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，但在大多数可卡因试验中，主要的结果衡量指标是尿检证实的可卡因使用率。然而，可卡因使用与社会心理结果之间的关系并没有得到很好的记录。为了研究这种关系并确定最佳尿液筛查方法，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名依赖美沙酮的可卡因/海洛因使用者进行了强化戒断。通过定性尿液分析、苯甲酰ecgonine浓度（BE）和应用BE算法估计可卡因新用途，每周测量三次可卡因使用情况。在研究结束时测定社会适应（SAS-SR）、可卡因依赖的当前诊断（根据DSM-IV标准）和抑郁症状（贝克抑郁量表）。与对照组相比，强化戒断组的可卡因使用量明显降低。在各组中，治疗期间的可卡因使用与较差的社会适应、当前的可卡因依赖诊断和退出时的抑郁显著相关。与定性尿液分析或BE相比，新用途检测到显著差异的频率更高。然而，尿液筛查所占的差异量通常小于15%。尿液筛查，特别是新用途标准，可以预测社会心理功能，但不能代替更直接的社会心理功能测量。

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.