EVALUATION OF TREATMENTS OF OPIOID AND COCAINE DEPENDENCE

该科继续调查药物滥用的药理和行为治疗方法，并探索治疗方法的组合。NIDA/IRP治疗研究已经证明了行为干预(加强可卡因阴性尿样)在市中心静脉注射多药滥用者大样本中的有效性，并已开始评估应用这种治疗的最佳方式。旨在提高可卡因依赖患者戒毒率的承诺干预努力侧重于通过单独或与社区强化咨询程序相结合的基于凭单的应急管理来重新安排吸毒者的环境。第二种有希望的方法是通过认知行为疗法(CBT)来提高应对技能的质量和数量，以解决可卡因依赖者对内部和外部刺激的不良适应反应。可卡因滥用应急管理的好处是迅速的，但可能是暂时的，而CBT的好处可能在治疗后6至12个月才显现。我们假设，将一种主要旨在启动行为变化(应急管理)的方法与另一种专注于促进维持(CBT)的方法相结合，将产生比单独应用这两种方法时更长的可卡因戒断和艾滋病毒保护行为的持续时间。接受美沙酮治疗的门诊患者被随机分配到团体治疗条件(CBT与社会支持治疗，其中咨询师不教授应对技能)和代金券条件(根据可卡因阴性尿液的代金券与非或有代金券进行应急管理)。干预持续12周，随访1年。这项研究已经完成，但后续工作仍在进行中。在收到应急代金券的两组人中，可卡因的使用量大幅减少。CBT并没有减少可卡因的使用。干预后，同时收到CBT代金券和应急代金券的参与者似乎受到保护，不会在紧急情况下恢复使用可卡因。这在治疗后的前12周内没有达到统计学意义，这与早期的发现一致。最后一次为期12个月的治疗后随访将于明年完成，届时我们将分析随访数据，以检验治疗后出现的预测效果。爱泼斯坦，霍金，W，Umbricht A，Preston KL.药物依赖问题学院年度科学会议，2000年6月，波多黎各圣胡安)。我们目前正在进行一项研究，以解决一个假想的美沙酮维持诊所如何最好地分配其资源(药理学和非药理学)来减少海洛因和可卡因滥用的问题，如果该诊所要实施基于凭证的应急管理的话。通过将一项主要旨在通过行为强化(应急管理)减少可卡因使用的干预措施与另一项侧重于通过药物治疗(大剂量美沙酮维持)减少非法阿片类药物使用的干预措施相结合，我们假设，与单独应用这两种方法时相比，我们将看到更大的可卡因和非法阿片类药物戒断。

The section continues to investigate pharmacological and behavioral treatments of substance abuse and to explore combinations of treatments. NIDA/IRP treatment studies have already demonstrated the effectiveness of behavioral interventions (reinforcement of cocaine-negative urine samples) in large inner-city samples of intravenous polydrug abusers and has begun to evaluate the best way to apply the treatment. Promising intervention efforts to increase abstinence in cocaine-dependent patients have focused on rearranging the drug user's environment through voucher-based contingency management alone or in combination with community reinforcement counseling procedures. A second promising approach is to improve the quality and quantity of coping skills through cognitive-behavior therapy (CBT) to address the maladaptive responses to internal and external stimuli so commonly found in cocaine-dependent patients. The benefits of contingency management for cocaine abuse are rapid but may be transient, whereas the benefits of CBT may only emerge 6 to 12 months after treatment. We hypothesized that combining an approach that is primarily aimed at initiating behavior change (contingency management) with another approach that is focused on promoting maintenance (CBT) would produce longer sustained durations of cocaine abstinence and HIV protective behavior than when such approaches are applied separately. Methadone-maintained outpatients were randomly assigned to a group therapy condition (CBT vs. a social-support therapy in which the counselor taught no coping skills) and a voucher condition (contingency management with vouchers contingent on cocaine-negative urines vs. noncontingent vouchers). The intervention lasted 12 weeks, with follow-up for one year. The study is completed, though follow-ups are ongoing. There was a substantial reduction in cocaine use in the two groups that received contingent vouchers. Cocaine use was not reduced by CBT. After the intervention, participants who had received both CBT and contingent vouchers seemed to be protected against post-contingency resumption of cocaine use. This did not reach statistical significance during the first 12 weeks after treatment, consistent with earlier findings. The last of the 12-month posttreatment follow-ups will be completed next year, at which point we will analyze the follow-up data to test for the predicted posttreatment emergence of effects. (Epstein DH, Hawkin, W, Umbricht A, Preston KL. Annual scientific meeting of the College on Problems of Drug Dependence, June, 2000, San Juan, Puerto Rico). We are currently conducting a study to address the question of how a hypothetical methadone-maintenance clinic could best allocate its resources (both pharmacological and nonpharmacological) to reduce both heroin and cocaine abuse, if the clinic were to institute voucher-based contingency management. By combining an intervention primarily aimed at decreasing cocaine use through behavioral reinforcement (contingency management) with another intervention focused on decreasing illicit-opiate use through pharmacological treatment (high-dose methadone maintenance), we hypothesize that we will see greater abstinence from cocaine and illicit opiates than has been seen when either approach was applied separately.