Perspective is everything: the predictive validity of six working alliance instruments.

The predictive validity of instruments commonly used to measure the therapeutic alliance was evaluated, using 46 sessions drawn from a clinical trial comparing manual-guided therapies for substance use. The California Psychotherapy Alliance Scale, Penn Helping Alliance Rating Scale, Vanderbilt Therapeutic Alliance Scale, and Working Alliance Inventory (Observer, Therapist, and Client versions) were rated for participants receiving either cognitive-behavioral therapy or twelve-step facilitation. All observer-rated instruments were significantly correlated with outcome; however, therapist-rated and client-rated instruments did not predict outcome. Findings suggest that the different observer-rated instruments are minimally different with respect to predictive validity, whereas patient- and therapist-rated measures may have a weaker relationship to outcome when highly objective outcome measures are used.

Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: efficacy of contingency management and significant other involvement.

BACKGROUND: Contingency management (CM) and significant other involvement (SO) were evaluated as strategies to enhance treatment retention, medication compliance, and outcome for naltrexone treatment of opioid dependence. METHODS: One hundred twenty-seven recently detoxified opioid-dependent individuals were randomly assigned to 1 of 3 conditions delivered for 12 weeks: (1) standard naltrexone treatment, given 3 times a week; (2) naltrexone treatment plus contingency management (CM), with delivery of vouchers contingent on naltrexone compliance and drug-free urine specimens; or (3) naltrexone treatment, CM, plus significant other involvement (SO), where a family member was invited to participate in up to 6 family counseling sessions. Principal outcomes were retention in treatment, compliance with naltrexone therapy, and number of drug-free urine specimens. RESULTS: First, CM was associated with significant improvements in treatment retention (7.4 vs 5.6 weeks; P =.05) and in reduction in opioid use (19 vs 14 opioid-free urine specimens; P =.04) compared with standard naltrexone treatment. Second, assignment to SO did not significantly improve retention, compliance, or substance abuse outcomes compared with CM. Significant effects for the SO condition over CM on retention, compliance, and drug use outcomes were seen only for the subgroup who attended at least 1 family counseling session. The SO condition was associated with significant (P =.02) improvements in family functioning. CONCLUSION: Behavioral therapies, such as CM, can be targeted to address weaknesses of specific pharmacotherapies, such as noncompliance, and thus can play a substantial role in broadening the utility of available pharmacotherapies.

One-year follow-up of disulfiram and psychotherapy for cocaine-alcohol users: sustained effects of treatment.

AIM: To evaluate outcomes 1 year after cessation of treatment for cocaine- and alcohol-dependent individuals. DESIGN: Randomized controlled trial. SETTING: Urban substance abuse treatment center. PARTICIPANTS: Ninety-six of 122 subjects randomized to treatment. INTERVENTIONS: One of five treatments delivered over 12 weeks. Cognitive-behavioral treatment (CBT) plus disulfiram; Twelve-Step facilitation (TSF) plus disulfiram; clinical management (CM) plus disulfiram; CBT without disulfiram; TSF without disulfiram. MEASUREMENTS: Percentage of days of cocaine and alcohol use during follow-up, verified by urine toxicology screens and breathalyzer tests. RESULTS: First, as a group, participants reported significant decreases in frequency of cocaine, but not alcohol, use after the end of treatment. Secondly, the main effects of disulfiram on cocaine and alcohol use were sustained during follow-up. Finally, initiation of abstinence for even brief periods of time within treatment was associated with significantly better outcome during follow-up. CONCLUSIONS: These findings support the efficacy of disulfiram with this challenging population and suggest that comparatively brief treatments that facilitate the initiation of abstinence may have long-term benefits.

Disulfiram treatment for cocaine dependence in methadone-maintained opioid addicts.

AIMS: Cocaine use by patients on methadone maintenance treatment is a widespread problem and is associated with a poorer prognosis. Recent studies have evaluated disulfiram as a treatment for individuals with comorbid alcohol and cocaine abuse. We evaluated the efficacy of disulfiram for cocaine dependence, both with and without co-morbid alcohol abuse, in a group of methadone-maintained opioid addicts. DESIGN: Randomized double-blind, placebo-controlled trial. SETTING: Urban methadone maintenance clinic. PARTICIPANTS: Sixty-seven cocaine-dependent, methadone-maintained, opioid-dependent subjects (52% female; 51% Caucasian). INTERVENTION: Study medication, either disulfiram or placebo, was placed directly in the methadone to ensure compliance for 12 weeks. MEASUREMENTS: Primary outcome measures included weekly assessments of the frequency and quantity of drug and alcohol use, weekly urine toxicology screens and breathalyzer readings. FINDINGS: Disulfiram treated subjects decreased the quantity and frequency of cocaine use significantly more than those treated with placebo. Alcohol use was minimal for all subjects regardless of the medication. CONCLUSIONS: Disulfiram may be an effective pharmacotherapy for cocaine abuse among methadone-maintained opioid addicts, even in those individuals without co-morbid alcohol abuse. Disulfiram inhibits dopamine beta-hydroxylase resulting in an excess of dopamine and decreased synthesis of norepinephrine. Since cocaine is a potent catecholamine re-uptake inhibitor, disulfiram may blunt cocaine craving or alter the "high", resulting in a decreased desire to use cocaine.

A general system for evaluating therapist adherence and competence in psychotherapy research in the addictions.

The Yale Adherence and Competence Scale (YACS) is a general system for rating therapist adherence and competence in delivering behavioral treatments for substance use disorders. The system includes three scales measuring 'general' aspects of drug abuse treatment (assessment, general support, goals of treatment), as well as three scales measuring critical elements of three treatments that are frequently implemented as control or comparison treatments in clinical research in the addictions (clinical management (CM), twelve step facilitation (TSF), and cognitive behavioral therapy (CBT)). Validation of the YACS using data from a randomized clinical trial indicated that the scales have excellent reliability, factor structure, concurrent and discriminant validity. Correlations between adherence and competence scores within scales were in the moderate range, indicating independence (and thus nonredundancy) of these dimensions. Strategies for using the YACS in both psychotherapy and pharmacotherapy research in the addictions are described.