Old psychotherapies for cocaine dependence revisited.
Explore the source record for details and available documents.
Cocaine-Related Disorders↗
Biomedical subjects
K M Carroll
Publications and source records attributed to K M Carroll.
Gender differences in treatment-seeking cocaine abusers--implications for treatment and prognosis.
This study examined gender differences in demographics, psychosocial functioning, substance abuse severity, psychopathology, and 1-year outcome in cocaine-dependent patients with the goal of identifying factors important to improving treatment and identifying prognostic indicators. The sample included 298 cocaine-dependent adults (92 women). Ninety-four patients (29 women) provided 1-year follow-up assessments. Compared to men, women consumed similar quantities of cocaine by more addictive routes and experienced more rapid progression of drug dependence, thus highlighting the need to facilitate treatment entry. The substantial rates of positive treatment outcomes emphasizes the effectiveness of treatment for cocaine-dependent individuals.
Adult↗
Telescoping of landmark events associated with drinking: a gender comparison.
OBJECTIVE: The literature suggests that women exhibit "telescoped" development of (i.e., faster progression to) alcoholism, with fewer years drinking than men. The purpose of this study was to use data gathered in the course of a large clinical trial to further examine this issue. METHOD: Subjects in this retrospective study were from a pool of 1,307 men and 419 women enrolled in Project MATCH, a multisite alcohol treatment matching study. MATCH subjects were recruited from both outpatient and aftercare settings over a 2-year period. Age-of-onset for landmark events in the development of alcoholism were determined from self-report and clinical interviews given at baseline entry into the study. Gender differences in age-of-onset variables were assessed within both outpatient and aftercare settings. Gender differences in progression times between successive landmarks were also examined. Differences were tested with both multivariate and univariate ANOVA techniques. RESULTS: Women generally began getting drunk regularly at a later average age than men (26.6 versus 22.7 years, p< or =.001), began experiencing their first drinking problems at a later average age than men (27.5 versus 25.0 years, p< or =.001) and exhibited loss of control over their drinking at a later average age than men (29.8 versus 27.2 years, p< or =.001). However, these gender differences were most pronounced for older individuals and attenuated for younger subjects. Women also progressed faster than men, on average, between first getting drunk regularly and first encountering drinking problems (0.9 versus 2.3 years, p< or =.001) and between first loss of drinking control and onset of worst drinking problems (5.5 versus 7.8 years, p< or =.001). Women also exhibited shorter average progression times between first getting drunk regularly and first seeking treatment (11.6 versus 15.8 years, p< or =.001), although this effect was negligible for younger subjects. CONCLUSIONS: Telescoping is a relatively robust phenomenon in treatment-seeking alcoholics and indicates that women are more likely to progress faster through the landmark events in the development of alcoholism than are men.
Adult↗
Fluoxetine treatment of depressive disorders in methadone-maintained opioid addicts.
This study tested the effectiveness of fluoxetine as a treatment for depression in a population of methadone-maintained opioid addicts. Methadone-maintained opioid addicts (44) with depression received fluoxetine or placebo in addition to their methadone, in a double-blind randomized trial, for 12 weeks. Depressive symptoms decreased significantly overall with no significant differences between the groups treated with fluoxetine versus placebo. In addition, drug use outcomes, including cocaine and heroin self-reported use and urine toxicology were measured. There was a significant decrease in heroin use in treatment, but no medication effect. Cocaine use, was unchanged from pre-treatment to endpoint. In separately analyzing data for the subsample of subjects with the most severe depression, there was a significant decrease in depression during treatment and a significant decrease in self-reported cocaine use, but no medication effect on either depressive symptoms or on cocaine use. This study suggests that fluoxetine is not an effective agent in treating depression or cocaine use in this population.
Adult↗
A randomized trial of buprenorphine maintenance for heroin dependence in a primary care clinic for substance users versus a methadone clinic.
PURPOSE: Buprenorphine is an alternative to methadone for the maintenance treatment of heroine dependence and may be effective on a thrice weekly basis. Our objective was to evaluate the effect of thrice weekly buprenorphine maintenance for the treatment of heroin dependence in a primary care clinic on retention in treatment and illicit opioid use. SUBJECTS AND METHODS: Opioid-dependent patients were randomly assigned to receive thrice weekly buprenorphine maintenance in a primary care clinic that was affiliated with a drug treatment program (n = 23) or in a traditional drug treatment program (n = 23) in a 12-week clinical trial. Primary outcomes were retention in treatment and urine toxicology for opioids; secondary outcomes were opioid withdrawal symptoms and toxicology for cocaine. RESULTS: Retention during the 12-week study was higher in the primary care setting (78%, 18 of 23) than in the drug treatment setting (52%, 12 of 23; P = 0.06). Patients admitted to primary care had lower rates of opioid use based on overall urine toxicology (63% versus 85%, P < 0.01) and were more likely to achieve 3 or more consecutive weeks of abstinence (43% versus 13%, P = 0.02). Cocaine use was similar in both settings. CONCLUSIONS: Buprenorphine maintenance is an effective treatment for heroin dependence in a primary care setting.
Adult↗
Internal validity of Project MATCH treatments: discriminability and integrity.
Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.
Adult↗
Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram.
AIMS: To evaluate disulfiram and three forms of manual guided psychotherapy for individuals with cocaine dependence and concurrent alcohol abuse or dependence. DESIGN: Randomized controlled trial. SETTING: Urban substance abuse treatment center. PARTICIPANTS: One hundred and twenty-two cocaine/alcohol abusers (27% female; 61% African-American or Hispanic). INTERVENTIONS: One of five treatments delivered over 12 weeks: cognitive behavioral treatment (CBT) plus disulfiram; Twelve Step facilitation (TSF) plus disulfiram; clinical management (CM) plus disulfiram; CBT plus no medication; TSF plus no medication. MEASUREMENTS: Duration of continuous abstinence from cocaine or alcohol; frequency and quantity of cocaine and alcohol use by week, verified by urine toxicology and breathalyzer screens. FINDINGS: Disulfiram treatment was associated with significantly better retention in treatment, as well as longer duration of abstinence from alcohol and cocaine use. The two active psychotherapies (CBT and TSF) were associated with reduced cocaine use over time compared with supportive psychotherapy (CM). Cocaine and alcohol use were strongly related throughout treatment, particularly for subjects treated with disulfiram. CONCLUSIONS: For the large proportion of cocaine-dependent individuals who also abuse alcohol, disulfiram combined with outpatient psychotherapy may be a promising treatment strategy. This study underlines (a) the significance of alcohol use among treatment-seeking cocaine abusers, (b) the promise of the strategy of treating co-morbid disorders among drug-dependent individuals, and (c) the importance of combining psychotherapy and pharmacotherapy in the treatment of drug use disorders.
Adult↗
Compliance with treatment and follow-up protocols in project MATCH: predictors and relationship to outcome.
Treatment and follow-up session attendance data from Project MATCH, a multisite clinical trial investigating patient-treatment matching, were analyzed to study compliance. High rates of compliance to both therapy and research protocols were achieved, enhancing treatment integrity and data quality. Strong baseline predictors of compliance did not emerge, and the small relationships found were consistent with reports from previous studies. Attendance at therapy sessions was moderately correlated with research follow-up participation. Treatment compliance predicted drinking outcome, underscoring the importance of retaining patients in treatment. Future studies should examine the associations between compliance and structural features of the treatment environment, treatment delivery, and context-features that are often under the control of the clinician/investigator.
Adult↗
Three methods of opioid detoxification in a primary care setting. A randomized trial.
BACKGROUND: Opioid detoxification in a primary care setting followed by ongoing substance abuse treatment may be appropriate for selected opioid-dependent patients. OBJECTIVE: To compare three pharmacologic protocols for opioid detoxification in a primary care setting. DESIGN: Randomized, double-blind clinical trial with random assignment to treatment protocols. SETTING: A free-standing primary care clinic affiliated with drug treatment programs. PATIENTS: 162 heroin-dependent patients. INTERVENTIONS: Three detoxification protocols: donidine, combined donidine and naltrexone, and buprenorphine. MEASUREMENTS: Successful detoxification (that is, when study participants received a full opioid-blocking dose [50 mg] of naltrexone), treatment retention (8 days), and withdrawal symptoms. RESULTS: Overall, 65% of participants (36 of 55) who received clonidine, 81% (44 of 54) who received combined clonidine and naltrexone, and 81% (43 of 53) who received buprenorphine were successfully detoxified. Retention did not differ significantly across the groups: 65% of participants (36 of 55) who received clonidine, 54% (29 of 54) who received combined clonidine and naltrexone, and 60% (32 of 53) who received buprenorphine. Participants who received buprenorphine had a significantly lower mean withdrawal symptom score than those who received clonidine or combined clonidine and naltrexone. CONCLUSIONS: Participants in the combined clonidine and naltrexone group and those in the buprenorphine group were more likely to complete detoxification, although retention at 8 days did not differ among the groups. Participants who were assigned to the buprenorphine group experienced less severe withdrawal symptoms than those assigned to the other two groups.
Adolescent↗
Manual-guided psychosocial treatment. A new virtual requirement for pharmacotherapy trials?
The conduct of randomized clinical trials to evaluate the efficacy of pharmacotherapies for mental disorders is guided by research standards (at a high level of rigor) that govern most design elements, including randomization of subjects, use of placebo controls, formulation and dosage of the therapeutic agent, and monitoring of serum levels. In contrast, no such widely accepted guidelines are recognized for standardization of an essential, if unacknowledged, element of all such studies: the concomitant provision of at least a minimal form of psychosocial treatment. Standardized provision of psychosocial treatments in pharmacotherapy trials will foster replicability of findings and address several common problems (e.g., attrition, medication noncompliance, reduction of error variance, and ethical issues associated with placebo controls). Careful selection and standardization of the psychosocial context in which medications are delivered will improve the validity, precision, and power of pharmacotherapy efficacy research, and should be considered a virtual requirement in research design.
Clinical Protocols↗
Nonpharmacologic approaches to substance abuse treatment.
Familiarity with nonpharmacologic approaches to substance abuse treatment is critical for medical practitioners to act effectively to prevent the progression of substance use to medically harmful use, abuse, or dependence; to identify patients with substance use disorders and motivation behavioral changes; and to maximize the likelihood of successful treatment. At their most basic level, these nonpharmacologic approaches involve components of practice that are requisite to the successful management of any medical disorder: fostering an empathic, supportive relationship; routinely evaluating the system or problem area; providing accurate medical information about diagnosis, natural history, and treatment; and following up on identified problems to improve compliance, evaluate the impact of treatment, and modify treatment as indicated. Because of the nature of substance use disorders, their impact on multiple areas of functioning, and the conditioned craving that occurs following repeated substance use, nonpharmacologic treatments can improve outcome, even when effective pharmacologic treatments are also employed. Treatment of nicotine dependence provides a useful example. Physician advice to stop smoking substantially increases the likelihood of smoking cessation and long-term abstinence. Combined with physician advice, nicotine replacement therapies, using nicotine gum or transdermal preparations, approximately double the rate of long-term abstinence, compared with physician advice alone. Providing behavioral treatment in addition to physician advice and nicotine replacement treatment leads to the highest rates of sustained abstinence, significantly higher than advice alone or rates associated with nicotine replacement alone. Nonpharmacologic treatments complement pharmacologic approaches often by addressing different target symptom and problem areas. In the case of nicotine dependence, nicotine replacement ameliorates withdrawal symptoms and craving associated with withdrawal. Behavioral treatment improves outcome by focusing on cue-evoked craving and developing effective long-term strategies to avoid or cope with craving and other cues. As discussed in this article, brief motivation approaches are particularly well suited for general medical practice settings. These approaches have been evaluated most extensively and shown to be most effective in preventing the progression of heavy drinking to problem drinking and alcohol dependence. Following a thorough evaluation of a patient's drinking habits, providing advice about sensible and safe drinking to patients identified as heavy drinkers leads to meaningful reductions in drinking. For patients who have developed problems of abuse or dependence, motivation approaches can be used to foster an interest and commitment to stop use and accept a referral to treatment. This article also provides an overview of the major psychosocial approaches used in more intensive specialty treatment of patients with substance use disorders. Familiarity with these approaches is essential for clinicians in general medical settings to facilitate referral of patients and monitor and improve the efficacy of treatments provided to patients. Medical practitioners must be able to educate patients about the need for more intensive specialty treatment and about what treatment entails. Medical practitioners must also be able to engage in informed discussions with substance abuse treatment specialists about the specific treatment recommendations made for a patient and the rationale for them. Medical practitioners who are informed about the treatment plans, rationale for treatment, and patient progress can play critical roles in encouraging patients to persist with the often difficult process of treatment.
Adaptation, Psychological↗
Contribution of the therapeutic alliance to outcome in active versus control psychotherapies.
Few studies have examined the role of the therapeutic alliance scores in active versus control psychotherapies. Using data from a randomized clinical trial of psychotherapy and pharmacotherapy for cocaine dependence, it was found that therapeutic alliance scores were rated as significantly more positive in cognitive-behavioral treatment than clinical management, a psychotherapy control condition. However, level of the therapeutic alliance was associated with outcome for the control but not the active psychotherapy. These data suggest that control conditions, which are intended to control for common factors of psychotherapies such as the therapeutic alliance, may exert their effect on outcomes primarily through the level of those common factors.
Adult↗
The therapeutic alliance and its relationship to alcoholism treatment participation and outcome.
The relationship between the therapeutic alliance and treatment participation and drinking outcomes during and after treatment was evaluated among alcoholic outpatient and aftercare clients. In the outpatient sample, ratings of the working alliance, whether provided by the client or therapist, were significant predictors of treatment participation and drinking behavior during the treatment and 12-month posttreatment periods, after a variety of other sources of variance were controlled. Ratings of the alliance by the aftercare clients did not predict treatment participation or drinking outcomes. Therapists ratings of the alliance in the aftercare sample predicted only percentage of days abstinent during treatment and follow-up. The results document the independent contribution of the therapeutic alliance to treatment participation and outcomes among alcoholic outpatients.
Adult↗
New methods of treatment efficacy research: bridging clinical research and clinical practice.
A variety of methodological advances are allowing alcoholism treatment researchers to develop effective new treatments and to answer more complex questions regarding the efficacy of treatments for alcohol use disorders. These advances include the use of standardized diagnostic criteria; thorough description of the study populations; standardization of treatments (e.g., through the use of manuals); training of treatment providers; quality control procedures and manipulation checks; and multidimensional, longitudinal assessments. Many of these methods can be adopted by clinicians to improve clinical care as well as to meet the challenges posed by managed care and other changes in the years ahead.
Alcoholism↗
Addiction severity and MMPI-derived typologies in cocaine abusers.
This study replicated the two Minnesota Multiphasic Personality Inventory subtypes (psychopathic and severe psychiatric) found in inpatient male cocaine abusers in an outpatient sample of 132 men and women. The Addiction Severity Index validated these subtype differences on the basis of psychiatric severity.
Adult↗
Enhancing retention in clinical trials of psychosocial treatments: practical strategies.
Given the close links between retention and outcome in substance abuse treatment, it is important to recognize that treatments are successful to the degree they retain patients. This chapter described some practical strategies for improving retention in clinical trials of treatment for substance abuse. To summarize: 1. Retention can be conceived as an important treatment outcome that reflects good fit between patient, therapist, treatment, and setting. Procedures and practices that improve the quality of treatment are likely to also improve retention. 2. Attending to the problem of retention may help solve the problem. While trials are ongoing, investigators should monitor retention closely, attending to and addressing variations in retention that might be associated with setting, seasonal variations, therapist factors, and research procedure factors. 3. More data are needed on effective methods of enhancing retention in different treatment settings. It should be noted that the strategies presented here reflect common sense and are for the most part drawn from experience with several clinical trials. Few of them have been evaluated empirically. However, more data on effective retention strategies are likely to have broad clinical and research utility. For example, it would be possible to design studies that evaluate an adaptation of Higgins' voucher system (this volume) to specifically reinforce retention in treatments that have higher rates of attrition, different methods of rewarding clinicians with higher rates of retention, and the effect on retention of adding babysitting services, to mention but some areas where further research would be illuminating.
Clinical Trials as Topic↗
Variability in treatment-seeking cocaine abusers: implications for clinical pharmacotherapy trials.
The two examples provided in this chapter suggest that the inconsistent findings across studies evaluating identical pharmacologic agents may be associated with variations in sample characteristics, particularly those associated with (a) general treatment responsiveness (e.g., severity of cocaine use, sociopathy), or (b) responsiveness to specific treatment strategies (e.g., rates of depression where antidepressant agents are evaluated). Describing study samples and evaluating treatment response along multiple dimensions, using a common set of standardized assessments, would be an important advance in understanding variation in subjects' response to medication effects and comparison of findings across different studies. Moreover, consistent description of study samples across a number of dimensions would set the stage for meta-analyses of patient-treatment interactions. Similarly, as new medications are developed and evaluated, variables that have a theoretical basis as mediators of treatment response should be identified and evaluated. It should be noted, however, that success profiling and matching research is more complex than the search for simple main effects (Finney and Moos 1986; Project MATCH Research Group 1993). In particular, adequate power to detect patient-treatment interactions requires much larger sample sizes than those that have to date characterized pharmacotherapy research for cocaine dependence. This strategy, however, is likely to enhance the development of effective pharmacological interventions for this very challenging patient population as researchers' understand the complex processes associated with treatment seeking, retention, and outcome among cocaine abusers.
Clinical Trials as Topic↗
Abnormal splicing of the leptin receptor in diabetic mice.
Mutations in the mouse diabetes (db) gene result in obesity and diabetes in a syndrome resembling morbid human obesity. Previous data suggest that the db gene encodes the receptor for the obese (ob) gene product, leptin. A leptin receptor was recently cloned from choroid plexus and shown to map to the same 6-cM interval on mouse chromosome 4 as db. This receptor maps to the same 300-kilobase interval as db, and has at least six alternatively spliced forms. One of these splice variants is expressed at a high level in the hypothalamus, and is abnormally spliced in C57BL/Ks db/db mice. The mutant protein is missing the cytoplasmic region, and is likely to be defective in signal transduction. This suggests that the weight-reducing effects of leptin may be mediated by signal transduction through a leptin receptor in the hypothalamus.
Alternative Splicing↗