Treating Cocaine Abuse: A Behavioral Approach

描述（由申请人提供）：这是继续研究CRA +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。虽然在开发针对这种疾病的有效行为疗法方面取得了很大进展，但仍有相当大的改进空间。一个有希望的改进领域是将治疗参数与患者特征相匹配，使得较低严重程度的患者不会接受比积极治疗结果所需的更多治疗或较高严重程度的患者接受比积极治疗结果所需的更少治疗。可卡因依赖治疗的发展往往偏向于优化疗效，而不适当注意限制成本，或减少成本而不充分注意削弱疗效。将治疗剂量与中等治疗反应的特征相匹配有可能在这两种偏倚之间取得平衡。我们建议进行两项配对研究。 研究1将检查6周应急代金券干预的有效性，有和没有与患者严重程度匹配的代金券价值。我们将使用婚姻状况（目前已婚vs.其他）和可卡因给药途径（鼻内vs.吸烟/静脉注射）对严重程度进行分类。该严重程度指标可调节对CRA +治疗者治疗的凭证部分的反应。可卡因依赖门诊患者将被随机分配至CRA，外加三种6周代金券条件之一：非应急代金券，所有患者设定为正常值的应急代金券，或低严重程度用户设定为正常值和高严重程度用户设定为两倍正常值的应急代金券。我们假设治疗条件和严重程度之间存在显著的相互作用，6周或有凭证条件的疗效取决于凭证设置为通常值时患者的严重程度，但当值与患者的严重程度匹配时则无关。研究2将检查6周代金券与CRA相结合的有效性，CRA作为简短干预（2周）、中等持续时间干预（6周）或其中持续时间与CRA治疗反应、婚姻状况（目前已婚与其他）和酒精依赖（有与无）的两个调节因子相匹配的干预。我们假设一个显着的治疗条件和严重程度之间的相互作用，CRA的疗效依赖于婚姻状况和酒精依赖的统一持续时间的条件下，但不是在CRA持续时间匹配的条件下，患者的特征。我们还提出了两个次要目标：（a）检查延迟贴现的行为经济学概念作为治疗反应的潜在调节剂所发挥的作用，（B）进一步了解患者药物使用严重程度如何调节治疗反应。总体而言，拟议的研究有可能促进对如何更好地将治疗参数与可卡因依赖治疗中的患者严重程度相匹配的理解，其目标是在不影响向更严重患者提供的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.