Psychological And Methodological Issues In Substance Abuse Treatment/research

虽然改善心理社会功能是药物滥用治疗的一个共同目标，但大多数可卡因试验的主要结局指标是尿检证实的可卡因使用率。 然而，可卡因使用与心理社会结果之间的关系没有很好的记录。 为了研究这种关系并确定最佳的尿液筛查方法，我们回顾性分析了两项为期25周的随机对照试验的数据，这些试验对368名可卡因/海洛因使用者维持美沙酮的戒断强化进行了研究。 通过定性尿分析、苯甲酰芽子碱浓度（BE）和通过对BE应用算法估计可卡因的新用途，每周测量三次可卡因使用。 在研究退出时确定社会适应（SAS-SR）、可卡因依赖的当前诊断（通过DSM-IV标准）和抑郁症状（贝克抑郁量表）。 与对照组相比，禁欲强化组的可卡因使用率显著降低。 在各组中，治疗中可卡因的使用与更差的社会适应、当前可卡因依赖诊断和退出时的抑郁症显著相关。 与定性尿分析或BE相比，新用途更常检测到显著差异。 然而，尿液筛查所占的方差量通常<15%。 尿液筛查，特别是新用途标准，可以预测心理社会功能，但不能替代更直接的心理社会功能测量。 从成瘾中恢复的人经常引用灵性作为一种有益的影响。 然而，很少有人知道灵性是否或如何可以纳入正式治疗的方式是敏感的个体差异。 在本研究中，焦点小组进行了25美沙酮维持门诊检查信仰的精神在恢复中的作用及其在正式治疗的适当性。 小组还讨论了积极成瘾期间精神和行为之间的关系。 专题分析表明，精神和宗教习俗在活跃的成瘾期间以复杂的方式受到影响，但与恢复密切相关。 几乎所有与会者都同意，将自愿精神讨论小组纳入正式治疗比目前可用的替代方案更可取。 一个限制是，所有参与者都认为自己是强烈的精神。 对更多样化样本的研究将有助于指导正规治疗环境中基于精神的干预措施的制定和评估。 我们正在继续我们的工作与生态瞬时评估（EMA）评估的效用，手持电子日记收集结果数据的临床试验，评估药物滥用的治疗。 除了验证复发临床前模型的基础假设外，EMA可能是未来复发预防药物临床试验中有用的结果指标。 临床前研究表明，药物的作用可能是特定于某些类型的复发; EMA可能是人类前瞻性回答这一重要研究问题的唯一数据收集方法。

Although improvement in psychosocial functioning is a common goal in substance-abuse treatment, the primary outcome measure in most cocaine trials is rate of urinalysis-verified cocaine use. However, the relationship between cocaine use and psychosocial outcomes is not well documented. To investigate this relationship and identify the optimal urine-screen method, we retrospectively analyzed data from two 25-week randomized controlled trials of abstinence reinforcement in 368 cocaine/heroin users maintained on methadone. Cocaine use was measured thrice weekly by qualitative urinalysis, benzoylecgonine concentration (BE), and an estimate of New Uses of cocaine by application of an algorithm to BE. Social adjustment (SAS-SR), current diagnosis of cocaine dependence (by DSM-IV criteria), and depression symptoms (Beck Depression Inventory) were determined at study exit. Cocaine use was significantly lower in the abstinence-reinforcement groups compared to controls. Across groups, in-treatment cocaine use was significantly associated with worse social adjustment, current cocaine-dependence diagnosis, and depression at exit. Significant differences were detected more frequently with New Uses than qualitative urinalysis or BE. Nevertheless, the amount of variance accounted for by the urine screens was typically <15%. Urine screens, especially with New Uses criteria, can predict psychosocial functioning, but cannot substitute for more direct measures of psychosocial functioning. Individuals recovering from addictions frequently cite spirituality as a helpful influence. However, little is known about whether or how spirituality could be incorporated into formal treatment in a manner that is sensitive to individual differences. In the present study, focus groups were conducted with 25 methadone-maintained outpatients to examine beliefs about the role of spirituality in recovery and its appropriateness in formal treatment. Groups also discussed the relationship between spirituality and behavior during active addiction. Thematic analyses suggested that spirituality and religious practices suffered in complex ways during active addiction, but went hand in hand with recovery. Nearly all participants agreed that integration of a voluntary spiritual discussion group into formal treatment would be preferable to currently available alternatives. One limitation was that all participants identified as strongly spiritual. Studies of more diverse samples will help guide the development and evaluation of spiritually based interventions in formal treatment settings. We are continuing our work with ecological momentary assessment (EMA) evaluating the utility of hand-held electronic diaries to collect outcome data in clinical trials evaluating treatments for substance abuse. In addition to validating assumptions underlying preclinical models of relapse, EMA may be a useful outcome measure in future clinical trials of relapse-prevention medications. Preclinical research has shown that medications effects may be specific to certain types of relapse; EMA may be the only data collection approach in humans to prospectively answer this important research question.