Evaluation Of Treatments Of Opioid And Cocaine Dependence

阿片类药物和可卡因依赖的治疗评估

• 批准号: 8336419
• 负责人: Kenzie Preston
• 金额: $ 73.93万
• 依托单位: NATIONAL INSTITUTE ON DRUG ABUSE
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8336419
• 关键词: Abstinence; Address; Amaze; Behavior; Behavior Therapy; Behavioral; Buprenorphine; Characteristics; Cigarette; Clinic; Clinical Trials; Cocaine; Cocaine Dependence; Cocaine Users; Cognitive Therapy; Collaborations; Commit; Communities; Computer software; Cross-Over Studies; Data; Data Analyses; Devices; Drug usage; Electronics; Elements; Environment; Environmental Exposure; Evaluation; Evidence based treatment; Exposure to; Frequencies; Goals; Heroin Users; Incentives; Individual; Intervention; Management Decision Support Systems; Measures; Methadone; Moods; National Institute of Drug Abuse; Nicotine; Opiate Addiction; Opioid; Outcome; Outpatients; Pamphlets; Participant; Patients; Personal Digital Assistant; Pilot Projects; Population Intervention; Professional counselor; Psychological reinforcement; Randomized; Research Infrastructure; Resources; Sampling; Schedule; Simulate; Smoke; Smoker; Solutions; Spottings; Stress; Substance Addiction; System; Technology; Technology Transfer; Testing; Text; Treatment outcome; Urine; Withholding Treatment; Work; addiction; biomedical informatics; cigarette smoking; contingency management; cost; craving; design; diaries; drug abstinence; effective therapy; improved; insight; medication compliance; non-smoker; programs; psychosocial; response; self reported behavior; smoking cessation; stressor; substance abuser; technology development; treatment program; trend; usability

The Treatment Section has been engaged in a long-term project to improve treatment for substance dependence through behavioral, pharmacologic, or combined behavioral and pharmacologic interventions. Substantial effort has been directed toward identifying the most effective ways to deliver contingency management, a behavioral treatment in which incentives are used to increase the frequency of desirable behaviors, such as drug abstinence or medication adherence. A major challenge associated with contingency management is its likely prohibitive cost and staff/resource intensity, especially when the reinforcement follows an escalating schedule (i.e., when each consecutive occurrence of the desired behavior is reinforced more than the lastan especially effective treatment). One of the major implementation challenges for community clinics is keeping track of each patients prior earnings so that current earnings can be calculated on the spot. To address this and related challenges, in collaboration with the Biomedical Informatics Section of the NIDA IRP, we developed a software application, the Automated Contingency Management (ACM) decision support system for abstinence reinforcement. We are continuing to improve the system and to develop mechanisms to make it available to community treatment programs at no cost to them. We are completing a project field-testing the usability and robustness of the current version of the software, Motivational Incentives Implementation Software (MIIS), implemented under conditions simulating those of a community treatment program little technology infrastructure or staff expertise. This system will be distributed to community treatment programs to promote technology transfer and increase community use of evidence-based treatments for addiction. In further technology-development work, we are exploring the use of handheld electronic devices for treatment delivery in patients daily environments. We have completed a pilot study using these devices to remind patients to complete homework assigned by counselors as part of Cognitive-Behavioral Therapy (CBT). We conducted a within-subjects 2x2 randomized-block-design crossover study to investigate the effects of homework-task difficulty and electronic-diary reminders on compliance to and quality of homework completion among methadone-maintained cocaine and heroin users in CBT. Participants, in addition to completing a homework task between each of 12 weekly therapy sessions, carried a personal digital assistant (PDA), which was programmed to provide a daily reminder regarding homework completion during alternate weeks of the study. Homework was given in two different forms during alternating 3-week blocks: standard sheets of text versus simplified, illustrated booklets. Neither the simplified homework nor the PDA reminders significantly increased homework completion rates. For homework simplification, there were (non-significant) trends toward beneficial effects on homework completion; however, electronic prompting as implemented in this study had (non-significant) deleterious effects on homework completion. There were trends for the simplified homework tasks to be rated higher by counselors in terms of participants enthusiasm and understanding, although, unexpectedly, electronically prompted homework was also rated higher in terms of participants understanding. We suspect that a mobile intervention for this population may need to go beyond a reminder beep and incorporate interactive elements; we are beginning to pursue this line of intervention. In related work, we are developing Geographical Momentary Assessment, a descriptive approach to better measure and understand the relationships among mood, drug use, and environmental exposure to psychosocial stressors. We remain committed to transforming description into intervention. For example, we have shown that electronic-diary studies can provide amazing insight into the daily lives of substance abusers during treatment and data that are sensitive to behavioral changes during even brief periods of abstinence. The technologies that enable us to collect data on drug use, craving, and stress in the field may also be used for delivery of treatment in the field, perhaps in response to the patients own self-reported behaviors or previously identified triggers. The Treatment Section continues to investigate predictors that might be useful for patient-treatment matching to improve the delivery of appropriate treatments to individual patients. We recently undertook a secondary analysis of data from one of our outpatient clinical trials of buprenorphine treatment for concurrent cocaine and opioid dependence (13 weeks, N = 200). We evaluated the association between cigarette smoking (lifetime cigarette smoking status, number of cigarettes smoked per day prior to study entry) and short-term treatment outcome (% of urine samples positive for cocaine or opioids, treatment retention). Nicotine-dependent smokers (66% of participants) had a significantly higher percentage of cocaine-positive urine samples than non-smokers (12% of participants) (76% vs. 62%), but did not differ in percentage of opioid-positive urine samples or treatment retention. Number of cigarettes smoked per day at baseline was positively associated with percentage of cocaine-positive urine samples, even after controlling for baseline sociodemographic and drug-use characteristics, but was not significantly associated with percentage of opioid-positive urine samples or treatment retention. These results suggest that cigarette smoking is associated with poorer short-term outcome in outpatient treatment for cocaine dependence, but perhaps not for concurrent opioid dependence, and support the importance of offering smoking-cessation treatment to cocaine-dependent patients.

治疗科一直致力于一项长期项目，通过行为、药理学或行为和药理学相结合的干预措施来改善物质依赖的治疗。 人们付出了大量的努力来确定最有效的方法来提供应急管理，这是一种行为治疗，其中使用激励措施来增加理想行为的频率，例如药物戒断或药物依从性。与应急管理相关的一个主要挑战是其可能令人望而却步的成本和人员/资源强度，特别是当强化遵循逐步升级的时间表时（即，当每次连续发生的所需行为得到的强化超过最后一个特别有效的治疗时）。 社区诊所的主要实施挑战之一是跟踪每个患者之前的收入，以便可以当场计算当前的收入。为了解决这一问题和相关挑战，我们与 NIDA IRP 生物医学信息学部门合作，开发了一款软件应用程序，即用于强化戒断的自动应急管理 (ACM) 决策支持系统。我们正在继续改进该系统并制定机制，使其免费提供给社区治疗项目。我们正在完成一个项目，对当前版本的软件（激励实施软件（MIIS））的可用性和稳健性进行现场测试，该软件是在模拟社区治疗计划的条件下实施的，几乎没有技术基础设施或员工专业知识。该系统将分发给社区治疗项目，以促进技术转让并增加社区对成瘾循证治疗的使用。 在进一步的技术开发工作中，我们正在探索使用手持电子设备在患者的日常环境中提供治疗。我们已经完成了一项试点研究，使用这些设备提醒患者完成辅导员布置的作业，作为认知行为治疗 (CBT) 的一部分。我们进行了一项受试者内 2x2 随机区组设计交叉研究，以调查家庭作业任务难度和电子日记提醒对 CBT 中使用美沙酮的可卡因和海洛因使用者遵守作业的依从性和作业完成质量的影响。 参与者除了在每周 12 次治疗期间完成一项家庭作业外，还携带一台个人数字助理 (PDA)，该设备被编程为在研究的每隔几周内提供有关家庭作业完成情况的每日提醒。在交替的三周时间内，家庭作业以两种不同的形式布置：标准的文本表格与简化的插图小册子。简化的作业和 PDA 提醒都没有显着提高作业完成率。对于家庭作业简化，存在对家庭作业完成产生有益影响的（非显着）趋势；然而，本研究中实施的电子提示对家庭作业的完成有（非显着）有害影响。在参与者的热情和理解方面，辅导员对简化的家庭作业任务的评分有较高的趋势，尽管出乎意料的是，电子提示的家庭作业在参与者的理解方面也得到了较高的评分。 我们怀疑针对这一人群的移动干预可能需要超越提示音并融入互动元素；我们正开始采取这种干预措施。 在相关工作中，我们正在开发地理瞬时评估，这是一种描述性方法，可以更好地测量和理解情绪、药物使用和社会心理压力源环境暴露之间的关系。我们仍然致力于将描述转化为干预。例如，我们已经证明，电子日记研究可以提供对药物滥用者在治疗期间日常生活的惊人洞察，以及对即使是短暂的戒断期间的行为变化敏感的数据。使我们能够在现场收集有关药物使用、渴望和压力数据的技术也可用于在现场提供治疗，也许是为了响应患者自己报告的行为或之前确定的触发因素。 治疗部分继续研究可能对患者治疗匹配有用的预测因素，以改善为个体患者提供适当治疗的情况。我们最近对一项丁丙诺啡治疗并发可卡因和阿片类药物依赖的门诊临床试验的数据进行了二次分析（13 周，N = 200）。我们评估了吸烟（终生吸烟状况、进入研究前每天吸烟的数量）和短期治疗结果（可卡因或阿片类药物阳性尿液样本的百分比、治疗保留）之间的关联。尼古丁依赖吸烟者（66% 的参与者）的可卡因阳性尿液样本比例显着高于非吸烟者（12% 的参与者）（76% vs. 62%），但阿片类药物阳性的比例没有差异尿液样本或治疗保留。即使在控制了基线社会人口统计学和药物使用特征之后，基线每天吸烟的数量与可卡因阳性尿液样本的百分比呈正相关，但与阿片类药物阳性尿液样本的百分比或治疗保留率没有显着相关。这些结果表明，吸烟与可卡因依赖门诊治疗的短期结果较差有关，但可能与并发的阿片类药物依赖无关，并支持为可卡因依赖患者提供戒烟治疗的重要性。