Evaluation Of Treatments Of Opioid And Cocaine Dependence

治疗科参与了一个长期项目，通过行为、药理学或行为和药理学联合干预改善药物依赖的治疗。 在确定提供应急管理的最有效方法方面已经做出了大量努力，这是一种行为治疗，利用激励来增加理想行为的频率，如戒毒或坚持用药。与应急管理相关的一个主要挑战是其可能令人望而却步的成本和人员/资源强度，特别是当增援遵循不断升级的时间表时(即，当预期行为的每一次连续发生的增援强度超过预期行为的增援强度时)，特别是有效的治疗。社区诊所的主要实施挑战之一是跟踪每个患者的先前收入，以便可以当场计算当前收入。为了应对这一挑战和相关挑战，我们与NIDA IRP的生物医学信息科合作，开发了一个软件应用程序--自动应急管理(ACM)决策支持系统，用于加强戒毒。我们正在继续改进这一系统，并制定机制，使其免费提供给社区治疗方案。我们正在完成一个项目，实地测试当前版本的软件--激励激励实施软件(MIIS)的可用性和健壮性，该软件在模拟社区治疗计划的条件下实施，几乎没有技术基础设施或工作人员的专业知识。该系统将被分发给社区治疗项目，以促进技术转让，并增加社区对成瘾循证治疗的使用。 在进一步的技术开发工作中，我们正在探索在患者的日常环境中使用手持电子设备进行治疗。我们已经完成了一项试点研究，使用这些设备来提醒患者完成咨询师布置的家庭作业，这是认知行为疗法(CBT)的一部分。采用2×2随机区组设计的受试者内交叉研究方法，探讨家庭作业难度和电子日记提醒对CBT中美沙酮依赖的可卡因和海洛因使用者完成家庭作业的依从性和质量的影响。参与者除了在每周12次治疗期间完成一项家庭作业任务外，还携带了一台个人数字助理(PDA)，它被编程为在研究的隔周提供关于家庭作业完成的每日提醒。作业以两种不同的形式在3周内交替进行：标准的课文和简明的图文并茂的小册子。无论是简化作业还是掌上电脑提醒都不会显著提高作业完成率。对于家庭作业简化，有(不显著)有益于家庭作业完成的影响的趋势；然而，本研究实施的电子提示对家庭作业完成有(不显著)有害影响。在参与者的热情和理解方面，辅导人员对简化的家庭作业任务的评分更高，尽管出人意料的是，在参与者的理解程度方面，电子提示的家庭作业也得到了更高的评分。我们怀疑，对这一人群的移动干预可能需要超越提醒的哔哔声，并纳入互动元素；我们正在开始实施这一干预路线。 在相关工作中，我们正在开发地理瞬时评估，这是一种描述性方法，可以更好地测量和理解情绪、药物使用和环境暴露于心理社会应激源之间的关系。我们仍然致力于将描述转化为干预。例如，我们已经证明，电子日记研究可以提供惊人的洞察力，了解药物滥用者在治疗期间的日常生活，以及在即使是短暂的戒毒期内对行为变化敏感的数据。使我们能够收集关于现场药物使用、渴求和压力的数据的技术也可以用于现场治疗，也许是为了回应患者自己的自我报告行为或先前确定的诱因。 治疗科继续调查可能有助于患者与治疗配对的预测因素，以改进向个别患者提供适当治疗的情况。我们最近对丁丙诺啡同时治疗可卡因和阿片依赖的门诊临床试验之一的数据进行了二次分析(13周，N=200)。我们评估了吸烟(终生吸烟状态，进入研究前每天吸烟的数量)和短期治疗结果(尿样可卡因或阿片类药物阳性的百分比，治疗保留时间)之间的关系。尼古丁依赖吸烟者(66%的参与者)的可卡因阳性尿样百分比显著高于非吸烟者(12%的参与者)(76%对62%)，但在阿片类药物阳性尿样百分比或治疗滞留方面没有差异。即使在控制了基线的社会人口学和药物使用特征之后，基线每天吸烟的数量也与可卡因阳性尿样的百分比呈正相关，但与阿片类药物阳性尿样的百分比或治疗保留时间没有明显的相关性。这些结果表明，吸烟与可卡因依赖门诊治疗的短期效果较差有关，但可能与并发阿片类药物依赖无关，并支持向可卡因依赖患者提供戒烟治疗的重要性。

The Treatment Section has been engaged in a long-term project to improve treatment for substance dependence through behavioral, pharmacologic, or combined behavioral and pharmacologic interventions. Substantial effort has been directed toward identifying the most effective ways to deliver contingency management, a behavioral treatment in which incentives are used to increase the frequency of desirable behaviors, such as drug abstinence or medication adherence. A major challenge associated with contingency management is its likely prohibitive cost and staff/resource intensity, especially when the reinforcement follows an escalating schedule (i.e., when each consecutive occurrence of the desired behavior is reinforced more than the lastan especially effective treatment). One of the major implementation challenges for community clinics is keeping track of each patients prior earnings so that current earnings can be calculated on the spot. To address this and related challenges, in collaboration with the Biomedical Informatics Section of the NIDA IRP, we developed a software application, the Automated Contingency Management (ACM) decision support system for abstinence reinforcement. We are continuing to improve the system and to develop mechanisms to make it available to community treatment programs at no cost to them. We are completing a project field-testing the usability and robustness of the current version of the software, Motivational Incentives Implementation Software (MIIS), implemented under conditions simulating those of a community treatment program little technology infrastructure or staff expertise. This system will be distributed to community treatment programs to promote technology transfer and increase community use of evidence-based treatments for addiction. In further technology-development work, we are exploring the use of handheld electronic devices for treatment delivery in patients daily environments. We have completed a pilot study using these devices to remind patients to complete homework assigned by counselors as part of Cognitive-Behavioral Therapy (CBT). We conducted a within-subjects 2x2 randomized-block-design crossover study to investigate the effects of homework-task difficulty and electronic-diary reminders on compliance to and quality of homework completion among methadone-maintained cocaine and heroin users in CBT. Participants, in addition to completing a homework task between each of 12 weekly therapy sessions, carried a personal digital assistant (PDA), which was programmed to provide a daily reminder regarding homework completion during alternate weeks of the study. Homework was given in two different forms during alternating 3-week blocks: standard sheets of text versus simplified, illustrated booklets. Neither the simplified homework nor the PDA reminders significantly increased homework completion rates. For homework simplification, there were (non-significant) trends toward beneficial effects on homework completion; however, electronic prompting as implemented in this study had (non-significant) deleterious effects on homework completion. There were trends for the simplified homework tasks to be rated higher by counselors in terms of participants enthusiasm and understanding, although, unexpectedly, electronically prompted homework was also rated higher in terms of participants understanding. We suspect that a mobile intervention for this population may need to go beyond a reminder beep and incorporate interactive elements; we are beginning to pursue this line of intervention. In related work, we are developing Geographical Momentary Assessment, a descriptive approach to better measure and understand the relationships among mood, drug use, and environmental exposure to psychosocial stressors. We remain committed to transforming description into intervention. For example, we have shown that electronic-diary studies can provide amazing insight into the daily lives of substance abusers during treatment and data that are sensitive to behavioral changes during even brief periods of abstinence. The technologies that enable us to collect data on drug use, craving, and stress in the field may also be used for delivery of treatment in the field, perhaps in response to the patients own self-reported behaviors or previously identified triggers. The Treatment Section continues to investigate predictors that might be useful for patient-treatment matching to improve the delivery of appropriate treatments to individual patients. We recently undertook a secondary analysis of data from one of our outpatient clinical trials of buprenorphine treatment for concurrent cocaine and opioid dependence (13 weeks, N = 200). We evaluated the association between cigarette smoking (lifetime cigarette smoking status, number of cigarettes smoked per day prior to study entry) and short-term treatment outcome (% of urine samples positive for cocaine or opioids, treatment retention). Nicotine-dependent smokers (66% of participants) had a significantly higher percentage of cocaine-positive urine samples than non-smokers (12% of participants) (76% vs. 62%), but did not differ in percentage of opioid-positive urine samples or treatment retention. Number of cigarettes smoked per day at baseline was positively associated with percentage of cocaine-positive urine samples, even after controlling for baseline sociodemographic and drug-use characteristics, but was not significantly associated with percentage of opioid-positive urine samples or treatment retention. These results suggest that cigarette smoking is associated with poorer short-term outcome in outpatient treatment for cocaine dependence, but perhaps not for concurrent opioid dependence, and support the importance of offering smoking-cessation treatment to cocaine-dependent patients.