EVALUATION OF TREATMENTS OF OPIOID AND COCAINE DEPENDENCE

本节继续调查药物滥用的药理学和行为治疗，并探索治疗的组合。NIDA/IRP治疗研究已经在市内大量静脉注射多种药物滥用者样本中证明了行为干预（加强可卡因阴性尿样）的有效性，并已开始评估应用这种治疗的最佳方法。有希望增加可卡因依赖患者戒断的干预努力集中在通过单独的基于凭证的应急管理或与社区强化咨询程序相结合来重新安排吸毒者的环境。第二种有希望的方法是通过认知行为疗法（CBT）提高应对技能的质量和数量，以解决对内外刺激的适应不良反应，这在可卡因依赖患者中很常见。对可卡因滥用进行应急管理的好处是迅速的，但可能是短暂的，而CBT的好处可能只在治疗后6至12个月出现。我们假设，将一种主要旨在启动行为改变（应急管理）的方法与另一种侧重于促进维持（CBT）的方法相结合，将比单独应用这些方法时产生更持久的可卡因戒断和艾滋病毒保护行为。使用美沙酮的门诊病人被随机分配到小组治疗组（CBT vs.不教授应对技巧的社会支持治疗组）和代金券组（代金券的应急管理与可卡因阴性尿检vs.非代金券）。干预持续12周，随访1年。这项研究已经完成，但后续研究仍在进行中。在接受临时代金券的两组中，可卡因的使用量大幅减少。CBT并没有减少可卡因的使用。干预后，同时接受CBT和临时代金券的参与者似乎受到保护，不会在意外事件后重新使用可卡因。这在治疗后的前12周没有达到统计学意义，与早期的发现一致。治疗后12个月的最后一次随访将于明年完成，届时我们将对随访数据进行分析，以检验预测的治疗后出现的效果。（Epstein DH, hawkins， W, Umbricht A, Preston KL.药物依赖问题学院年度科学会议，2000年6月，波多黎各圣胡安）。我们目前正在进行一项研究，以解决假设的美沙酮维持诊所如何最好地分配其资源（药理学和非药理学）以减少海洛因和可卡因滥用的问题，如果诊所要建立基于凭证的应急管理。通过将一种主要旨在通过行为强化（应急管理）减少可卡因使用的干预措施与另一种通过药物治疗（高剂量美沙酮维持）减少非法阿片类药物使用的干预措施相结合，我们假设我们将看到可卡因和非法阿片类药物的戒断程度比单独应用任何一种方法时都要高。

The section continues to investigate pharmacological and behavioral treatments of substance abuse and to explore combinations of treatments. NIDA/IRP treatment studies have already demonstrated the effectiveness of behavioral interventions (reinforcement of cocaine-negative urine samples) in large inner-city samples of intravenous polydrug abusers and has begun to evaluate the best way to apply the treatment. Promising intervention efforts to increase abstinence in cocaine-dependent patients have focused on rearranging the drug user's environment through voucher-based contingency management alone or in combination with community reinforcement counseling procedures. A second promising approach is to improve the quality and quantity of coping skills through cognitive-behavior therapy (CBT) to address the maladaptive responses to internal and external stimuli so commonly found in cocaine-dependent patients. The benefits of contingency management for cocaine abuse are rapid but may be transient, whereas the benefits of CBT may only emerge 6 to 12 months after treatment. We hypothesized that combining an approach that is primarily aimed at initiating behavior change (contingency management) with another approach that is focused on promoting maintenance (CBT) would produce longer sustained durations of cocaine abstinence and HIV protective behavior than when such approaches are applied separately. Methadone-maintained outpatients were randomly assigned to a group therapy condition (CBT vs. a social-support therapy in which the counselor taught no coping skills) and a voucher condition (contingency management with vouchers contingent on cocaine-negative urines vs. noncontingent vouchers). The intervention lasted 12 weeks, with follow-up for one year. The study is completed, though follow-ups are ongoing. There was a substantial reduction in cocaine use in the two groups that received contingent vouchers. Cocaine use was not reduced by CBT. After the intervention, participants who had received both CBT and contingent vouchers seemed to be protected against post-contingency resumption of cocaine use. This did not reach statistical significance during the first 12 weeks after treatment, consistent with earlier findings. The last of the 12-month posttreatment follow-ups will be completed next year, at which point we will analyze the follow-up data to test for the predicted posttreatment emergence of effects. (Epstein DH, Hawkin, W, Umbricht A, Preston KL. Annual scientific meeting of the College on Problems of Drug Dependence, June, 2000, San Juan, Puerto Rico). We are currently conducting a study to address the question of how a hypothetical methadone-maintenance clinic could best allocate its resources (both pharmacological and nonpharmacological) to reduce both heroin and cocaine abuse, if the clinic were to institute voucher-based contingency management. By combining an intervention primarily aimed at decreasing cocaine use through behavioral reinforcement (contingency management) with another intervention focused on decreasing illicit-opiate use through pharmacological treatment (high-dose methadone maintenance), we hypothesize that we will see greater abstinence from cocaine and illicit opiates than has been seen when either approach was applied separately.