Project#2 Extending Treatment Effects Through an Adaptive Aftercare Intervention

摘要项目#2 强化干预措施对减少可卡因使用具有显著效果。在中心的支持下，我们 开发并评估了一种低成本的强化干预措施，系统地将其通过以下阶段： 发展到传播和广泛的临床实施。在我们正在进行的中心项目中， 如果在治疗开始时提供更长时间的减毒剂，干预措施就会产生效益。 然而，只有不到一半的患者在12周内仍然接受传统的强化干预， 这需要经常出席以监测和加强禁欲。干预措施延伸到 迫切需要康复后的护理，以及可接受和有效防止长期复发的护理。 强化干预措施在有效期间是有效的，试点数据显示， 可变间隔（VI）强化计划，一旦行为发生变化，保持潜在的维持 不常服用时会有增益。评估扩大这些干预措施效益的方法， 最重要的科学和临床问题。组件项目2将评估一种新的方法， 强化频率因患者表现而异。在这次干预中，将加强 24周，按照渐进式VI计划，根据患者状态进行调整。患者保持 禁欲获得最大的奖励，平均每三周一次，而 对复吸者的监测和加强戒断将增加，直至恢复戒断。 为了测试疗效，将280名可卡因使用障碍患者随机分配到：标准治疗（SC）， SC+传统的每周两次强化，或SC+自适应VI强化。评价将于 在基线和整个18个月期间，评估客观和自我报告的药物使用、心理社会 问题和艾滋病风险行为。主要假设是（1）适应性VI强化干预将 在治疗期间和整个随访期间，相对于标准治疗，改善结局，以及（2） 自适应VI强化干预将改善相对于传统强化系统的结果。 本研究还将评估认知控制和对金钱奖励的反应以及它们的神经功能的作用。 与治疗结果相关。认知控制能力较好的患者， 不同条件下禁欲的持续时间。预期患者对金钱奖励更敏感 以在强化条件下实现更长的禁欲持续时间。如果这些措施与 这些结果表明，配对强化干预措施的潜力， 最有可能从中受益的个体;它们也可能表明可能的生物标志物， 具体的治疗方式。如果认知指标介导治疗反应，未来的研究可以完善 改善认知过程和长期结果的干预措施。

ABSTRACT Project #2 Reinforcement interventions have pronounced effects on reducing cocaine use. With Center support, we developed and evaluated a low-cost reinforcement intervention, systematically moving it through the Stages of development to dissemination and broad clinical implementation. In our ongoing Center project, reinforcement interventions are yielding benefits when reinforcers are provided at treatment initiation and for longer durations. However, less than half of patients remain engaged for 12 weeks with traditional reinforcement interventions, which require frequent attendance for monitoring and reinforcing abstinence. Interventions that extend into aftercare and that are acceptable to and efficacious in preventing long-term relapse are critically needed. Reinforcement interventions are efficacious during periods they are in effect, and pilot data show that variable interval (VI) reinforcement schedules, once behavior change occurs, hold potential for maintaining gains when administered infrequently. Assessing methods to extend benefits of these interventions is of paramount scientific and clinical concern. Component Project 2 will evaluate a novel approach in which reinforcement frequency varies by patient performance. In this intervention, reinforcement will be available for 24 weeks, on a progressive VI schedule, that adapts according to patient status. Patients who maintain abstinence earn maximum reinforcers as infrequently as every three weeks on average, while frequency of monitoring and reinforcing abstinence will increase in those who relapse until abstinence is re-instated. To test efficacy, 280 patients with cocaine use disorder will be randomly assigned to: standard care (SC), SC+traditional twice weekly reinforcement, or SC+adaptive VI reinforcement. Evaluations will be completed at baseline and throughout 18 months to assess objective and self-reported indices of drug use, psychosocial problems, and HIV risk behaviors. Primary hypotheses are (1) the adaptive VI reinforcement intervention will improve outcomes relative to standard care during the treatment period and throughout follow-up, and (2) the adaptive VI reinforcement intervention will improve outcomes relative to the traditional reinforcement system. This study will also evaluate the roles of cognitive control and reactivity to monetary rewards and their neural correlates in treatment outcome. Patients with better cognitive control are expected to maintain longer durations of abstinence across conditions. Patients with greater sensitivity to monetary rewards are expected to achieve greater durations of abstinence in reinforcement conditions. If these measures differentially relate to outcomes across treatments, such results suggest the potential of pairing reinforcement interventions to individuals most likely to benefit from them; they may also indicate possible biomarkers of response in a treatment-specific manner. If cognitive indices mediate treatment response, future studies can refine interventions to improve cognitive processes and long-term outcomes.