaptation of Kendler's developmental model for major depression showed high predictive power for smoking initiation and ND.

Predictors of quit attempts and successful quit attempts among individuals with alcohol use disorders in a nationally representative sample

BACKGROUND

This study sought to identify predictors of attempting to quit and of successfully quitting alcohol abuse or dependence in the general population.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

RESULTS

Approximately 10% of individuals with alcohol abuse and 18% of those with dependence attempted to quit over the three year follow-up period. Of those who tried, 38% of individuals with abuse and 30% of those with dependence successfully quit. Among individuals with alcohol abuse or dependence, being single, younger than 40 years old, having low income, a co-occurring psychiatric disorder and greater number of dependence symptoms increased the likelihood of attempting to quit. Among individuals with alcohol abuse, male gender and low educational attainment further increased the odds of quit attempts. However, greater severity of alcohol use disorder, having a co-occurring drug use disorder and greater number of psychiatric disorders decreased the odds of success among individuals with alcohol abuse, while female gender, being married and older than 40 years old increased the odds of success. Among individuals with alcohol dependence, having nicotine dependence, greater number of psychiatric disorders and personality disorders decreased the odds of success.

CONCLUSIONS

Predictors of attempts to quit are different and sometimes opposite from those leading to successful quitting probably indicating that some factors that increase motivation may decrease ability to quit. These findings may help in the development of more targeted and effective interventions for alcohol use disorders.

Contingency management for smoking cessation among treatment-seeking patients in a community setting

BACKGROUND

Contingency management (CM) is an efficacious intervention for reducing cigarette smoking. However, CM is rarely adopted as a smoking cessation treatment in the community. This study analyzed the effectiveness of a CM procedure in combination with a cognitive-behavioral treatment (CBT) for smoking cessation among treatment-seeking patients from the general population.

METHODS

A total of 92 patients were randomly assigned to one of two treatment conditions: CBT (N=49) or CBT+CM (N=43). The CM procedure included a voucher program through which nicotine abstinence was reinforced on a schedule of escalating magnitude of reinforcement with a reset contingency. Self-reported smoking status was confirmed with both carbon monoxide (CO) level in expired air and cotinine levels in urine.

RESULTS

Of the patients who received CBT+CM 97.7%, completed 6 weeks of treatment, versus 81.6% of those who received CBT (p=.03). At the post-treatment assessment, 95.3% of the patients assigned to the CBT+CM condition achieved abstinence in comparison to the 59.2% in the CBT group (p=.000). At the one-month follow-up, 72.1% of the patients who received CBT+CM maintained smoking abstinence, versus 34.7% in the CBT group (p=.001). At the six-month follow-up, 51.2% of the patients who received CBT+CM maintained smoking abstinence in comparison to the 28.6% in the CBT group (p=.04).

CONCLUSIONS

Results from this randomized clinical trial showed that adding CM to a CBT is effective, and is feasible as an intervention approach with treatment-seeking patients in a community setting.

Decreased delay discounting in former cigarette smokers at one year after treatment

Current cigarette smokers exhibit greater delay discounting relative to ex-smokers. However, few studies have assessed longitudinal changes in delay discounting and cigarette smoking. The purpose of this study was to assess changes in delay discounting of hypothetical monetary rewards and smoking among treatment-seeking smokers (N=80) at baseline, after 6 weeks of behavioral treatment, and at 12-month follow-up. Results showed no changes in delay discounting in either smokers or abstainers at the end-of-treatment. In contrast, at 12-month follow-up, significant decreases in delay discounting were observed in abstainers while delay discounting remained the same for smokers. To our knowledge, this is the first study to observe significant decreases in delay discounting following prolonged smoking abstinence. Such findings provide evidence that delay discounting may have more state-like characteristics than previously believed.

Self-change among Spanish speakers with alcohol and drug use disorders in Spain and the United States

OBJECTIVE

Few cross-cultural studies have investigated the self-change process with substance abusers. This study examined commonalities and differences related to the self-change process with Spanish speaking self-changers in Spain and the United States (U.S.) who reported recovering from an alcohol or drug problem on their own (i.e., without formal help or treatment) for ≥1 year.

METHOD

Advertisements were primarily used to recruit participants. There were 56 participants in the final sample (Spain, n=29; US; n=27). Participants provided demographic and substance use history information and completed the Drug Use History Questionnaire, Reasons for Change Scale, the Life Events Checklist, and a checklist for maintenance factors after recovery.

RESULTS

Significantly more self-changers from the U.S. met DSM IV-TR criteria for alcohol dependence, reported significantly more life events in the year prior to recovery and significantly more maintenance/support events in the year after their recovery than their counterparts in Spain. The majority of participants' recoveries involved abstinence. Some alcohol abusers, however, report successfully engaging in low-risk drinking with no consequences(50% Spain; 22% U.S.), and some drug abusers in Spain (23%) reported a few days per year of very little drug use.

CONCLUSIONS

The two groups of Spanish speakers represented very different cultures, and those from the U.S. came from several countries in the Southern hemisphere. The results of this study suggest that even though people speak the same language that does not mitigate against cultural differences. Additional studies of the process of self change with larger participant samples are needed to better inform the development and provision of interventions for Spanish speakers with alcohol and drug use disorders across different cultures and countries.

Contingency management improves outcomes in cocaine-dependent outpatients with depressive symptoms

Despite depressive symptoms being very common among patients seeking treatment for cocaine dependence, few studies have examined the effects of depressive symptoms on cocaine outpatient treatment outcomes, and there is even less research in the context of Contingency Management (CM). The purpose of this study was to assess the main and interactive effects of co-occurring depressive symptoms on CM outcomes. Cocaine-dependent individuals (N = 108) were randomized to Community Reinforcement Approach (CRA) or CRA plus CM in two outpatient community clinical settings. Participants were categorized according to depression symptoms, self-reported by means of the BDI at treatment entry. Outcome measures included treatment retention and documented cocaine abstinence over a 6-month treatment period. Depressive symptoms were more commonly found in females and in unemployed participants, and were associated with more drug-related, social, and psychiatric problems at treatment entry. Individuals with baseline depressive symptoms had poorer treatment outcomes than patients without depressive symptoms. The addition of CM to CRA made the program more effective than with CRA alone, regardless of depressive symptoms. CM was associated with better abstinence treatment outcomes, while the interaction between unemployment and depressive symptoms was associated with negative retention treatment outcomes. This study supports the efficacy of CM for cocaine-dependent outpatients with and without depressive symptoms, and highlights its importance for improving treatment for unemployed and depressed cocaine-dependent individuals.

Probability and predictors of relapse to smoking: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

The goal of this study was to estimate rates of relapse to smoking in the community and to identify predictors of relapse.

METHODS

Data were drawn from the Waves 1 and 2 of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC). Logistic regression analyses were used to estimate the probability of relapse at Wave 2 among individuals who were abstinent at Wave 1 given length of abstinence as well as the presence of several sociodemographic, psychopathologic and substance use-related variables at Wave 1.

RESULTS

The risk for relapse among individuals who had been abstinent for 12 months or less at the baseline assessment was above 50%. Among individuals who had been abstinent for over a year, risk of relapse decreased hyperbolically as a function of time, and stabilized around 10% after 30 years of abstinence. Although several sociodemographic, psychopathologic and tobacco-related variables predicted relapse in univariate analyses, only younger age at cessation and shorter duration of abstinence independently predicted risk of relapse in multivariable analyses.

CONCLUSIONS

The first year after a quit attempt constitutes the period of highest risk for relapse. Although the risk for relapse decreases over time, it never fully disappears. Furthermore, younger age at smoking cessation also increases the risk for relapse. This information may help develop more targeted and effective relapse prevention programs.

Smoking a virtual cigarette increases craving among smokers

Previous studies have shown the efficacy of virtual reality (VR) environments that reproduce smoking-related stimuli for increasing self-reported craving and psychophysiological reactivity in smokers. However, no study to date has attempted to simulate smoking behavior itself by means of VR technology. The aim of this study was to assess the effect of smoking a virtual cigarette on self-reported craving levels and heart rate (HR) in a sample of smokers. Participants were 45 smokers randomly assigned to three VR conditions built into a virtual pub: smoking a virtual cigarette, throwing virtual darts at a virtual dartboard or just being in the virtual pub. Results showed that smoking a virtual cigarette significantly increased self-reported craving and HR when compared to the other two conditions. These results reveal that simulation of smoking behavior in a VR environment functions as an efficacious proximal cue that can be used for triggering craving under the cue-exposure paradigm.

Probability and predictors of cannabis use disorders relapse: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

This study aims to estimate the odds and predictors of Cannabis Use Disorders (CUD) relapse among individuals in remission.

METHODS

Analyses were done on the subsample of individuals with lifetime history of a CUD (abuse or dependence) who were in full remission at baseline (Wave 1) of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) (n=2350). Univariate logistic regression models and hierarchical logistic regression model were implemented to estimate odds of relapse and identify predictors of relapse at 3 years follow up (Wave 2).

RESULTS

The relapse rate of CUD was 6.63% over an average of 3.6 year follow-up period. In the multivariable model, the odds of relapse were inversely related to time in remission, whereas having a history of conduct disorder or a major depressive disorder after Wave 1 increased the risk of relapse.

CONCLUSIONS

Our findings suggest that maintenance of remission is the most common outcome for individuals in remission from a CUD. Treatment approaches may improve rates of sustained remission of individuals with CUD and conduct disorder or major depressive disorder.

Gender differences in early alcohol and tobacco use as a risk factor in Spanish adolescents

The sample is made up of 1,190 adolescents (52.8% boys; mean age = 16.81) from 37 random schools in the urban and rural areas of Asturias (northern Spain). The survey was conducted in 2008, assessing the use and patterns of use of alcohol and other drugs, age at onset of use, and psychosocial consequences. Items from the ESPAD and FRIDA questionnaires were employed. Univariate analyses and binary logistic regression analyses were carried out to determine the different predictive value for boys and girls of early-onset alcohol and tobacco use. The study's limitations and implications are noted.

Predictors of quit attempts and successful quit attempts in a nationally representative sample of smokers

Although most current smokers report that they would like to quit, most quit attempts fail suggesting that predictors of quitting attempts may differ from those of successful attempts. We examined sociodemographic and clinical predictors of quit attempts and successful quit attempts in a nationally representative sample of US adults. Data was collected in 2001-2002 (Wave 1) and 2004-2005 (Wave 2). Almost 40% of individuals who had not previously attempted to quit, tried to quit over the next three years; only 4.6% of those who tried had succeeded at the time of the evaluation. Hispanics, Asians, individuals with high income, and those with college education were less likely to attempt to quit, whereas those with daily nicotine use, younger age at first use and most symptoms of dependence were more likely to do so. Having an educational level below high school and older age at first nicotine use were predictors of successful quitting. Despite relatively high rates of quit attempts, rates of success are extremely low, indicating a gap between the public health need of decreasing tobacco use, and existing means to achieve it. Although there is a need to encourage people to quit tobacco, there may be an equally large need to develop more effective interventions that increase the rate of successful quit attempts.

Psychosocial Predictors of Relapse in Cocaine-Dependent Patients in Treatment

Relapses in cocaine abusers in treatment are an important problem. The majority of patients are incapable of sustaining abstinence over any length of time. To identify the factors associated to relapses risk in the cocaine use can be an optimal choice to improve the treatment strategies. The aim of this study was to analyze relapse-risk factors in cocaine-dependent patients on treatment. Participants were 102 patients who had begun outpatient treatment at a public health center in Spain. Some functional areas and cocaine use are evaluated for a period of six months. A structural equations model was used to identify possible predictive variables. The results show that social-family environment and economic-employment situation were associated with greater risk of relapse. Likewise, the social-family environment was related to severity of addiction. It is concluded that the incorporation of family intervention strategies and vocational/employment counseling may help to reduce relapse rates in cocaine addicts receiving treatment.

Peak provoked craving after smoking cessation

Peak provoked craving (PPC) is an alternative approach to cue-induced craving that focuses on the highest craving level experienced during the exposure to drug-related cues. The main objective of this study was to assess the effect of abstinence on PPC in smokers and to determine whether PPC is altered by continuous abstinence. Results showed reductions on PPC levels only 24 hours after achieving abstinence and craving levels remain significantly lower after 7 days of abstinence.

Motivation for change and barriers to treatment among young cannabis users

BACKGROUND/AIMS

Despite cannabis use among adolescents has shown to be related to psychosocial and mental health problems, the demand from adolescents for professional help is very low, and determinants of motivation for change among nonclinical populations remain unknown. The purpose of this study was to assess motivation for change among young cannabis users and to identify determinants of intention to change and self-change, as well as perceived barriers to seeking professional help.

METHODS

261 cannabis users aged 16-21 participated in a computerized survey in Spain.

RESULTS

Data from this cross-sectional study indicated that few users intend to stop taking the drug. Determining factors of intention to change were the following: having more drug-related problems, paranoid symptomatology and greater concern about the consequences of use. Self-change was facilitated by lower use of cannabis, and could be hindered by tobacco smoking and cannabis dependence. Lack of awareness of the problems and the desire to solve one's problems alone constitute the main barriers to seeking professional help.

CONCLUSIONS

Adolescent cannabis users show low motivation for change though experiencing more problems associated with its use emerges as a determinant of increased motivation. Several barriers impede this motivation from turning into treatment demand.

Contingency management is effective across cocaine-dependent outpatients with different socioeconomic status

Contingency management (CM) has demonstrated its efficacy for treating cocaine dependence, but there is still some controversy with regard to its dissemination. Understanding how individual differences affect CM outcomes is important for detecting barriers to its dissemination. The aim of this study is to examine the impact of socioeconomic variables in cocaine-dependent outpatients on the effectiveness of CM in a community setting. Cocaine-dependent outpatients (N=118) were randomized to community reinforcement approach (CRA) treatment or a CRA plus vouchers program. The impact of baseline economic variables, alone and in combination with treatment conditions, on abstinence and retention outcomes after 6 months of treatment was assessed. Results showed that income had no effect on retention or abstinence outcomes after 6 months of treatment in either treatment condition. The addition of a CM component was beneficial for individuals with any socioeconomic status. These results support the generalizability of CM strategies with patients of different socioeconomic status in community settings.

Validation of smoking-related virtual environments for cue exposure therapy

Craving is considered one of the main factors responsible for relapse after smoking cessation. Cue exposure therapy (CET) consists of controlled and repeated exposure to drug-related stimuli in order to extinguish associated responses. The main objective of this study was to assess the validity of 7 virtual reality environments for producing craving in smokers that can be used within the CET paradigm. Forty-six smokers and 44 never-smokers were exposed to 7 complex virtual environments with smoking-related cues that reproduce typical situations in which people smoke, and to a neutral virtual environment without smoking cues. Self-reported subjective craving and psychophysiological measures were recorded during the exposure. All virtual environments with smoking-related cues were able to generate subjective craving in smokers, while no increase was observed for the neutral environment. The most sensitive psychophysiological variable to craving increases was heart rate. The findings provide evidence of the utility of virtual reality for simulating real situations capable of eliciting craving. We also discuss how CET for smoking cessation can be improved through these virtual tools.

Virtual reality for smoking cessation: a case report

This study presents a case report describing the use of Virtual Stop Smoking (VSS) program. The VSS includes a multicomponent behavioural approach and a Virtual Reality graded exposure technique. The subject was a 22-year-old female who smoked 20 cigarettes per day. Six weekly 90-minute sessions were conducted once a week over a 6-week period. Measures of efficacy included the number of cigarettes smoked, breath carbon monoxide levels, and self-reported subjective craving. The results obtained supported the efficacy of VSS for smoking cessation.

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.