The relationship between in-treatment abstinence and post-treatment abstinence in a smoking cessation treatment.

Previous research has indicated that abstinence early in a smoking cessation program is predictive of successful posttreatment abstinence. However, it has not been established whether or not this effect is independent of other in-treatment abstinence patterns. In this paper the relationship between three potentially important aspects of in-treatment smoking abstinence and posttreatment smoking abstinence are examined: early abstinence, extended abstinence, and end-of-treatment abstinence. We examined the relationship between smoking behavior measured each weekday over 70 visits (approximately 14 weeks) of a contingency management smoking cessation program and at a follow-up visit 6 months after study entry (3 months after the scheduled end of treatment). Ninety-five of 102 participants were successfully followed-up. Seven of these 95 participants were confirmed abstinent. Early abstinence, defined as abstinence during the first 10 treatment visits, was significantly and independently related to follow-up abstinence (OR = 56.67 [7.29–440.63]). Extended abstinence and end-of-treatment abstinence were related to follow-up abstinence, but not independent of early abstinence based on multiple regression models. Inclusion of a variety of demographic and environmental characteristics did not significantly alter this relationship. Thus, consistent with the previous literature, the establishment of early abstinence appears to be crucial to establishing longer-term abstinence, independent of other in-treatment abstinence patterns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Examining Interrelationships Between Abstinence and Coping Self-Efficacy in Cocaine-Dependent Outpatients.

Initial abstinence and self-efficacy predict treatment outcome in cocaine-dependent outpatients. Associations between abstinence and coping self-efficacy were examined among cocaine-dependent outpatients (N=126). Abstinence was verified by urinalysis. Coping self-efficacy was measured using a modified Situational Confidence Questionnaire (SCQ; H. M. Annis, 1984). The modified SCQ had good validity and reliability, and scores increased during treatment. In bivariate analyses, early abstinence and SCQ scores each predicted subsequent abstinence and confidence during treatment and posttreatment follow-up. Based on structural equation modeling, early confidence was a significant predictor of later confidence but not of later abstinence, whereas early abstinence was a significant predictor of later abstinence and confidence. Results suggest a unidirectional relationship wherein prior abstinence predicts subsequent abstinence and confidence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up.

Abstinence, employment, and homelessness treatment outcomes at 12-month follow-up are presented from a study comparing behavioral day treatment plus abstinence-contingent housing and work therapy with behavioral day treatment only among homeless persons who abuse crack cocaine. Within-group improvements were revealed, but group differences for drug abstinence found in J. B. Milby et al. (2000) failed to persist at 12 months. Drug use measurement and treatment termination explanations are discussed. Within- but not between-group differences were found for employment and homelessness outcomes at long-term follow-up. Research extending abstinence contingencies and continuous drug use monitoring is recommended. Questions about effectiveness of contingency management alone, role of coexisting psychiatric disorders on treatment outcome, and individualized treatment dosing are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Initial abstinence and success in achieving longer term cocaine abstinence.

This study's goals were to characterize the relationship between early and longer term cocaine abstinence and assess whether increasing early abstinence increases longer term abstinence. Results from 190 cocaine-dependent outpatients were analyzed. Participants were divided into 2 conditions: (a) those treated with community reinforcement approach (CRA) plus contingent vouchers (n?=?125) and (b) those treated with control treatments (n?=?65). A period of sustained abstinence during treatment was associated with significantly greater odds of posttreatment abstinence, with no evidence of differences between the 2 treatment conditions in that regard. Treatment conditions differed in that CRA plus contingent vouchers increased the proportion of participants who sustained a period of during-treatment abstinence and increased abstinence during 6-month posttreatment follow-up. Devising interventions that increase the proportion of individuals who achieve an early period of sustained abstinence may be key to increasing longer term cocaine abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Transitions During Effective Treatment for Cocaine-Abusing Homeless Persons: Establishing Abstinence, Lapse, and Relapse, and Reestablishing Abstinence.

Data are reported on drug use among cocaine-dependent homeless persons who participated in a clinical trial that compared day treatment only (DT, n = 69) with day treatment plus abstinent-contingent housing and work (DT+, n = 72). Drug use was measured with multiple weekly urine toxicologies. Compared with DT participants, more DT+ participants established abstinence, maintained abstinence for longer durations, were marginally significantly more likely to lapse, and significantly less likely to relapse. Of all participants who established abstinence and then relapsed, DT+ participants relapsed later and were more likely to reestablish abstinence. These analyses yield information on the processes involved in the manner in which drug use changes as a result of abstinent-contingent housing and work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Meta-analysis of day treatment and contingency-management dismantling research: Birmingham Homeless Cocaine Studies (1990-2006).

Four successive randomized clinical trials studying contingency management (CM), involving various treatment arms of drug-abstinent housing and work therapy and day treatment (DT) with a behavioral component, were compared on common drug abstinence outcomes at 2 treatment completion points (2 and 6 months). The clinical trials were conducted from 1990 to 2006 in Birmingham, Alabama, with a total of 644 homeless persons with primary crack cocaine addiction. The meta-analysis utilized the weighted least squares approach to integrate data encompassing 9 different treatment arms to assess the effects of CM and DT (neither, DT only, CM only, and CM = DT) on a common estimate of prevalence of drug abstinence. Taken together, the results show much stronger benefits from CM = DT and from CM only than for DT alone. Throughout all of the Birmingham Homeless Cocaine Studies, the CM = DT consistently produced higher abstinence prevalence than did no CM. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reaction time during cocaine versus alcohol withdrawal: longitudinal measures of visual and auditory suppression

Visual and auditory stimulus discrimination tasks, analogous to those used in the Reitan-Klove Sensory Perceptual Examination, were performed by 12 cocaine-dependent and 5 alcohol-dependent patients after 1 week, 3 weeks, and 3 months of verified abstinence. Sixteen control subjects, who were not substance-dependent, performed the same tasks after comparable intervals. During each task, either visual or auditory stimuli were presented in the left, in the right, or in both sensory fields. A simple key press was made to discriminate these conditions. Cocaine-dependent patients responded more slowly than control subjects during both tasks. The reaction-time slowing persisted across all three sessions, spanning a 3-month period of abstinence. There were no significant differences between the cocaine-dependent and control groups in response accuracy. In the context of other findings, these findings are interpreted as reflecting an enduring effect of prior cocaine dependence on motor as opposed to sensory functioning.     

Outpatient behavioral treatment for cocaine dependence: One-year outcome.

This article describes outcomes observed during the year after treatment entry from two controlled trials in which cocaine-dependent outpatients were randomly assigned to either a multicomponent behavioral treatment or to one of two control treatments. The behavioral treatment integrated the community reinforcement approach (CRA) with an incentive program in which cocaine abstinence was reinforced with vouchers exchangeable for retail items. The two control treatments were drug abuse counseling and CRA without the incentive program. All treatment groups improved significantly compared to intake, and those changes were maintained through the follow-up period. When efficacy differences were observed during treatment and follow-up, they supported CRA with vouchers over control treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An Experimental Examination of the Initial Weeks of Abstinence in Cigarette Smokers.

Gaining experimental control over abstinence may help define processes that change during abstinence that may be related to the association between initial abstinence and relapse risk often noted in clinical trials. Adult smokers (n = 34) were randomly assigned to receive monetary incentives contingent on abstinence (CO ± 4 ppm) or noncontingent for 12 days. Carbon monoxide (CO) tests were conducted 3 times per day, saliva samples were collected on Days 5 and 12, and all other measures were collected 1 time per day. In the contingent group, 59% of participants abstained throughout the study versus 0% in the control condition. Abstinence was associated with increases in participant-rated ease of abstaining and confidence in abstinence; nicotine withdrawal severity and craving decreased over time. Results indicate that it is feasible to experimentally manipulate smoking abstinence and that doing so can enhance understanding of the relationship between early abstinence and relapse risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up.

This study assessed whether contingent incentives can be used to reinforce cocaine abstinence in dependent outpatients. Seventy cocaine-dependent outpatients were randomized into 2 conditions. All participants received 24 weeks of treatment and 1 year of follow-up. The treatment provided to all participants combined counseling based on the community reinforcement approach with incentives in the form of vouchers exchangeable for retail items. In 1 condition, incentives were delivered contingent on cocaine-free urinalysis results, whereas in the other condition incentives were delivered independent of urinalysis results. Abstinence-contingent incentives significantly increased cocaine abstinence during treatment and 1 year of follow-up compared with noncontingent incentives. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of personalized written feedback through a mail intervention for smoking cessation: A randomized-controlled trial in Spanish smokers.

This study evaluated the effects of written feedback adapted to a self-help mail intervention. The efficacy of the standard mail intervention treatment was 37% at the end of treatment, 22% at the 3-month follow-up, 19% at the 6-month follow-up, and 13% at the 12-month follow-up. In contrast, the standard mail program combined with personalized written feedback resulted in an efficacy of 51% at the end of treatment, 37% at the 3-month follow-up, 32% at the 6-month follow-up, and 27% at the 12-month follow-up. Both groups were significantly different from the control group at the end of treatment (0%), at the 3-month follow-up (1%), and at the 6-month follow-up (1%). There was a significant reduction in the number of cigarettes smoked daily among continuing smokers under both experimental conditions. The authors conclude that written feedback substantially increases abstinence rates when it is applied following similar guidelines to those used in clinical settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnostic compared with abstinence outcomes of day treatment and contingency management among cocaine-dependent homeless persons.

Substance use disorder diagnoses were used as a treatment outcome measure in a randomized comparison of day treatment (DT) and day treatment plus contingency management (DT+) among homeless persons with primarily crack/cocaine disorders. Participants (N = 127, DT+ = 69, DT = 58, 73.2% male, 82.7% African American) were assessed at baseline and 6-month treatment completion. Binary positive and negative diagnostic outcomes for cocaine, marijuana, and alcohol were compared by treatment group. DT+ was 2.1 times more likely to have a positive treatment outcome than DT. Concordance between diagnostic change and point and continuous abstinence outcomes were found. The use of diagnostic change can be a practical addition to drug toxicology and self-report treatment outcome measures for research and practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of depression diagnoses to 2-year outcomes in cocaine-dependent patients in a randomized continuing care study.

This study examined the relation between depression diagnoses and outcomes in 132 cocaine-dependent patients who were randomized to relapse prevention (RP) or standard 12-step focused group continuing rare and followed for 2 years. Depressed patients attended more treatment sessions and had more cocaine-free urines during treatment than participants without depression, but they drank alcohol more frequently before treatment and during the 18-month posttreatment follow-up. Cocaine outcomes in depressed patients deteriorated to a greater degree after treatment than did cocaine outcomes in patients without depression, particularly in patients in RP who had a current depressive disorder at baseline. The best alcohol outcomes were obtained in nondepressed patients who received RIP. The results suggest that extended continuing care treatment may be warranted for cocaine-dependent patients with co-occurring depressive disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients.

Contingency management (CM) interventions frequently utilize vouchers as reinforcers, but a prize-based system is also efficacious. This study compared these approaches. Seventy-four cocaine-dependent methadone outpatients were randomly assigned to standard treatment (ST), ST plus a maximum of $585 in contingent vouchers, or ST plus an expected average maximum of $300 in contingent prizes for 12 weeks. CM participants achieved longer durations of abstinence (LDA) than ST participants, and CM conditions did not differ significantly in outcomes or amount of reinforcement earned. Although long-term abstinence did not differ by group, LDA during treatment was the best predictor of abstinence at 9 months. Thus, reinforcement with prizes was similar to voucher CM in promoting LDA, which is associated with posttreatment benefits. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison between low-magnitude voucher and buprenorphine medication contingencies in promoting abstinence from opioids and cocaine.

This study compared the relative efficacy of low-magnitude, contingent monetary vouchers, contingent buprenorphine medication, and standard counseling in promoting abstinence from illicit opioids and cocaine among opioid-dependent adults. Following an 8-week baseline period during which participants received buprenorphine maintenance treatment with no contingencies in place, 60 participants were randomly assigned to one of 3 treatment groups for 12 weeks: (a) Participants in the voucher group earned vouchers for each opioid- and cocaine-negative urine sample, in accordance with an escalating schedule. Continuous abstinence resulted in voucher earnings equivalent to a total of $269, which participants could exchange for material reinforcers of their choice. (b) Participants in the medication contingency group received half their scheduled buprenorphine dose for clinic attendance and the other half for remaining abstinent from opiates and cocaine. Thus, they received only half of their scheduled dose on submission of an opioid- and/or cocaine-positive urine sample. (c) Participants in standard treatment did not receive programmed consequences contingent on urinalysis results. All participants were maintained with buprenorphine according to a 3-times-per-week dosing regimen and participated in behavioral drug counseling. Retention rate did not significantly differ across the groups; however, participants in the medication contingency group achieved significantly more weeks of continuous abstinence from opiates and cocaine compared with participants in the voucher group (Ms = 5.95 and 2.90, respectively). Results suggest that the use of medication-based contingencies in combination with behavioral therapy in promoting drug abstinence may have clinical utility. Limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nicotine withdrawal in smokers with current depressive disorders undergoing intensive smoking cessation treatment.

The authors investigated withdrawal in smokers with current threshold and subthreshold depressive disorders (N = 21) who were participating in a pilot study of intensive counseling interventions for smoking cessation. The majority of participants (67%) were taking antidepressants when they entered the trial. Withdrawal symptoms were compared in prolonged abstainers versus nonabstainers across a 12-week treatment period and at the 3-month follow-up assessment visit. Prolonged abstinence was associated with an increase in positive affect and a decrease in depressive symptoms and craving over time. Nonabstinence was associated with little overall change in these variables from treatment onset to the 3-month follow-up. At the 3-month follow-up, 44% of prolonged abstainers were in complete remission of their baseline depressive disorders, compared with 0% remission among nonabstainers. Findings suggest that within the context of an intensive smoking cessation intervention, some smokers with current depressive disorders may experience significant improvement in affective and craving symptoms. Findings also suggest that abstinence may be associated with improvement in affect. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management in cocaine abusers: A dose-effect comparison of goods-based versus cash-based incentives.

Goods-based contingency management interventions (e.g., those using vouchers or prizes as incentives) have demonstrated efficacy in reducing cocaine use, but cost has limited dissemination to community clinics. Recent research suggests that development of a cash-based contingency management approach may improve treatment outcomes while reducing operational costs of the intervention. However, the clinical safety of providing cash-based incentives to substance abusers has been a concern. The present 16-week study compared the effects of goods-based versus cash-based incentives worth $0, $25, $50, and $100 on short-term cocaine abstinence in a small sample of cocaine-dependent methadone patients (N = 12). A within-subject design was used; a 9-day washout period separated each of 8 incentive conditions. Higher magnitude ($50 and $100) cash-based incentives (checks) produced greater cocaine abstinence compared with the control ($0) condition, but a magnitude effect was not seen for goods-based incentives (vouchers). A trend was observed for greater rates of abstinence in the cash-based versus goods-based incentives at the $50 and $100 magnitudes. Receipt of $100 checks did not increase subsequent rates of cocaine use above those seen in control conditions. The efficacy and safety data provided in this and other recent studies suggest that use of cash-based incentives deserves consideration for clinical applications of contingency management, but additional confirmation in research using larger samples and more prolonged periods of incentive delivery is needed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abstinence Self-Efficacy and Abstinence 1 Year After Substance Use Disorder Treatment.

To better understand the relationship between abstinence self-efficacy and treatment outcomes in substance use disorder patients, experts in the field need more information about the levels of abstinence self-efficacy most predictive of treatment outcomes. Participants (N = 2,967) from 15 residential substance use disorder treatment programs were assessed at treatment entry, discharge, and 1-year follow-up. A signal detection analysis compared the ability of different measures of self-efficacy to predict 1-year abstinence and identified the optimal cutoffs for significant predictors. The maximal level of abstinence self-efficacy (i.e., 100% confident) measured at discharge was the strongest predictor of 1-year abstinence. Treatment providers should focus on obtaining high levels of abstinence self-efficacy during treatment with the goal of achieving 100% confidence in abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Completion and subject loss within an intensive hepatitis vaccination intervention among homeless adults: The role of risk factors, demographics, and psychosocial variables.

Objective: Unprotected sexual behavior, needle sharing, and a prison history are major correlates of hepatitis B Virus (HBV). These risk factors are common among homeless people who also have elevated rates of HBV. We examine whether these behaviors were associated with completion or loss to follow-up of the most intensive and successful condition of a 3-arm HBV vaccination intervention. Significant results would imply that those most in need are the least compliant. Contributions of baseline demographics, physical health, psychosocial variables, and health beliefs were also assessed. Design: Three-hundred thirty- one adults from Los Angeles' Skid Row were assigned to nurse-case-managed sessions with hepatitis education, incentives, and tracking. Successive predictive structural equation models assessed the amount of variance accounted for by the risk variables, demographics, and the health-related variables. Main Outcome Measures: (1) Completion of 3 injections by 6 months; and (2) loss to a 6-month follow-up questionnaire. Results: The 3 risk factors explained 2% of the variance in completion and 1% of the variance in loss. Adding the other variables increased the variance explained to 14% for completion and 13% for loss. African American ethnicity, positive coping, social support, poorer health, no prison history, and greater efficacy significantly predicted completion. White ethnicity, less social support, better health, and less intention to complete predicted participant loss. Conclusion: The program was not strongly rejected differentially as a function of preexisting hepatitis B risk behaviors. Programs designed for homeless people should include malleable psychosocial and health belief model variables. These aspects of the lives of homeless people provide leverage points for future interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparable efficacy of contingency management for cocaine dependence among African American, Hispanic, and White methadone maintenance clients.

Cocaine use is a significant problem among methadone maintenance clients. Contingency management (CM) is a reinforcement-based approach with demonstrated efficacy for reducing cocaine use. This study examines whether the efficacy of CM treatment for cocaine-dependent individuals receiving methadone maintenance for opioid dependence differs by ethnicity. Participants were 191 African American, Hispanic, and White cocaine-dependent methadone maintenance clients, randomly assigned to standard methadone treatment or standard methadone treatment plus CM for 12 weeks. Hispanic participants were younger, less educated, and reported fewer years of cocaine use than did African American and White participants and reported fewer years of heroin use than did African American participants. African American participants were less likely to report a history of psychiatric symptoms or treatment in comparison with Hispanic and White participants. While CM was associated with longer duration of continuous cocaine abstinence and a greater proportion of submitted urine samples negative for cocaine, ethnicity was not related to treatment outcomes, and there was no significant interaction between treatment and ethnicity. CM appears to be an efficacious treatment for cocaine dependence among methadone maintenance clients, regardless of ethnicity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)