IMPROVING COMBINED BUPRENORPHINE-BEHAVIORAL TREATMENT

社区强化方法配合应变管理是一种有效的药物滥用治疗方法。不幸的是，仅凭疗效不足以使一种治疗方法被治疗方案所采用。如果能够以成本较低的方式提供应急评估，则可能有助于采用附带应急管理的应急评估。本提案的目的是检查对应急管理的CRA进行的两项修改的有效性，这些修改降低了提供应急管理的成本。第一种方法将包括通过基于计算机的交互技术提供应急评估。这种技术可以减少咨询师的接触时间，从而降低治疗费用。第二种方法将通过使用一种激励系统来降低成本，该系统采用丁丙诺啡的特权，而不是基于货币的激励。我们建议在丁丙诺啡维持治疗阿片类药物依赖的背景下，研究这些降低成本的方法的有效性。虽然阿片类药物依赖经常被认为是城市地区的一个公共卫生问题，但很少被认为是农村地区的一个问题。然而，阿片类药物依赖在农村地区可能是一个严重的问题，特别是目前由于药物滥用者的高风险行为而造成艾滋病的威胁。该项目的目的是通过继续在佛蒙特州开设第一家也是唯一一家为阿片类药物依赖提供药物治疗的门诊诊所，解决这一严重的公共卫生问题。在治疗期间，患者将参加两项随机临床试验。在第一次试验中，患者将被随机分配接受三种治疗中的一种：(1)计算机提供的CRA与代金券激励系统（例如，根据药物戒断提供货币代金券），(2)治疗师提供的CRA与代金券激励系统，或(3)标准咨询。在第二种治疗中，患者将被随机分配接受三种治疗中的一种：(1)CRA与丁丙诺啡相关的应急管理（替代剂量方案和剂量调整），(2)CRA与代金券奖励计划，或(3)标准咨询。两项试验中的应急管理程序都将针对这一人群的阿片类药物和可卡因戒断。主要结果衡量标准将包括戒断、保留和成本效益。还将对艾滋病毒风险行为采取措施。总之，本研究将提供新的经验信息，通过确定应急管理处理降低CRA成本的两种方法的有效性。这些信息可能有助于采用这种有效的治疗方法。这项研究还将检验计算机化药物滥用治疗的效用。一些药物滥用治疗服务的计算机化是一种可能对药物滥用治疗服务的未来产生积极影响的新方法。最后，通过为佛蒙特州阿片类药物依赖提供唯一的门诊药物治疗服务，该项目将为该地区的公共卫生做出积极贡献。

The Community Reinforcement Approach (CRA) with contingency management is an efficacious drug abuse treatment. Unfortunately, efficacy alone is not sufficient for a treatment to be adopted by treatment programs. Adoption of CRA with contingency management may be facilitated if it could be delivered in ways that are less costly. The aim of this proposal is to examine the efficacy of two modifications to CRA with contingency management that make it less costly to provide. The first method will consist of delivering CRA via computer-based interactive technology. Such technology may render the treatment less costly by decreasing counselor contact time. The second method will reduce costs by using an incentive system that employs buprenorphine privileges contingent on drug abstinence as opposed to monetary-based incentives. We propose to examine the efficacy of these cost-reducing methods in the context of buprenorphine maintenance treatment of opioid dependence. While opioid dependence is frequently acknowledged as a public health problem of urban areas, it is less frequently acknowledged as an issue for rural areas. Opioid dependence, however, can be a serious problem in rural areas, especially with the current threat of AIDS due to high-risk behavior by substance abusers. The aims of this project are to address this serious public health concern by continuing the first and only outpatient clinic to provide pharmacotherapies for opioid dependence in the State of Vermont. While in treatment, patients will participate in two randomized clinical trials. In the first trial, patients will be randomly assigned to receive one of three treatments: (1) computer- delivery CRA with the voucher incentive system (e.g., provision of monetary vouchers contingent on drug abstinence), (2) therapist-delivered CRA with the voucher incentive systems, or (3) standard counseling. In the second treatment, patients will be randomly assigned to receive one of three treatments: (1) CRA with buprenorphine-related contingency management (alternative dose regimens and dose adjustment), (2) CRA with the voucher incentive program, or (3) standard counseling. Contingency management procedures in both trials will target both opioid and cocaine abstinence in this population. Primary outcome measures will include abstinence, retention and cost-effectiveness. Measures will also be taken of HIV-risk behavior. Overall, this research will contribute new empirical information by identifying the efficacy of two methods of reducing costs of CRA with contingency management treatment. Such information may contribute to the adoption of this efficacious treatment. This research will also examine the utility of computerizing substance abuse treatment. The computerization of some substance abuse treatment services is a novel approach that may positively impact the future of drug abuse treatment services. Finally, by providing the only outpatient pharmacotherapy services for opioid dependence in the State of Vermont, this project will contribute positively to this region's public health.