EVALUATION OF TREATMENTS OF OPIOID AND COCAINE DEPENDENCE

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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.