Treating Cocaine Abuse: A Behavioral Approach

描述（由申请人提供）：这是继续研究CRA +凭证治疗可卡因依赖的申请的第一次修订。可卡因依赖是美国一个根深蒂固的公共卫生问题。虽然在开发有效的行为疗法治疗这种疾病方面已经取得了很大的进展，但仍有很大的改进空间。一个有希望的改进领域是使治疗参数与患者特征相匹配，以便较轻的患者不会接受更多的治疗，或较重的患者不会接受少于积极治疗结果所需的治疗。可卡因依赖的治疗发展往往倾向于优化疗效，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，有可能在这两种偏差之间取得平衡。我们建议进行两项配对研究。研究1将检验6周随机代金券干预的有效性，有无与患者严重程度相匹配的代金券。我们将使用婚姻状况（已婚vs其他）和可卡因给药途径（鼻内vs吸烟/静脉注射）来对严重程度进行分类。这种严重程度措施缓和了对CRA +凭单治疗中凭单部分的反应。可卡因依赖门诊患者将被随机分配到CRA加上三种为期6周的代金券条件中的一种：非偶然代金券，所有患者的偶然代金券设置为通常值，或低严重程度的偶然代金券设置为通常值，高严重程度的偶然代金券设置为两倍通常值。我们假设治疗条件和严重程度之间存在显著的相互作用，当凭单被设置为通常值时，6周随机凭单条件的有效性取决于患者的严重程度，而当凭单的值与患者的严重程度相匹配时则无关。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），中等持续时间干预（6周），或干预的持续时间与对CRA治疗反应的两个调节因子相匹配，婚姻状况（已婚或其他）和酒精依赖（有或没有）。我们假设在治疗条件和严重程度之间存在显著的相互作用，在统一持续时间条件下，CRA的疗效依赖于婚姻状况和酒精依赖，而在CRA持续时间与患者特征匹配的条件下则不存在。我们还提出了两个次要目标：(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)进一步了解患者药物使用严重程度如何调节治疗反应。总的来说，拟议的研究有可能促进对如何在治疗可卡因依赖时更好地将治疗参数与患者严重程度相匹配的理解，目的是在不影响向更严重的患者提供护理质量的情况下简化干预措施的成本。

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.