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López G, Orchowski LM, Reddy MK, Nargiso J, Johnson JE. A review of research-supported group treatments for drug use disorders. Subst Abuse Treat Prev Policy 2021; 16:51. [PMID: 34154619 PMCID: PMC8215831 DOI: 10.1186/s13011-021-00371-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 11/10/2022] Open
Abstract
This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women's recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.
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Affiliation(s)
- Gabriela López
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, 02912, USA
| | - Lindsay M Orchowski
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, 02904, USA.
| | - Madhavi K Reddy
- Walter Reed Army Institute of Research, Silver Spring, MD, 20910, USA
| | - Jessica Nargiso
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Jennifer E Johnson
- Division of Public Health, Michigan State University, Flint, MI, 48502, USA
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Bentzley BS, Han SS, Neuner S, Humphreys K, Kampman KM, Halpern CH. Comparison of Treatments for Cocaine Use Disorder Among Adults: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e218049. [PMID: 33961037 PMCID: PMC8105751 DOI: 10.1001/jamanetworkopen.2021.8049] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE In the US and the United Kingdom, cocaine use is the second leading cause of illicit drug overdose death. Psychosocial treatments for cocaine use disorder are limited, and no pharmacotherapy is approved for use in the US or Europe. OBJECTIVE To compare treatments for active cocaine use among adults. DATA SOURCES PubMed and the Cochrane Database of Systematic Reviews were searched for clinical trials published between December 31, 1995, and December 31, 2017. STUDY SELECTION This meta-analysis was registered on Covidence.org (study 8731) on December 31, 2015. Clinical trials were included if they (1) had the term cocaine in the article title; (2) were published between December 31, 1995, and December 31, 2017; (3) were written in English; (4) enrolled outpatients 18 years or older with active cocaine use at baseline; and (5) reported treatment group size, treatment duration, retention rates, and urinalysis results for the presence of cocaine metabolites. A study was excluded if (1) more than 25% of participants were not active cocaine users or more than 80% of participants had negative test results for the presence of cocaine metabolites at baseline and (2) it reported only pooled urinalysis results indicating the presence of multiple substances and did not report the specific proportion of positive test results for cocaine metabolites. Multiple reviewers reached criteria consensus. Of 831 records screened, 157 studies (18.9%) met selection criteria and were included in the analysis. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Search results were imported from PubMed XML into Covidence.org then Microsoft Excel. Data extraction was completed in 2 iterations to ensure fidelity. Analyses included a multilevel random-effects model, a multilevel mixed-effects meta-regression model, and sensitivity analyses. Treatments were clustered into 11 categories (psychotherapy, contingency management programs, placebo, opioids, psychostimulants, anticonvulsants, dopamine agonists, antidepressants, antipsychotics, miscellaneous medications, and other therapies). Missing data were imputed using multiple imputation by chained equations. The significance threshold for all analyses was P = .05. Data were analyzed using the metafor and mice packages in R software, version 3.3.2 (R Foundation for Statistical Computing). Data were analyzed from January 1, 2018, to February 28, 2021. MAIN OUTCOMES AND MEASURES The primary outcome was the intention-to-treat logarithm of the odds ratio (OR) of having a negative urinalysis result for the presence of cocaine metabolites at the end of each treatment period compared with baseline. The hypothesis, which was formulated after data collection, was that no treatment category would have a significant association with objective reductions in cocaine use. RESULTS A total of 157 studies comprising 402 treatment groups and 15 842 participants were included. Excluding other therapies, the largest treatment groups across all studies were psychotherapy (mean [SD] number of participants, 40.04 [36.88]) and contingency management programs (mean [SD] number of participants, 37.51 [25.51]). Only contingency management programs were significantly associated with an increased likelihood of having a negative test result for the presence of cocaine (OR, 2.13; 95% CI, 1.62-2.80), and this association remained significant in all sensitivity analyses. CONCLUSIONS AND RELEVANCE In this meta-analysis, contingency management programs were associated with reductions in cocaine use among adults. Research efforts and policies that align with this treatment modality may benefit those who actively use cocaine and attenuate societal burdens.
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Affiliation(s)
- Brandon S. Bentzley
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Summer S. Han
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Sophie Neuner
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Kyle M. Kampman
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Casey H. Halpern
- Department of Neurosurgery, Stanford University, Stanford, California
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3
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Therapeutic efficacy of environmental enrichment for substance use disorders. Pharmacol Biochem Behav 2019; 188:172829. [PMID: 31778722 DOI: 10.1016/j.pbb.2019.172829] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/13/2019] [Accepted: 11/15/2019] [Indexed: 12/18/2022]
Abstract
Addiction to drug and alcohol is regarded as a major health problem worldwide for which available treatments show limited effectiveness. The biggest challenge remains to enhance the capacities of interventions to reduce craving, prevent relapse and promote long-term recovery. New strategies to meet these challenges are being explored. Findings from preclinical work suggest that environmental enrichment (EE) holds therapeutic potential for the treatment of substance use disorders, as demonstrated in a number of animal models of drug abuse. The EE intervention introduced after drug exposure leads to attenuation of compulsive drug taking, attenuation of the rewarding (and reinforcing) effects of drugs, reductions in control of behavior by drug cues, and, very importantly, relapse prevention. Clinical work also suggests that multidimensional EE interventions (involving physical activity, social interaction, vocational training, recreational and community involvement) might produce similar therapeutic effects, if implemented continuously and rigorously. In this review we survey preclinical and clinical studies assessing the efficacy of EE as a behavioral intervention for substance use disorders and address related challenges. We also review work providing empirical evidence for EE-induced neuroplasticity within the mesocorticolimbic system that is believed to contribute to the seemingly therapeutic effects of EE on drug and alcohol-related behaviors.
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Nesvåg S, McKay JR. Feasibility and Effects of Digital Interventions to Support People in Recovery From Substance Use Disorders: Systematic Review. J Med Internet Res 2018; 20:e255. [PMID: 30139724 PMCID: PMC6127498 DOI: 10.2196/jmir.9873] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/01/2018] [Accepted: 06/18/2018] [Indexed: 12/18/2022] Open
Abstract
Background The development and evaluation of digital interventions aimed at preventing or treating substance use–related problems and disorders is a rapidly growing field. Previous reviews of such interventions reveal a large and complex picture with regard to targeted users, use, and efficacy. Objective The objective of this review was to investigate the feasibility and effects of interventions developed specifically for digital platforms. These interventions are focused on supporting people in recovery from substance use disorders by helping them achieve their substance use goals and develop a more satisfying life situation. Methods The review is based on a systematic search in MEDLINE, Embase, PsycInfo, and Cochrane Library databases. Of the 1149 identified articles, 722 were excluded as obviously not relevant. Of the remaining articles, 21 were found to be previous reviews, 269 were on interventions aimed at reducing hazardous alcohol or cannabis use, and 94 were on digitized versions of standard treatment methods. The remaining 43 articles were all read in full and systematically scored by both authors. Results The 43 articles cover 28 unique interventions, of which 33 have been published after 2013. The interventions are aimed at different target groups (defined by age, substance, or comorbidity). Based on the number of features or modules, the interventions can be categorized as simple or complex. Fourteen of the 18 simple interventions and 9 of the 10 complex interventions have been studied with quantitative controlled methodologies. Thirteen of the 18 simple interventions are integrated in other treatment or support systems, mainly delivered as mobile phone apps, while 6 of the 10 complex interventions are designed as stand-alone interventions, most often delivered on a platform combining desktop/Web and mobile phone technologies. The interventions were generally easy to implement, but in most cases the implementation of the complex interventions was found to be dependent on sustained organizational support. Between 70% and 90% of the participants found the interventions to be useful and easy to use. The rates of sustained use were also generally high, except for simple interventions with an open internet-based recruitment and some information and education modules of the complex interventions. Across all interventions, slightly more than half (55%) of the studies with control groups generated positive findings on 1 or more substance use outcomes, with 57% of the interventions also found to be efficacious in 1 or more studies. In the positive studies, effects were typically in the small to moderate range, with a few studies yielding larger effects. Largely due to the inclusion of stronger control conditions, studies of simple interventions were less likely to produce positive effects. Conclusions The digital interventions included in this review are in general feasible but are not consistently effective in helping people in recovery from substance use disorder reduce their substance use or achieving other recovery goals.
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Affiliation(s)
- Sverre Nesvåg
- Centre for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway
| | - James R McKay
- Centre for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Philadelphia VA Medical Center, Philadelphia, PA, United States
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Oluwoye O, Hirchak K, Leickly E, Skalisky J, McPherson S, Srebnik D, Roll JM, Ries RK, McDonell MG. Interaction between pre-treatment drug use and heterogeneity of psychiatric diagnosis predicts outcomes in outpatients with co-occurring disorders. Psychiatry Res 2018; 260:233-235. [PMID: 29220679 PMCID: PMC5975078 DOI: 10.1016/j.psychres.2017.11.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 11/06/2017] [Accepted: 11/25/2017] [Indexed: 11/30/2022]
Abstract
We examined whether the interaction of baseline stimulant use, assessed by urine drug tests, and type of serious mental illness (SMI) diagnosis predicted stimulant use in a trial of contingency management (CM). The interaction between baseline stimulant use and SMI diagnoses was significant in the overall sample (p=0.002) when controlling for the main effects of treatment condition, baseline stimulant use, and SMI diagnosis. Similar results were also found within the CM sample. Individuals with bipolar disorder were more or less likely, depending on their baseline stimulant-drug test results, to use stimulants during treatment compared to those with other SMI diagnoses.
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Affiliation(s)
- Oladunni Oluwoye
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane, WA, USA; Program of Excellence in Addictions Research, Washington State University, Spokane, WA, USA.
| | - Katherine Hirchak
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane, WA, USA; Program of Excellence in Addictions Research, Washington State University, Spokane, WA, USA.
| | - Emily Leickly
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane, WA, USA; Program of Excellence in Addictions Research, Washington State University, Spokane, WA, USA.
| | - Jordan Skalisky
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane, WA, USA; Program of Excellence in Addictions Research, Washington State University, Spokane, WA, USA.
| | - Sterling McPherson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Program of Excellence in Addictions Research, Washington State University, Spokane, WA, USA; Providence Medical Research Center, Providence Health Care, Spokane, WA, USA.
| | - Debra Srebnik
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.
| | - John M Roll
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Program of Excellence in Addictions Research, Washington State University, Spokane, WA, USA.
| | - Richard K Ries
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.
| | - Michael G McDonell
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane, WA, USA; Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Program of Excellence in Addictions Research, Washington State University, Spokane, WA, USA.
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Carlson E, Holtyn AF, Fingerhood M, Friedman-Wheeler D, Leoutsakos JMS, Silverman K. The effects of the therapeutic workplace and heavy alcohol use on homelessness among homeless alcohol-dependent adults. Drug Alcohol Depend 2016; 168:135-139. [PMID: 27648854 DOI: 10.1016/j.drugalcdep.2016.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND A clinical trial demonstrated that a therapeutic workplace could promote alcohol abstinence in homeless, alcohol-dependent adults. This secondary-data analysis examined rates of homelessness and their relation to the therapeutic workplace intervention and alcohol use during the trial. METHODS In the trial, homeless, alcohol-dependent adults could work in a therapeutic workplace for 6 months and were randomly assigned to Unpaid Training, Paid Training, or Contingent Paid Training groups. Unpaid Training participants were not paid for working. Paid Training participants were paid for working. Contingent Paid Training participants were paid for working if they provided alcohol-negative breath samples. Rates of homelessness during the study were calculated for each participant and the three groups were compared. Mixed-effects regression models were conducted to examine the relation between alcohol use (i.e., heavy drinking, drinks per drinking day, and days of alcohol abstinence) and homelessness. RESULTS Unpaid Training, Paid Training, and Contingent Paid Training participants did not differ in the percentage of study days spent homeless (31%, 28%, 17%; respectively; F(2,94)=1.732, p=0.183). However, participants with more heavy drinking days (b=0.350, p<0.001), more drinks per drinking day (b=0.267, p<0.001), and fewer days of alcohol abstinence (b=-0.285, p<0.001) spent more time homeless. CONCLUSIONS Reducing heavy drinking and alcohol use may help homeless, alcohol-dependent adults transition out of homelessness.
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Affiliation(s)
- Emily Carlson
- Johns Hopkins University, 5200 Eastern Avenue, Baltimore, MD 21224, USA
| | - August F Holtyn
- Johns Hopkins University, 5200 Eastern Avenue, Baltimore, MD 21224, USA.
| | | | | | | | - Kenneth Silverman
- Johns Hopkins University, 5200 Eastern Avenue, Baltimore, MD 21224, USA
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7
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Substance Abuse Treatment Patients in Housing Programs Respond to Contingency Management Interventions. J Subst Abuse Treat 2016; 72:97-102. [PMID: 27492676 DOI: 10.1016/j.jsat.2016.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/21/2016] [Accepted: 07/11/2016] [Indexed: 11/20/2022]
Abstract
Use of homeless and transitional housing (e.g., recovery homes) programs can be associated with success in substance abuse treatment, perhaps because many of these programs encourage or mandate sobriety. In this study, we examined whether contingency management (CM) protocols that use tangible incentives for submission of drug-free specimens or other specific behaviors are effective for treatment-seeking substance abusers whose behavior may also be shaped by housing programs. Of 355 participants in randomized trials of CM, 56 (16%) reported using transitional housing during the 12-week treatment period. Main and interaction effects of housing status and treatment condition were evaluated for the primary substance abuse treatment outcomes: a) longest duration of abstinence from alcohol, cocaine, and opioids, b) percentage of samples submitted that were negative for these substances, and c) treatment retention. After controlling for demographic and clinical characteristics, those who accessed housing programs submitted a higher percentage of negative samples (75%) compared to those who did not access housing programs (67%). Housing status groups did not differ in terms of longest duration of abstinence (accessed housing: M=3.1 weeks, SE=0.6; did not access housing: M=3.9 weeks, SE=0.3) or retention in substance abuse treatment (accessed housing: M=6.4 weeks, SE=0.6; did not access housing: M=6.6 weeks, SE=0.3). Regardless of housing status, CM was associated with longer durations of abstinence and treatment retention. No interactive effects of housing and treatment condition were observed (p>.05). Results suggest that those who accessed housing programs during substance abuse treatment benefit from CM to a comparable degree as their peers who did not use such programs. These effects suggest that CM remains appropriate for those accessing housing in community-based programs.
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Baggett TP, Chang Y, Singer DE, Porneala BC, Gaeta JM, O'Connell JJ, Rigotti NA. Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. Am J Public Health 2015; 105:1189-97. [PMID: 25521869 PMCID: PMC4431083 DOI: 10.2105/ajph.2014.302248] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVES We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults. METHODS We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences. RESULTS Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults. CONCLUSIONS In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality.
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Affiliation(s)
- Travis P Baggett
- Travis P. Baggett and James J. O'Connell are with the Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, the Department of Medicine, Harvard Medical School, Boston, MA, and the Boston Health Care for the Homeless Program, Boston, MA. Bianca C. Porneala is with the Division of General Internal Medicine, Massachusetts General Hospital, Boston. Yuchiao Chang, Daniel E. Singer, and Nancy A. Rigotti are with the Division of General Internal Medicine, Massachusetts General Hospital, Boston, and the Department of Medicine, Harvard Medical School, Boston. Jessie M. Gaeta is with the Boston Health Care for the Homeless Program and the Section of General Internal Medicine, Department of Medicine, Boston University, School of Medicine, Boston, MA
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Petry NM, DePhilippis D, Rash CJ, Drapkin M, McKay JR. Nationwide dissemination of contingency management: the Veterans Administration initiative. Am J Addict 2014; 23:205-10. [PMID: 24724876 DOI: 10.1111/j.1521-0391.2014.12092.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 04/10/2013] [Accepted: 05/10/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Contingency management (CM) is an empirically validated intervention but one not often applied in practice settings in the US. OBJECTIVES The aim of this article is to describe the Veterans Administration (VA) nationwide implementation of CM treatment. METHODS In 2011, the VA called for integration of CM in its intensive outpatient substance abuse treatment clinics. As part of this initiative, the VA funded training and ongoing implementation support, and it provided direct funds for reinforcers and other intervention costs. RESULTS Over 100 clinics received this funding in 2011, and CM has been implemented in over 70 substance abuse treatment clinics since August 2011. CONCLUSIONS This training and implementation experience has been highly successful and represents the largest scale training in evidence-based treatments for substance use disorders in the VA health care system to date. SCIENTIFIC SIGNIFICANCE This program may serve as a model for training in evidence-based treatments.
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Affiliation(s)
- Nancy M Petry
- University of Connecticut School of Medicine, Farmington, Connecticut
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10
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Carroll KM. Lost in translation? Moving contingency management and cognitive behavioral therapy into clinical practice. Ann N Y Acad Sci 2014; 1327:94-111. [PMID: 25204847 PMCID: PMC4206586 DOI: 10.1111/nyas.12501] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the treatment of addictions, the gap between the availability of evidence-based therapies and their limited implementation in practice has not yet been bridged. Two empirically validated behavioral therapies, contingency management (CM) and cognitive behavioral therapy (CBT), exemplify this challenge. Both have a relatively strong level of empirical support but each has weak and uneven adoption in clinical practice. This review highlights examples of how barriers to their implementation in practice have been addressed systematically, using the Stage Model of Behavioral Therapies Development as an organizing framework. For CM, barriers such as cost and ideology have been addressed through the development of lower-cost and other adaptations to make it more community friendly. For CBT, barriers such as relative complexity, lack of trained providers, and need for supervision have been addressed via conversion to standardized computer-assisted versions that can serve as clinician extenders. Although these and other modifications have rendered both interventions more disseminable, diffusion of innovation remains a complex, often unpredictable process. The existing specialty addiction-treatment system may require significant reforms to fully implement CBT and CM, particularly greater focus on definable treatment goals and performance-based outcomes.
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Affiliation(s)
- Kathleen M Carroll
- Division of Substance Abuse, Yale University School of Medicine, West Haven, Connecticut
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Festinger DS, Dugosh KL, Kirby KC, Seymour BL. Contingency management for cocaine treatment: cash vs. vouchers. J Subst Abuse Treat 2014; 47:168-74. [PMID: 24746956 PMCID: PMC4504189 DOI: 10.1016/j.jsat.2014.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 01/29/2014] [Accepted: 03/03/2014] [Indexed: 11/17/2022]
Abstract
The efficacy of contingency management (CM) for treating drug abuse is well supported. The most widely used form of CM is voucher-based reinforcement therapy (VBRT), where clients receive an escalating schedule of vouchers that can be redeemed for goods and services for meeting treatment goals. Though generally rejected due to concerns about potential harms to drug using participants, research suggests that cash may be a more effective reinforcer. This three-group randomized trial compared the efficacy of cash-based reinforcement therapy (CBRT) to VBRT and a non-CM condition on cocaine abstinence and treatment attendance; and examined whether CBRT resulted in greater levels of harm than VBRT. Findings indicated that the CBRT was as effective as VBRT when compared to the non-CM condition and that it did not increase rates of drug use, cravings, or high-risk behaviors. Future research should examine potential cost savings associated with a cash-based CM approach as this could have important implications for the wider adoption of the CM model.
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Affiliation(s)
- David S Festinger
- Treatment Research Institute, Philadelphia, PA 19106, USA; University of Pennsylvania, Department of Psychiatry, Philadelphia, PA 19104, USA.
| | - Karen L Dugosh
- Treatment Research Institute, Philadelphia, PA 19106, USA
| | - Kimberly C Kirby
- Treatment Research Institute, Philadelphia, PA 19106, USA; University of Pennsylvania, Department of Psychiatry, Philadelphia, PA 19104, USA
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Abstract
Over the past 3 years the number of homeless people in the UK has increased by 34%. Most will die young, largely due to treatable conditions. Secondary care can, and must, do more for the silent killer that homelessness is.
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Affiliation(s)
- Pippa Medcalf
- Acute Medicine, Gloucestershire Royal Hospitals, Gloucester, UK and Royal College of Physicians, London, UK
| | - Georgina K Russell
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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13
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Davidson A, Jensen M, Burgess E, Stevens A, Hayes L, Sieweke S, Stough K, Wright A, McCarty R, Eddleman L, Kim YI, Milby JB, Schumacher JE. Effects of therapeutic goal management (TGM) on treatment attendance and drug abstinence among men with co-occurring substance use and axis I mental disorders who are homeless: results of the Birmingham EARTH program. Addict Sci Clin Pract 2013; 8:17. [PMID: 24499617 PMCID: PMC3829098 DOI: 10.1186/1940-0640-8-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 10/21/2013] [Indexed: 11/21/2022] Open
Abstract
Purpose This study describes the implementation and impact of Therapeutic Goal Management (TGM) in a Substance Abuse and Mental Health Services Administration (SAMHSA)-sponsored demonstration project entitled Enhanced Addiction Recovery through Housing (EARTH). Participants The sample included 28 male participants followed at six months who completed some treatment. Forty-three percent were Caucasian, and 57% were African American. The average age of participants was 42 years. Design The relationships between TGM goal achievement, treatment attendance, and drug abstinence outcomes were studied among EARTH program participants who were homeless and met criteria for co-occurring substance use and severe DSM-IV Axis I mental disorders. Results The results revealed an overall drug abstinence rate of 72.4% over six months and significant positive relationships between TGM goal achievement and drug abstinence (r = 0.693) and TGM goal achievement and treatment attendance (r = 0.843). Conclusions This research demonstrated the relationship and potential positive impact of systematically setting, monitoring, and reinforcing personalized goals in multiple life areas on drug abstinence and treatment attendance outcomes among persons who are homeless with co-occurring substance use and other Axis I disorders in a integrated community service delivery program.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Joseph E Schumacher
- Division of Preventive Medicine, University of Alabama at Birmingham, 1717 11th Avenue South, MT 616, Birmingham, AL 35205, USA.
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Using incentives to reduce substance use and other health risk behaviors among people with serious mental illness. Prev Med 2012; 55 Suppl:S54-60. [PMID: 22197799 PMCID: PMC3336027 DOI: 10.1016/j.ypmed.2011.11.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 11/23/2011] [Accepted: 11/30/2011] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Serious mental illness (SMI) is associated with high rates of tobacco and other drug dependence, poor treatment compliance, obesity and low levels of physical activity, which have severe medical and psychosocial consequences. Interventions that effectively reduce these health risk behaviors among people with SMI are urgently needed. METHODS Published reports from studies evaluating incentive-based treatments for promoting tobacco and other drug abstinence, treatment attendance, medication use and increased physical activity are reviewed. RESULTS Results of this review indicate the efficacy of incentive-based treatments for reducing tobacco and other drug use among people with SMI. Few studies have examined whether incentive-based treatments improve treatment attendance, medication use and physical activity levels in people with SMI; however, initial evidence is positive and indicates that further research in these areas is warranted. CONCLUSION Given the medical and psychosocial costs of tobacco and other drug use, treatment non-compliance and physical inactivity, and the efficacy of incentive-based treatments for improving these behaviors, such interventions should be further developed and integrated into behavioral health treatment programs for people with SMI.
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Tuten M, DeFulio A, Jones HE, Stitzer M. Abstinence-contingent recovery housing and reinforcement-based treatment following opioid detoxification. Addiction 2012; 107:973-82. [PMID: 22151478 PMCID: PMC3421907 DOI: 10.1111/j.1360-0443.2011.03750.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To conduct a randomized, controlled trial of abstinence-contingent recovery housing delivered with or without intensive day treatment among individuals exiting residential opioid detoxification. DESIGN Random assignment to one of three conditions: recovery housing alone (RH), abstinence-contingent recovery housing with reinforcement-based treatment RBT (RH + RBT) or usual care (UC). RH and RH + RBT participants received 12 weeks of paid recovery housing contingent upon drug abstinence. RH + RBT participants also received 26 weeks of RBT, initiated concurrently with recovery housing. Assessments were conducted at 1, 3 and 6 months after treatment enrollment. SETTING Out-patient drug-free substance abuse treatment program in Baltimore, Maryland. PARTICIPANTS Patients (n = 243) who completed medication-assisted opioid detoxification. MEASUREMENTS Primary outcome was drug abstinence (opioid- and cocaine-negative urine and no self-reported opioid or cocaine use in the previous 30 days). Secondary outcomes included abstinence at all time-points (1, 3 and 6 months), days in recovery housing and employment. FINDINGS Overall rates of drug abstinence were 50% for RH + RBT, 37% for RH and 13% for UC (P < 0.001). At 6 months, RH + RBT participants remained more likely to meet abstinence criteria than UC participants (37% versus 20%, P = 0.016). Length of stay in recovery housing mediated abstinence outcomes and was longer in RH + RBT (49.5 days) than in RH (32.2 days; P < 0.002). CONCLUSIONS Abstinence-contingent recovery housing improves abstinence in opioid-dependent adults following medication-assisted detoxification. The addition of intensive 'reinforcement-based treatment' behavioural counseling further improves treatment outcomes, in part by promoting longer recovery house stays.
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Affiliation(s)
- Michelle Tuten
- Johns Hopkins University School of Medicine, Psychiatry and Behavioral Sciences, Baltimore, MD 21224, USA.
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Petry NM, Ford JD, Barry D. Contingency management is especially efficacious in engendering long durations of abstinence in patients with sexual abuse histories. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2011; 25:293-300. [PMID: 21443305 DOI: 10.1037/a0022632] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Exposure to sexual victimization is prevalent among persons with substance use disorders (SUDs). Contingency management (CM) treatments utilize concrete and relatively immediate positive reinforcers to retain patients in treatment and reduce substance use, and CM may have particular benefits for patients with histories of sexual victimization. Using data from three randomized trials of CM (N = 393), this study evaluated main and interactive effects of sexual abuse history and treatment condition (standard care versus CM) with respect to during treatment outcomes (retention, proportion of negative urine samples submitted, and longest duration of abstinence) and abstinence at a nine-month follow-up. Compared to patients without sexual abuse histories (N = 316), those with sexual abuse histories (N = 77) submitted a significantly higher proportion of negative samples in treatment. In CM, but not in standard care, patients with sexual abuse histories achieved significantly longer durations of abstinence during treatment than those without sexual abuse histories. Although sexual abuse history was not associated with abstinence at nine-month follow-up evaluations, longest duration of abstinence during treatment was significantly associated with this long-term outcome. Results suggest that SUD patients with sexual abuse histories may accrue particular benefits during CM treatment that are associated with long-term abstinence. (PsycINFO Database Record (c) 2011 APA, all rights reserved).
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Affiliation(s)
- Nancy M Petry
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3944, USA.
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Fitzpatrick-Lewis D, Ganann R, Krishnaratne S, Ciliska D, Kouyoumdjian F, Hwang SW. Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review. BMC Public Health 2011; 11:638. [PMID: 21831318 PMCID: PMC3171371 DOI: 10.1186/1471-2458-11-638] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 08/10/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status. METHODS A total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality. RESULTS Eighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations. CONCLUSIONS These studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.
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Affiliation(s)
- Donna Fitzpatrick-Lewis
- The Effective Public Health Practice Project, School of Nursing, McMaster University, Hamilton, Canada
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Koffarnus MN, Wong CJ, Diemer K, Needham M, Hampton J, Fingerhood M, Svikis DS, Bigelow GE, Silverman K. A randomized clinical trial of a Therapeutic Workplace for chronically unemployed, homeless, alcohol-dependent adults. Alcohol Alcohol 2011; 46:561-9. [PMID: 21622676 DOI: 10.1093/alcalc/agr057] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To assess the efficacy of the Therapeutic Workplace, a substance abuse intervention that promotes abstinence while simultaneously addressing the issues of poverty and lack of job skills, in promoting abstinence from alcohol among homeless alcoholics. METHODS Participants (n = 124) were randomly assigned to conditions either requiring abstinence from alcohol to engage in paid job skills training (Contingent Paid Training group), offering paid job skills training with no abstinence contingencies (Paid Training group) or offering unpaid job skill training with no abstinence contingencies (Unpaid Training group). RESULTS Participants in the Contingent Paid Training group had significantly fewer positive (blood alcohol level ≥ 0.004 g/dl) breath samples than the Paid Training group in both randomly scheduled breath samples collected in the community and breath samples collected during monthly assessments. The breath sample results from the Unpaid Training group were similar in absolute terms to the Contingent Paid Training group, which may have been influenced by a lower breath sample collection rate in this group and fewer reported drinks per day consumed at intake. CONCLUSION Overall, the results support the utility of the Therapeutic Workplace intervention to promote abstinence from alcohol among homeless alcoholics, and support paid training as a way of increasing engagement in training programs.
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Affiliation(s)
- Mikhail N Koffarnus
- Center for Learning and Health, Johns Hopkins University School of Medicine, MFL W142, 5200 Eastern Ave., Baltimore, MD 21224, USA.
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Abstract
BACKGROUND Assertive Community Treatment (ACT) has been studied extensively in people with severe mental illness, but there have only been a few clinical trials in which substance use was one of the measured outcomes. OBJECTIVE The goal of this article was to describe the efficacy of ACT in treating co-occurring substance use disorders and suggest approaches to make it more efficacious. DESIGN A literature review was conducted and randomized clinical trials describing ACT's impact on substance use were reviewed. RESULTS Four randomized clinical trials of ACT that measured substance abuse adequately were identified, all of which showed small to no effect on substance abuse compared with control conditions. Methodological issues might account for the small effects. ACT might further reduce substance use by being paired with evidenced-based substance abuse treatment, helping clients become housed or helping them manage their money better. CONCLUSION Integrated ACT, in which the ACT team provides substance abuse counseling, has the potential to reduce substance use by several mechanisms, but this has been difficult to demonstrate in clinical trials when participants in control groups receive similar interventions.
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Affiliation(s)
- Heather P Fries
- Yale University School of Medicine, New Haven, CT 06112, USA.
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North CS, Eyrich-Garg KM, Pollio DE, Thirthalli J. A prospective study of substance use and housing stability in a homeless population. Soc Psychiatry Psychiatr Epidemiol 2010; 45:1055-62. [PMID: 19816646 DOI: 10.1007/s00127-009-0144-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 09/22/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study examined self-report and urine test data about homeless substance use over time, prospectively comparing substance use with attainment of stable housing. METHODS 400 homeless people systematically sampled from shelters and streets in St. Louis, Missouri were assessed with structured diagnostic interviews and urine substance testing annually over 2 years. Nearly two-thirds (n = 255) completed all three assessments, constituting the sample for this prospective study. RESULTS More than half (55%) of this homeless sample had detectable cocaine use during the study. Most cocaine users continued using during the next 2 years and failed to achieve and maintain stable housing. Cocaine use in the first follow-up year predicted housing patterns over the next 2 years, independent of lifetime diagnosis of cocaine use disorder. Alcohol abuse/dependence in the 2-year follow-up period did not predict housing outcomes. CONCLUSIONS The course of cocaine use and abuse/dependence, but not continuing alcohol addiction, was associated with subsequent attainment of stable housing, especially cocaine use in the first prospective year. Replication of these findings in other locations to determine generalizability may have implications for designing housing service models.
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Affiliation(s)
- Carol S North
- VA North Texas Health Care System, 4500 S. Lancaster Rd., Dallas, TX 75216, USA.
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21
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Addiction treatment and stable housing among a cohort of injection drug users. PLoS One 2010; 5:e11697. [PMID: 20657732 PMCID: PMC2908142 DOI: 10.1371/journal.pone.0011697] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 06/25/2010] [Indexed: 11/19/2022] Open
Abstract
Background Unstable housing and homelessness is prevalent among injection drug users (IDU). We sought to examine whether accessing addiction treatment was associated with attaining stable housing in a prospective cohort of IDU in Vancouver, Canada. Methods We used data collected via the Vancouver Injection Drug User Study (VIDUS) between December 2005 and April 2010. Attaining stable housing was defined as two consecutive “stable housing” designations (i.e., living in an apartment or house) during the follow-up period. We assessed exposure to addiction treatment in the interview prior to the attainment of stable housing among participants who were homeless or living in single room occupancy (SRO) hotels at baseline. Bivariate and multivariate associations between the baseline and time-updated characteristics and attaining stable housing were examined using Cox proportional hazard regression models. Principal Findings Of the 992 IDU eligible for this analysis, 495 (49.9%) reported being homeless, 497 (50.1%) resided in SRO hotels, and 380 (38.3%) were enrolled in addiction treatment at the baseline interview. Only 211 (21.3%) attained stable housing during the follow-up period and of this group, 69 (32.7%) had addiction treatment exposure prior to achieving stable housing. Addiction treatment was inversely associated with attaining stable housing in a multivariate model (adjusted hazard ratio [AHR] = 0.71; 95% CI: 0.52–0.96). Being in a partnered relationship was positively associated with the primary outcome (AHR = 1.39; 95% CI: 1.02–1.88). Receipt of income assistance (AHR = 0.65; 95% CI: 0.44–0.96), daily crack use (AHR = 0.69; 95% CI: 0.51–0.93) and daily heroin use (AHR = 0.63; 95% CI: 0.43–0.92) were negatively associated with attaining stable housing. Conclusions Exposure to addiction treatment in our study was negatively associated with attaining stable housing and may have represented a marker of instability among this sample of IDU. Efforts to stably house this vulnerable group may be occurring in contexts outside of addiction treatment.
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Milby JB, Schumacher JE, Wallace D, Vuchinich R, Mennemeyer ST, Kertesz SG. Effects of sustained abstinence among treated substance-abusing homeless persons on housing and employment. Am J Public Health 2009; 100:913-8. [PMID: 19833998 DOI: 10.2105/ajph.2008.152975] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined whether cocaine-dependent homeless persons had stable housing and were employed 6, 12, and 18 months after they entered a randomized controlled trial comparing 2 treatments. METHODS One group (n = 103) received abstinence-contingent housing, vocational training, and work; another group (n = 103) received the same intervention plus cognitive behavioral day treatment. We examined baseline and early treatment variables for association with long-term housing and employment. RESULTS Although the enhanced-treatment group achieved better abstinence rates, the groups did not differ in long-term housing and employment stability. However, consecutive weeks of abstinence during treatment (and to a lesser extent, older age and male gender) predicted long-term housing and employment stability after adjustment for baseline differences in employment, housing, and treatment. CONCLUSIONS Our data showed a relationship of abstinence with housing stability. Contrasting these results with the increasingly popular Housing First interventions reveals important gaps in our knowledge to be addressed in future research.
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Affiliation(s)
- Jesse B Milby
- Department of Psychology, University of Alabama at Birmingham, CH 201, 1530 3rd Ave S, Birmingham, AL 35294-1170, USA.
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Kertesz SG, Crouch K, Milby JB, Cusimano RE, Schumacher JE. Housing first for homeless persons with active addiction: are we overreaching? Milbank Q 2009; 87:495-534. [PMID: 19523126 PMCID: PMC2881444 DOI: 10.1111/j.1468-0009.2009.00565.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
CONTEXT More than 350 communities in the United States have committed to ending chronic homelessness. One nationally prominent approach, Housing First, offers early access to permanent housing without requiring completion of treatment or, for clients with addiction, proof of sobriety. METHODS This article reviews studies of Housing First and more traditional rehabilitative (e.g., "linear") recovery interventions, focusing on the outcomes obtained by both approaches for homeless individuals with addictive disorders. FINDINGS According to reviews of comparative trials and case series reports, Housing First reports document excellent housing retention, despite the limited amount of data pertaining to homeless clients with active and severe addiction. Several linear programs cite reductions in addiction severity but have shortcomings in long-term housing success and retention. CONCLUSIONS This article suggests that the current research data are not sufficient to identify an optimal housing and rehabilitation approach for an important homeless subgroup. The research regarding Housing First and linear approaches can be strengthened in several ways, and policymakers should be cautious about generalizing the results of available Housing First studies to persons with active addiction when they enter housing programs.
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Affiliation(s)
- Stefan G Kertesz
- Center for Surgical, Medical Acute Care Research and Transitions at the Birmingham Veterans Affairs Medical Center, University of Alabama, Birmingham, AL 35294, USA.
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Milby JB, Schumacher JE, Vuchinich RE, Freedman MJ, Kertesz S, Wallace D. Toward cost-effective initial care for substance-abusing homeless. J Subst Abuse Treat 2008; 34:180-91. [PMID: 17512156 PMCID: PMC2764243 DOI: 10.1016/j.jsat.2007.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 02/28/2007] [Accepted: 03/04/2007] [Indexed: 11/17/2022]
Abstract
In a randomized controlled trial, behavioral day treatment, including contingency management (CM+), was compared to contingency management components alone (CM). All 206 cocaine-dependent homeless participants received a furnished apartment with food and work training/employment contingent on drug-negative urine tests. CM+ also received cognitive-behavioral therapy, therapeutic goal management, and other intervention components. Results revealed that CM+ treatment attendance and abstinence were not significantly different from CM during 24 weeks of treatment. After treatment and contingencies ended, however, CM+ showed more abstinence than CM, indicating a delayed effect of treatment from 6 to 18 months. CM+ had more consecutive weeks abstinent across 52 weeks, but not during active treatment. We conclude that CM alone may be viable as initial care for cocaine-dependent homeless persons. That CM+ yields more durable abstinence indicates that it may be appropriate as stepped-up care for clients not responding to CM (Clinical Trials.gov, no. NCT00368524).
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Affiliation(s)
- Jesse B Milby
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL 35294-1170, USA.
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Slesnick N, Kang MJ, Bonomi AE, Prestopnik JL. Six- and twelve-month outcomes among homeless youth accessing therapy and case management services through an urban drop-in center. Health Serv Res 2008; 43:211-29. [PMID: 18211526 PMCID: PMC2323142 DOI: 10.1111/j.1475-6773.2007.00755.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
RESEARCH OBJECTIVE To evaluate the impact of case management and individual therapy offered through a drop-in center for homeless youth on substance use, mental health, housing, education, employment, and medical care utilization. STUDY POPULATION All youth (n=172) between the ages of 14-24 who accessed treatment services through an urban, southwestern drop-in center were included. DATA SOURCE Semistructured and self-report questionnaires were administered to youth between October 2002 and April 2005. STUDY DESIGN A repeated measures design was utilized. Youth were assessed at baseline, 6 months, and 12 months postbaseline. Hierarchical linear modeling was used to test the hypotheses. PRINCIPAL FINDINGS Statistically significant improvements were found in substance abuse, mental health, and percent days housed up to 12 months postbaseline. Decreased alcohol and drug use was associated with an increase in housing. However, most youth did not acquire permanent housing, and education, employment, and medical service utilization did not significantly change over time. CONCLUSIONS While treatment offered through drop-in centers for homeless youth can positively impact homeless youth, policy, funding, and service provision need greater focus, collaboration, and support if youth homelessness is to be successfully addressed.
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Affiliation(s)
- Natasha Slesnick
- Department of Human Development and Family Science, 135 Campbell Hall, 1787 Neil Avenue, The Ohio State University, Columbus, OH 43210, USA
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Cleary M, Hunt G, Matheson S, Siegfried N, Walter G. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev 2008:CD001088. [PMID: 18253984 DOI: 10.1002/14651858.cd001088.pub2] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES To assess the effects of psychosocial interventions for substance reduction in people with a serious mental illness. SEARCH STRATEGY For this update (2007) we searched the Cochrane Schizophrenia Group Trials Register (May 2006) which is based on regular searches of major databases. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random effects model. We calculated numbers needed to treat/harm (NNT/NNH) where data were homogeneous. For continuous data, we calculated weighted mean differences (WMD) again based on a random effects model. MAIN RESULTS Evaluation of long-term integrated care included 4 RCTs (total n=735). We found no significant difference on measures of substance use (n=85, 1 RCT, RR 0.89 CI 0.6 to 1.3) or loss to treatment (n=603, 3 RCTs, RR 1.09 CI 0.8 to 1.5). For the non-integrated intensive case management trials (4 RCTs, total n=151) we also found no significant difference for loss (n=134, 3 RCTs, RR 1.35 CI 0.8 to 2.2). Motivational interviewing plus cognitive behavioural therapy (3 RCTs, total n=276) did not reveal any advantage for retaining participants (n=36, 1 RCT, RR lost to treatment 0.50 CI 0.1 to 5.0) or for relapse (n=36, 1 RCT, RR 0.58 CI 0.3 to 1.1), and no benefit for reducing substance use (n=119, 1 RCT, RR 0.19 CI -0.2 to 0.6). Cognitive behavioural therapy alone (4 trials, total n=260) showed fewer participants lost from treatment (n=260, 4 RCTs, p=0.02, RR 0.61 CI 0.4 to 0.9). No benefits were observed on measures of lessening cannabis use (n=47, 1 RCT, RR 1.30 CI 0.8 to 2.2) or on the number of participants using substances (alcohol; n=46, 1 RCT, RR 5.88 CI 0.8 to 44.0, drugs; n=46, 1 RCT, RR 2.02 CI 0.9 to 4.8) and no differences were observed on measures of mental state (n=105, 1 RCT, RR 0.52 CI -0.8 to 1.8). We found no advantage for motivational interviewing alone (5 trials, total n=338) in reducing 'lost to evaluation' (n=338, 5 RCTs, RR 0.96 CI 0.6 to 1.5) compared with treatment as usual, although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n=93, 1 RCT, RR 0.69 CI 0.5 to 0.9, NNT 4 CI 3 to 12). Some differences were observed in abstaining from alcohol favouring treatment (n=28, 1 RCT, RR 0.36 CI 0.2 to 0.8, NNT 2 CI 2 to 5), but not other substances (n=89, 1 RCT, RR -0.07 CI -0.6 to 0.4) and no differences were observed in mental state (n=30, 1 RCT, WMD -4.20 CI -18.7 to 10.3). Finally, we found no significant differences for skills training in the numbers lost to treatment by 12 months (n=94, 2 RCTs, RR 0.70 CI 0.4 to 1.1). AUTHORS' CONCLUSIONS We included 25 RCTs and found no compelling evidence to support any one psychosocial treatment over another to reduce substance use (or improve mental state) by people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results; high drop out rates, varying fidelity of interventions, varying outcome measures, settings and samples and comparison groups may have received higher levels of treatment than standard care. Further studies are required which address these concerns and improve the evidence in this important area.
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Affiliation(s)
- M Cleary
- Sydney South West Area Health Service (Eastern Zone), Research Unit, Rozelle Hospital, P.O. Box 1, Rozelle, Australia, NSW 2039.
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Tracy K, Babuscio T, Nich C, Kiluk B, Carroll KM, Petry NM, Rounsaville BJ. Contingency Management to reduce substance use in individuals who are homeless with co-occurring psychiatric disorders. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2007; 33:253-8. [PMID: 17497548 PMCID: PMC3390023 DOI: 10.1080/00952990601174931] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Homeless shelters provide a unique opportunity to intervene with occupants who have substance abuse problems, as not addressing these issues may lead to continuation of problems playing a contributing role in homelessness. Attempts to implement Contingency Management (CM) with this population have often been complex, costly, and not straightforward to replicate in community settings. We conducted a randomized trial evaluating a simple, low-cost 4-week CM program for 30 individuals seeking shelter in a community-based homeless shelter who had both current substance and psychiatric disorders. Behavioral assessments were performed at baseline, weekly, and termination of the study. Overall retention in the trial was high; participants assigned to CM reduced their cocaine and alcohol use more than those in assessment-only. This pilot trial suggests that application of low-cost CM procedures is feasible within this novel setting and may decrease substance use.
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Affiliation(s)
- Kathlene Tracy
- New York University School of Medicine, New York, NY 10032, USA
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Fisk D, Sells D, Rowe M. Sober housing and motivational interviewing: the Treatment Access Project. J Prim Prev 2007; 28:281-93. [PMID: 17551837 DOI: 10.1007/s10935-007-0096-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Accepted: 03/22/2007] [Indexed: 10/23/2022]
Abstract
This paper describes an innovative program that provides rental subsidies for sober housing and supportive services to persons in early recovery who are homeless and have substance use disorders. Preliminary data point to the success of this program in enhancing recovery and exiting from homelessness. In supporting sober house placements, the Treatment Access Project creates a bridge that supports these individuals in their transition from clinical treatment services to the community. Integration with natural community supports can help to build self-efficacy, which can enhance the likelihood that this population will obtain and maintain abstinence, gainful employment, and permanent housing.
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Affiliation(s)
- Deborah Fisk
- Department of Psychiatry, LCSW, Connecticut Mental Health Center, Yale School of Medicine, 235 Nicoll Street, New Haven, CT 06511, USA.
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Abstract
BACKGROUND Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis. METHODS This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis. RESULTS Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes. CONCLUSIONS Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.
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Affiliation(s)
- Quyen Q Tiet
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, California 94025, USA.
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Kertesz SG, Mullins AN, Schumacher JE, Wallace D, Kirk K, Milby JB. Long-term housing and work outcomes among treated cocaine-dependent homeless persons. J Behav Health Serv Res 2006; 34:17-33. [PMID: 17171458 PMCID: PMC1885681 DOI: 10.1007/s11414-006-9041-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 10/11/2006] [Indexed: 11/30/2022]
Abstract
Communities across the United States have initiated plans to end chronic homelessness. In many of these communities, addiction treatment programs remain the default point of entry to housing and services. This study examined the percentage of cocaine-using homeless persons (all with psychiatric distress) attaining stable housing and employment 12 months after entering a randomized trial of intensive behavioral day treatment, plus one of the following for 6 months: no housing; housing contingent on drug abstinence; housing not contingent on abstinence. Of 138 participants, the percentages with stable housing and employment at 12 months were 34.1 and 33.3%, respectively. Analyses suggested superior outcomes in trial arms that offered housing as part of the behavioral treatment. The majority of participants, however, did not achieve housing or employment, in part because of the limited capacity of the local housing programs to accommodate persons who had not achieved perfect abstinence. The findings demonstrate a helpful role for addiction treatment and suggest the need for services to support housing of persons who reduce but do not eliminate all substance use.
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Affiliation(s)
- Stefan G Kertesz
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham and Deep South Center on Effectiveness at Birmingham Veterans' Affairs Medical Center, 1530 3rd Ave South MT608, Birmingham, AL 35294-4410, USA.
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Kertesz SG, Madan A, Wallace D, Schumacher JE, Milby JB. Substance abuse treatment and psychiatric comorbidity: do benefits spill over? Analysis of data from a prospective trial among cocaine-dependent homeless persons. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2006; 1:27. [PMID: 16965639 PMCID: PMC1584225 DOI: 10.1186/1747-597x-1-27] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Accepted: 09/11/2006] [Indexed: 11/10/2022]
Abstract
Background Comorbid psychiatric illness can undermine outcomes among homeless persons undergoing addiction treatment, and psychiatric specialty care is not always readily available. The prognosis for nonsubstance abuse psychiatric diagnoses among homeless persons receiving behaviorally-based addiction treatment, however, is little studied. Results Data from an addiction treatment trial for 95 cocaine-dependent homeless persons (1996–1998) were used to profile psychiatric diagnoses at baseline and 6 months, including mood-related disorders (e.g. depression) and anxiety-related disorders (e.g. post-traumatic stress disorder). Treatment interventions, including systematic reinforcement for goal attainment, were behavioral in orientation. There was a 32% reduction in the prevalence of comorbid non-addiction psychiatric disorder from baseline to 6 months, with similar reductions in the prevalence of mood (-32%) and anxiety-related disorders (-20%) (p = 0.12). Conclusion Among cocaine-dependent homeless persons with psychiatric comorbidity undergoing behavioral addiction treatment, a reduction in comorbid psychiatric disorder prevalence was observed over 6 months. Not all participants improved, suggesting that even evidence-based addiction treatment will prove insufficient for a meaningful proportion of the dually diagnosed homeless population.
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Affiliation(s)
- Stefan G Kertesz
- Division of Preventive Medicine, University of Alabama at Birmingham, School of Medicine and the Deep South Center on Effectiveness at the Birmingham Veterans' Affairs Medical Center; 1530 3rd Ave South MT 608 Birmingham, Alabama 35294, USA
| | - Alok Madan
- Department of Psychiatry, University of North Carolina School of Medicine, Medical School Wing E, CB#7205 Chapel Hill, North Carolina 27599-7205, USA
| | - Dennis Wallace
- Rho Federal Systems, Inc., Chapel Hill, North Carolina 27517, USA
| | - Joseph E Schumacher
- Division of Preventive Medicine, The University of Alabama at Birmingham, School of Medicine. 1530 3rd Ave South MT 616 Birmingham, Alabama 35294, USA
| | - Jesse B Milby
- Department of Psychology, The University of Alabama at Birmingham, Division of Preventive Medicine, The University of Alabama at Birmingham, 1530 3rd Ave South CH 415 Birmingham, Alabama 35294, USA
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Abstract
Clinical research trials demonstrate the efficacy of contingency management procedures in treating substance use disorders. Usually, reinforcement, in the form of vouchers exchangeable for retail goods and services, is provided for drug abstinence in patients treated in psychosocial or methadone maintenance clinics. Recently, the types of reinforcers have been adapted to include lower cost alternatives, and reinforcement is being expanded to alter other target behaviors such as attendance at treatment, adherence to treatment goals, and compliance with medication. This chapter provides an overview of the populations and behaviors to which contingency management approaches have been applied. It also reviews design features that appear critical in the successful adaptation of the techniques. In addition, areas for future research are described.
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Affiliation(s)
- Maxine Stitzer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224, USA.
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Milby JB, Schumacher JE, Wallace D, Freedman MJ, Vuchinich RE. To house or not to house: the effects of providing housing to homeless substance abusers in treatment. Am J Public Health 2005; 95:1259-65. [PMID: 15983278 PMCID: PMC1449349 DOI: 10.2105/ajph.2004.039743] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Housing typically is not provided to homeless persons during drug abuse treatment. We examined how treatment outcomes were affected under 3 different housing provision conditions. METHODS We studied 196 cocaine-dependent participants who received day treatment and no housing (NH), housing contingent on drug abstinence (ACH), or housing not contingent on abstinence (NACH). Drug use was monitored with urine testing. RESULTS The ACH group had a higher prevalence of drug abstinence than the NACH group (after control for treatment attendance), which in turn had a higher prevalence than the NH group. All 3 groups showed significant improvement in maintaining employment and housing. CONCLUSIONS The results of this and previous trials indicate that providing abstinence-contingent housing to homeless substance abusers in treatment is an efficacious, effective, and practical intervention. Programs to provide such housing should be considered in policy initiatives.
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Affiliation(s)
- Jesse B Milby
- Department of Psychology-CH415, University of Al-abama at Birmingham, 1530 3rd Ave S, Birmingham, AL 35294-1170, USA.
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Jones HE, Wong CJ, Tuten M, Stitzer ML. Reinforcement-based therapy: 12-month evaluation of an outpatient drug-free treatment for heroin abusers. Drug Alcohol Depend 2005; 79:119-28. [PMID: 16002021 DOI: 10.1016/j.drugalcdep.2005.01.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2004] [Revised: 01/03/2005] [Accepted: 01/03/2005] [Indexed: 10/25/2022]
Abstract
This controlled study examined the efficacy of reinforcement-based therapy (RBT) for producing enhanced abstinence outcomes over 12 months in opioid-dependent patients exiting a brief residential detoxification. Patients were randomly assigned upon completing their medically managed taper (i.e., detoxification) to RBT (N=66) or usual care (N=64) referral to community treatment programs. The 6-month RBT program offered an array of abstinence-based incentives including rent payment for recovery housing, program-led recreational activities and skills training for procuring employment. RBT produced significantly higher self-report and urinalysis-confirmed rates of abstinence from opioids and cocaine relative to usual care at 1 (42% versus 15%) and 3 (38% versus 17%) months during treatment but not at 6 or 12 months after enrollment. The RBT but not the usual care group showed significant increases in the number of days worked and the amount of legal income earned at 3, 6 and 12 months. The results of this randomized study suggest that an intensive reinforcement-based therapy that includes abstinence-based recovery housing is a promising approach; however, further research is needed to determine the role of treatment intensity and the specific efficacy of RBT's component parts.
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Affiliation(s)
- Hendree E Jones
- Cornerstone Treatment Research Clinic, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Cornerstone D-3-E, 4940 Eastern Avenue, Baltimore, MD 21224, USA.
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Carroll KM. Behavioral therapies for co-occurring substance use and mood disorders. Biol Psychiatry 2004; 56:778-84. [PMID: 15556123 PMCID: PMC3693566 DOI: 10.1016/j.biopsych.2004.07.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Revised: 07/14/2004] [Accepted: 07/20/2004] [Indexed: 11/24/2022]
Abstract
There has been marked progress in recent years in the development of effective behavioral therapies for substance use disorders and in the largely independent development of behavioral therapies for mood disorders. Until recently, however, there were few well-specified behavioral approaches that incorporated an integrated approach for individuals in whom these disorders co-occur. The emerging literature on the efficacy of several types of behavioral therapy for engaging individuals with co-occurring mood and substance use disorders in treatment, reducing substance use and affective symptoms, enhancing adherence, and preventing disengagement and relapse is reviewed, followed by discussion of the challenges likely to be met in integrating these behavioral approaches into clinical practice.
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Affiliation(s)
- Kathleen M Carroll
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06516, USA.
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Milby JB, Schumacher JE, Vuchinich RE, Wallace D, Plant MA, Freedman MJ, McNamara C, Ward CL. Transitions during effective treatment for cocaine-abusing homeless persons: establishing abstinence, lapse, and relapse, and reestablishing abstinence. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2004; 18:250-6. [PMID: 15482080 DOI: 10.1037/0893-164x.18.3.250] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Data are reported on drug use among cocaine-dependent homeless persons who participated in a clinical trial that compared day treatment only (DT, n = 69) with day treatment plus abstinent-contingent housing and work (DT+, n = 72). Drug use was measured with multiple weekly urine toxicologies. Compared with DT participants, more DT+ participants established abstinence, maintained abstinence for longer durations, were marginally significantly more likely to lapse, and significantly less likely to relapse. Of all participants who established abstinence and then relapsed, DT+ participants relapsed later and were more likely to reestablish abstinence. These analyses yield information on the processes involved in the manner in which drug use changes as a result of abstinent-contingent housing and work.
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Affiliation(s)
- Jesse B Milby
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL 35294-1170, USA
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Milby JB, Schumacher JE, Wallace D, Frison S, McNamara C, Usdan S, Michael M. Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up. J Consult Clin Psychol 2003; 71:619-21. [PMID: 12795584 DOI: 10.1037/0022-006x.71.3.619] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstinence, employment, and homelessness treatment outcomes at 12-month follow-up are presented from a study comparing behavioral day treatment plus abstinence-contingent housing and work therapy with behavioral day treatment only among homeless persons who abuse crack cocaine. Within-group improvements were revealed, but group differences for drug abstinence found in J. B. Milby et al. (2000) failed to persist at 12 months. Drug use measurement and treatment termination explanations are discussed. Within- but not between-group differences were found for employment and homelessness outcomes at long-term follow-up. Research extending abstinence contingencies and continuous drug use monitoring is recommended. Questions about effectiveness of contingency management alone, role of coexisting psychiatric disorders on treatment outcome, and individualized treatment dosing are offered.
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Affiliation(s)
- Jesse B Milby
- Department of Psychology, University of Alabama at Birmingham, 35294-1170, USA.
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Schumacher JE, Milby JB, Wallace D, Simpson C, Frison S, McNamara C, Usdan S. Diagnostic compared with abstinence outcomes of day treatment and contingency management among cocaine-dependent homeless persons. Exp Clin Psychopharmacol 2003; 11:146-57. [PMID: 12755459 DOI: 10.1037/1064-1297.11.2.146] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Substance use disorder diagnoses were used as a treatment outcome measure in a randomized comparison of day treatment (DT) and day treatment plus contingency management (DT+) among homeless persons with primarily crack/cocaine disorders. Participants (N = 127, DT+ = 69, DT = 58, 73.2% male, 82.7% African American) were assessed at baseline and 6-month treatment completion. Binary positive and negative diagnostic outcomes for cocaine, marijuana, and alcohol were compared by treatment group. DT+ was 2.1 times more likely to have a positive treatment outcome than DT. Concordance between diagnostic change and point and continuous abstinence outcomes were found. The use of diagnostic change can be a practical addition to drug toxicology and self-report treatment outcome measures for research and practice.
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