Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12-month follow-up.

Contingency management (CM) rapidly reduces cocaine use, but its effects subside after treatment. Cognitive-behavioral therapy (CBT) produces reductions months after treatment. Combined, the 2 might be complementary. One hundred ninety-three cocaine-using methadone-maintained outpatients were randomly assigned to 12 weeks of group therapy (CBT or a control condition) and voucher availability (CM contingent on cocaine-negative urine or noncontingent). Follow-ups occurred 3, 6, and 12 months posttreatment. Primary outcome was cocaine-negative urine (urinalysis 3 times/week during treatment and once at each follow-up). During treatment, initial effects of CM were dampened by CBT. Posttreatment, there were signs of additive benefits, significant in 3- versus 12-month contrasts. Former CBT participants were also more likely to acknowledge cocaine use and its effects and to report employment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Concurrent alcohol dependence among methadone-maintained cocaine abusers is associated with greater abstinence.

Concurrent alcohol dependence (AD) among polysubstance abusers has been associated with negative consequences, although it may not necessarily lead to poor treatment outcomes. One of the most efficacious treatments for cocaine abuse is contingency management (CM), but little research has explored the impact of AD on abstinence outcomes, particularly among patients in methadone maintenance. Using data from three trials of CM for cocaine use, we compared baseline characteristics and posttreatment and follow-up cocaine outcomes between methadone-maintained, cocaine-dependent patients (N = 193) with and without concurrent AD, randomized to standard care (SC) with or without CM. Patients with and without concurrent AD had similar baseline characteristics, with the exception that AD patients reported more alcohol use. AD patients achieved longer durations of cocaine abstinence and were more likely to submit a cocaine-negative sample at follow-up than non-AD patients. Patients randomized to CM achieved better outcomes than those randomized to SC, but there was no interaction between treatment condition and AD status. These findings suggest that cocaine-using methadone patients with AD achieve greater cocaine abstinence than their non-AD counterparts and should not necessarily be viewed as more difficult to treat. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Contingency management is efficacious for cocaine abusers with prior treatment attempts.

Efforts are underway to detect subgroups who may be more or less responsive to contingency management (CM) substance abuse treatments. This study examined the impact of prior treatment attempts on primary and posttreatment outcomes in a combined sample of cocaine abusers randomized to standard care substance abuse outpatient treatment (SC) or SC plus CM. Participants (N = 393) were categorized according to self-reported prior treatment attempts (0-1, ≥2). Participants with multiple prior treatment attempts were older, had more severe alcohol and cocaine use disorders, and had greater employment-related problems. Participants with 0?1 prior treatment attempts had comparable treatment retention, regardless of treatment condition; however, among participants with multiple prior treatment attempts, retention was greater for CM than SC. A similar, but nonsignificant (p = .08) pattern was evident for longest duration of abstinence (LDA). LDA was a significant predictor of negative (for cocaine, alcohol, and opiates) specimen results at Month 9. The results provide support for CM as an advantageous option for individuals with multiple prior treatment attempts, as well as for substance abuse treatment patients in general. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence.

Marijuana-dependent young adults (N = 136), all referred by the criminal justice system, were randomized to 1 of 4 treatment conditions: a motivational/skills-building intervention (motivational enhancement therapy/cognitive-behavioral therapy; MET/CBT) plus incentives contingent on session attendance or submission of marijuana-free urine specimens (contingency management; CM), MET/CBT without CM, individual drug counseling (DC) plus CM, and DC without CM. There was a significant main effect of CM on treatment retention and marijuana-free urine specimens. Moreover, the combination of MET/CBT plus CM was significantly more effective than MET/CBT without CM or DC plus CM, which were in turn more effective than DC without CM for treatment attendance and percentage of marijuana-free urine specimens. Participants assigned to MET/CBT continued to reduce the frequency of their marijuana use through a 6-month follow-up. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management for cocaine use in methadone maintenance patients: When does abstinence happen?

Contingency management (CM) is an efficacious intervention for cocaine abusing methadone patients, but typically only about half of patients respond. By investigating time to onset of cocaine abstinence and factors associated with abstinence, we may be able to more efficiently direct CM approaches to patients most likely to benefit. Onset of cocaine abstinence was evaluated in cocaine abusing methadone maintenance patients (N = 193) enrolled in one of three randomized clinical trials of CM. Participants received standard treatment with frequent urine toxicology monitoring or standard treatment plus CM during the trials. Slightly more than half the sample obtained at least 1 week of cocaine abstinence, and approximately a third of the sample obtained at least 4 weeks of cocaine abstinence. Discrete-time survival and hazard analyses found Weeks 1 and 2 of the intervention period had the greatest probability for the initiation of abstinence, and few participants initiated any period of abstinence after Week 4. Patients randomized to CM, those with more years of cocaine use, and those with less recent cocaine use were more likely to achieve abstinence. Overall, these results indicate onset of cocaine abstinence is likely to occur early in treatment and in individuals with less severe cocaine use. Practical implications of these results for designing and implementing CM interventions in methadone maintenance clinics are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cocaine abusers with and without alcohol dependence respond equally well to contingency management treatments.

Contingency management (CM) treatments are efficacious in treating cocaine abuse. Despite high prevalence rates of alcohol dependence (AD) among individuals with cocaine use disorders, relatively little data are available regarding whether comorbid AD is associated with poorer treatment outcomes in general, or in response to CM in particular. Using data from 3 randomized trials of CM for cocaine abuse, we compared cocaine abusers (N = 393) with and without AD in terms of abstinence and psychosocial problems during treatment and follow-up. Alcohol dependent participants had more lifetime years of cocaine and alcohol use and greater severity of alcohol and psychiatric problems. CM was positively and significantly associated with longer durations of abstinence, regardless of AD status. Although not significantly associated with abstinence, the presence of AD was related to improvement in medical and alcohol-related problems during treatment, and these gains were maintained posttreatment. The results suggest that cocaine abusers benefit equally well from CM treatments, regardless of AD status. Further, alcohol dependent participants are able to offset greater baseline severity in psychosocial functioning and maintain these improvements with CM. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized trial of continuing care enhancements for cocaine-dependent patients following initial engagement.

Objective: The effects of cognitive–behavioral relapse prevention (RP), contingency management (CM), and their combination (CM + RP) were evaluated in a randomized trial with 100 cocaine-dependent patients (58% female, 89% African American) who were engaged in treatment for at least 2 weeks and had an average of 44 days of abstinence at baseline. Method: The participants were from intensive outpatient programs, which provide 10 hr per week of group counseling. The CM protocol provided gift certificates (maximum value $1,150; mean received = $740) for cocaine-free urines over 12 weeks on an escalating reinforcement schedule, and weekly individual RP sessions were offered for up to 20 weeks. Average number of RP sessions attended was 3 in RP and 13 in CM + RP. Results: Generalizing estimation equation analyses over 18 months postrandomization showed significant effects for CM (but not RP) on urine toxicology and self-reported cocaine use (p = .05), with no significant CM × RP interactions. Secondary analyses indicated CM + RP produced better cocaine urine toxicology outcomes at 6 months than treatment as usual, odds ratio [OR] = 3.96 (1.33, 11.80), p p p p p = .06, and 9 months, OR = 2.93 (0.94, 9.10), p = .06. Differences between the conditions were not significant after 9 months. Conclusions: These results suggest CM can improve outcomes in cocaine-dependent patients in intensive outpatient programs who have achieved initial engagement, particularly when it is combined with RP. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients.

This study evaluated the efficacy of a low-cost contingency management (CM) procedure in reducing concurrent cocaine and opioid use among methadone patients. Forty-two patients were randomly assigned to 12 wks of standard treatment or standard treatment plus CM. CM patients earned the opportunity to draw from a bowl and win prizes ranging from $1 to $100 in value for submitting samples negative for cocaine and opioids. Patients in the CM condition achieved longer durations of continuous abstinence than patients in the standard treatment condition, and these effects were maintained throughout a 6-mo follow-up period. On average, patients in the CM condition earned $137 of prizes. These data suggest that this prize reinforcement procedure may be suitable for community-based settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management for smoking cessation in adolescent smokers.

This pilot study evaluated the use of contingency management (CM) procedures in combination with cognitive-behavioral therapy (CBT) for smoking cessation in adolescents. Twenty-eight treatment-seeking adolescent smokers participated in a 1-month, school-based smoking cessation program and were randomly assigned to receive either CM with weekly CBT or CBT alone. In the CM+CBT group, biochemical verification of abstinence was obtained twice daily during the first 2 weeks, followed by daily appointments during the 3rd week and once every other day during the 4th week. Participants were monetarily reinforced for abstinence on an escalating magnitude schedule with a reset contingency. At the end of 1 week and 1 month of treatment, abstinence verified using quantitative urine cotinine levels was higher in participants in the CM+CBT group (1 week: 76.7%; 1 month: 53.0%) when compared with the CBT-alone group (1 week: 7.2%; 4 weeks: 0%). These preliminary results provide a strong initial signal supporting the utility of CM techniques for smoking cessation in adolescents and demonstrate the feasibility of implementing such a program in a school setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting cocaine group treatment outcome in cocaine-abusing methadone patients.

The authors examined predictors of cocaine group treatment outcome in methadone maintenance treatment (MMT) patients, including cocaine urinalysis at intake and demographic variables. Clinic policy is that patients identified as using cocaine must attend a weekly cocaine-focused, cognitive–behavioral therapy (CBT) group. Cocaine treatment is based on a behavioral (escape) contingency model whereby completers must attend group-counseling sessions and produce cocaine-negative urinalysis results. Among the 113 patients enrolled in the cocaine group, 43 (38%) were treatment completers (who attended 6 consecutive weeks of group and produced 6 consecutive weeks of cocaine-free urine tests) and 70 (62%) were treatment noncompleters. Treatment completion (i.e., cocaine abstinence) was significantly associated with baseline cocaine-free urinalysis and higher methadone dose. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interaction effects of age and contingency management treatments in cocaine-dependent outpatients.

As the American population ages, older adults are accounting for a larger percentage of the drug-abusing population, but little attention has been given to this age group especially in regards to evaluating responsivity to different treatment modalities. Contingency management (CM) is a highly effective behavioral treatment that provides positive tangible reinforcers for objective evidence of behavior change. The purpose of this study was to examine main and interactive effects of age on outcomes in cocaine-dependent patients receiving CM with standard care (SC) or SC alone. Patients (N = 393) participating in 1 of 3 randomized trials of CM for cocaine dependence were divided into young, middle, and older age cohorts. Baseline characteristics and outcomes were compared across the age groups. The oldest age group had more medical problems than the youngest and middle age groups but had fewer legal difficulties and psychiatric symptoms. The oldest age group remained in treatment significantly longer than the other age groups, regardless of the type of treatment received. Although all age groups benefited from CM in terms of retention and longest duration of abstinence achieved, a significant age by treatment interaction effect emerged, with the older cohort improving relatively less from CM than the younger age groups. These findings demonstrate that age may play a role in moderating intervention outcomes, and tailoring CM to the needs of older and middle-aged substance abusers may be important for improving outcomes in this growing population. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Depression ratings, reported sexual risk behaviors, and methamphetamine use: Latent growth curve models of positive change among gay and bisexual men in an outpatient treatment program.

Although the cessation of substance use is the principal concern of drug treatment programs, many individuals in treatment experience co-occurring problems such as mood disruptions and sexual risk behaviors that may complicate their recovery process. This study assessed relationships among dynamic changes tracked over time in methamphetamine use, depression symptoms, and sexual risk behaviors (unprotected anal intercourse) in a sample of 145 methamphetamine-dependent gay and bisexual males enrolled in a 16-week outpatient drug treatment research program. Participants were randomly assigned into 1 of 4 conditions: contingency management (CM), cognitive behavioral therapy (CBT; the control condition), combined CM and CBT, and a tailored gay-specific version of the CBT condition. Using latent growth curve models, the authors assessed the relationship of means (intercepts) and the slopes of the 3 measures of interest over time to test whether changes in methamphetamine use predicted declining rates of depression and risky sexual behavior in tandem. Participants with the greatest downward trajectory in methamphetamine use (urine verified) reported the greatest and quickest decreases in reported depressive symptoms and sexual risk behaviors. The control group reported the most methamphetamine use over the 16 weeks; the tailored gay-specific group reported a more rapidly decreasing slope in methamphetamine use than the other participants. Findings indicate that lowering methamphetamine use itself has a concurrent and synergistic effect on depressive symptoms and risky sexual behavior patterns. This suggests that some users who respond well to treatment may show improvement in these co-occurring problems without a need for more intensive targeted interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prize Reinforcement Contingency Management for Cocaine Dependence: Integration With Group Therapy in a Methadone Clinic.

In this study, the authors evaluated a low-cost contingency management (CM) procedure for reducing cocaine use and enhancing group therapy attendance in 77 cocaine-dependent methadone patients. Patients were randomly assigned to 12 weeks of standard treatment or standard treatment with CM, in which patients earned the opportunity to win prizes ranging from $1 to $100 for submitting cocainenegative samples and attending therapy. Patients in the CM condition submitted more cocaine-negative samples and attended more groups than patients in standard treatment. The best predictor of cocaine abstinence at follow-up was duration of abstinence during treatment. On average, patients in the CM condition earned $117 in prizes. Data from this study suggest that some aspects of reinforcement can be implemented in group therapy in community-based clinics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management is especially efficacious in engendering long durations of abstinence in patients with sexual abuse histories.

Exposure to sexual victimization is prevalent among persons with substance use disorders (SUDs). Contingency management (CM) treatments utilize concrete and relatively immediate positive reinforcers to retain patients in treatment and reduce substance use, and CM may have particular benefits for patients with histories of sexual victimization. Using data from three randomized trials of CM (N = 393), this study evaluated main and interactive effects of sexual abuse history and treatment condition (standard care versus CM) with respect to during treatment outcomes (retention, proportion of negative urine samples submitted, and longest duration of abstinence) and abstinence at a nine-month follow-up. Compared to patients without sexual abuse histories (N = 316), those with sexual abuse histories (N = 77) submitted a significantly higher proportion of negative samples in treatment. In CM, but not in standard care, patients with sexual abuse histories achieved significantly longer durations of abstinence during treatment than those without sexual abuse histories. Although sexual abuse history was not associated with abstinence at nine-month follow-up evaluations, longest duration of abstinence during treatment was significantly associated with this long-term outcome. Results suggest that SUD patients with sexual abuse histories may accrue particular benefits during CM treatment that are associated with long-term abstinence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: main and matching effects

This study evaluated the efficacy of cognitive-behavioral therapy (CBT) and 12-step facilitation (12SF) in treating cocaine abuse. Participants (N = 128) were randomly assigned to treatment conditions and assessed at baseline and at Weeks 4, 8, 12, and 26. Treatment lasted for 12 weeks. It was hypothesized that participants treated with CBT would be significantly more likely to achieve abstinence from cocaine than participants treated with 12SF. A series of patient-treatment matching hypotheses was also proposed. Across 2 different outcome variables, it was found that participants in CBT were significantly more likely to achieve abstinence than participants in 12SF. In addition, some support for matching hypotheses was found, suggesting that both psychotherapies may be differentially effective for identified subgroups of persons that abuse cocaine.     

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)     

Contingency management improves abstinence and quality of life in cocaine abusers.

Contingency management (CM) treatments enhance drug abstinence. This study evaluated whether CM also improves quality of life and if these effects are mediated by abstinence. Across 3 independent trials, cocaine abusers in intensive outpatient treatment (n = 387) were randomly assigned to 12 weeks of standard treatment as usual or standard treatment with CM. The Quality Of Life Inventory (QOLI) was administered at baseline and at Months 1, 3, 6, and 9. Changes in QOLI scores over time differed significantly by treatment, with QOLI scores rising over time in CM participants and remaining stable in standard treatment participants. CM participants also achieved greater durations of abstinence, and duration of abstinence was correlated with posttreatment QOLI scores. During-treatment abstinence mediated the relationship between treatment condition and QOLI scores over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of homework in cognitive-behavioral therapy for cocaine dependence.

This study examines the effect of homework compliance on treatment outcome in 123 participants receiving cognitive-behavioral therapy (CBT) for cocaine dependence. Regression analyses revealed a significant relationship between homework compliance and cocaine use that was moderated by readiness to change. Homework compliance predicted less cocaine use during treatment but only for participants higher in readiness to change. For those lower in readiness to change, homework compliance was not associated with cocaine use during treatment. Homework compliance early in therapy was associated with better retention in treatment. Homework compliance was not predicted by participants' level of education or readiness to change. These findings support the use of homework during CBT for substance use disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive–behavioral therapy, behavioral weight loss, and sequential treatment for obese patients with binge-eating disorder: A randomized controlled trial.

Objective: Cognitive–behavioral therapy (CBT) is the best established treatment for binge-eating disorder (BED) but does not produce weight loss. The efficacy of behavioral weight loss (BWL) in obese patients with BED is uncertain. This study compared CBT, BWL, and a sequential approach in which CBT is delivered first, followed by BWL (CBT + BWL). Method: 125 obese patients with BED were randomly assigned to 1 of the 3 manualized treatments delivered in groups. Independent assessments were performed posttreatment and at 6- and 12-month follow-ups. Results: At 12-month follow-up, intent-to-treat binge-eating remission rates were 51% (CBT), 36% (BWL), and 40% (CBT + BWL), and mean percent BMI losses were ?0.9, ?2.1, and 1.5, respectively. Mixed-models analyses revealed that CBT produced significantly greater reductions in binge eating than BWL through 12-month follow-up and that BWL produced significantly greater percent BMI loss during treatment. The overall significant percent BMI loss in CBT + BWL was attributable to the significant effects during the BWL component. Binge-eating remission at major assessment points was associated significantly with greater percent BMI loss cross-sectionally and prospectively (i.e., at subsequent follow-ups). Conclusions: CBT was superior to BWL for producing reductions in binge eating through 12-month follow-up, while BWL produced statistically greater, albeit modest, weight losses during treatment. Results do not support the utility of the sequential approach of providing BWL following CBT. Remission from binge eating was associated with significantly greater percent BMI loss. Findings support BWL as an alternative treatment option to CBT for BED. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Evaluating alliance-focused intervention for potential treatment failures: A feasibility study and descriptive analysis.

This article describes a pilot study evaluating the feasibility of an approach developed to test the efficacy of a therapeutic intervention (brief relational therapy) for patients with whom it is difficult to establish a therapeutic alliance. In the first phase of the study, 60 patients were randomly assigned to either short-term dynamic therapy (STDP) or short-term cognitive therapy (CBT), and their progress in the first eight sessions of treatment was monitored. On the basis of a number of empirically derived criteria, 18 potential treatment failures were identified. In the second phase of the study, these identified patients were offered the option of being reassigned to another treatment. The 10 patients who agreed to switch treatments were reassigned either to the alliance-focused treatment, referred to as brief relational therapy (BRT), or a control condition. For patients coming from CBT, the control condition was STDP. For patients coming from STDP, the control condition was CBT. The results provide preliminary evidence supporting the potential value of BRT as an intervention that is useful in the context of alliance ruptures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)