Treating Cocaine Abuse: A Behavioral Approach

描述(由申请人提供)：这是第一次修订申请，以继续研究CRA代金券治疗可卡因依赖。可卡因依赖是美国根深蒂固的公共卫生问题。虽然在开发治疗这种疾病的有效行为疗法方面取得了很好的进展，但仍有相当大的改进空间。一个有希望改进的领域是将治疗参数与患者特征相匹配，从而使病情较轻的患者不会接受更多的治疗，而病情较重的患者则不会接受比积极治疗结果所需的更少的治疗。针对可卡因依赖的治疗开发往往偏向于优化疗效，而没有适当注意限制成本或降低成本，而没有充分注意破坏疗效。将治疗剂量与适度治疗反应的特征相匹配，有可能在这两种偏见之间取得平衡。我们提出了两项配对研究。研究1将检查为期6周的或有凭证干预的效果，其中有没有与患者严重程度匹配的凭证价值。我们将使用婚姻状况(目前已婚与其他人)和可卡因给药途径(鼻腔与吸烟/静脉注射)来划分严重程度。这一严重程度措施缓和了对CRA凭证处理的凭证部分的反应。可卡因依赖门诊患者将被随机分配到CRA加三个6周凭单条件中的一个：非或有凭单，为所有患者设置为普通值的或有凭单，或为低严重性用户设置为普通值的或有凭单，为高严重性用户设置为两倍普通值的或有凭单。我们假设治疗条件和严重程度之间存在显著的交互作用，当凭单设置为普通值时，6周或有凭单条件的疗效取决于患者严重程度，而不是当值与患者严重程度匹配时。研究2将检验将6周的代金券与CRA相结合的效果，作为短暂干预(2周)、中等持续时间的干预(6周)或干预，其中持续时间与CRA治疗的两个调节因素相匹配，即婚姻状况(已婚与其他)和酒精依赖(有与不有)。我们假设治疗条件和严重程度之间存在显著的交互作用，在持续时间一致的情况下，CRA的疗效取决于婚姻状况和酒精依赖，但在CRA持续时间与患者特征匹配的情况下，CRA的疗效不依赖于婚姻状况和酒精依赖。我们还提出了两个次要目标，以(A)检查延迟折扣的行为经济学概念作为治疗反应的潜在调节因素所起的作用，以及(B)进一步了解患者用药严重程度如何减缓治疗反应。总体而言，拟议的研究有可能促进人们对如何在治疗可卡因依赖的过程中更好地将治疗参数与患者的严重程度相匹配的理解，目的是在不影响向病情更严重的患者提供的护理质量的情况下，简化干预的成本。

DESCRIPTION (provided by applicant): This is the first revision of an application to continue researching the CRA + Vouchers treatment for cocaine dependence. Cocaine dependence is an entrenched U.S. public-health problem. While excellent progress has been made in developing efficacious behavioral therapies for this disorder, there is considerable room for improvement. One promising area for improvement is in matching treatment parameters to patient characteristics so that lower-severity patients not receive more treatment or higher-severity patients less treatment than necessary for a positive treatment outcome. Treatment development for cocaine dependence is often biased towards optimizing efficacy without appropriate attention to constraining costs or reducing costs without sufficient attention to undermining efficacy. Matching the dose of treatment to characteristics that moderate treatment response has the potential to strike a balance between those two biases. We are proposing two matching studies. Study 1 will examine the efficacy of a 6-week contingent voucher intervention with and without voucher values matched to patient severity. We will use marital status (currently married vs. other) and route of cocaine administration (intranasal vs. smoked/intravenous) to classify severity. This severity measure moderates response to the voucher component of the CRA + Vouchers treatment. Cocaine-dependent outpatients will be randomly assigned to CRA plus one of three 6-week voucher conditions: non-contingent vouchers, contingent vouchers set at usual values for all patients, or contingent vouchers set at usual values for low-severity and twice-usual value for high-severity users. We hypothesize a significant interaction between treatment condition and severity, with the efficacy of the 6-week contingent voucher condition being dependent on patient severity when vouchers are set at the usual values, but not when values are matched to patient severity. Study 2 will examine the efficacy of combining 6 weeks of vouchers with CRA delivered as a brief intervention (2 weeks), a moderate-duration intervention (6 weeks), or an intervention wherein duration is matched to two moderators of response to CRA therapy, marital status (currently married vs. other) and alcohol dependence (with vs. without). We hypothesize a significant interaction between treatment condition and severity, with the efficacy of CRA being dependent on marital status and alcohol dependence in the uniform-duration conditions, but not in the condition where CRA duration is matched to patient characteristics. We also are proposing two secondary aims to (a) examine the role played by the behavioral-economic concept of delayed discounting as a potential moderator of treatment response and (b) further understanding of how patient drug-use severity moderates treatment response. Overall, the proposed studies have the potential to advance understanding of how to better match treatment parameters to patient severity in the treatment of cocaine dependence with the goal of streamlining the costs of the interventions without compromising the quality of care offered to more severe patients.