Psychosocial predictors of relapse in cocaine-dependent patients in treatment.

Relapses in cocaine abusers in treatment are an important problem. The majority of patients are incapable of sustaining abstinence over any length of time. To identify the factors associated to relapses risk in the cocaine use can be an optimal choice to improve the treatment strategies. The aim of this study was to analyze relapse-risk factors in cocaine-dependent patients on treatment. Participants were 102 patients who had begun outpatient treatment at a public health center in Spain. Some functional areas and cocaine use are evaluated for a period of six months. A structural equations model was used to identify possible predictive variables. The results show that social-family environment and economic-employment situation were associated with greater risk of relapse. Likewise, the social-family environment was related to severity of addiction. It is concluded that the incorporation of family intervention strategies and vocational/employment counseling may help to reduce relapse rates in cocaine addicts receiving treatment.

[Relapse in cocaine addiction: a review]. / Recaídas en la adicción a cocaína: una revisión.

Relapse remains a common problem in disorders related to cocaine use. The aim of this paper is to review recent research data on the variables and factors related to relapse in cocaine-dependent individuals. We carried out a systematic search for studies including variables related to cocaine use in some of the most important national and international databases: PubMed, ISI Web of Knowledge, The Cochrane Library, IME and ISOC. To locate the latest research data, the search covered the period January 2000 to July 2011. Many and varied factors and variables identified with some predictive power were identified, notably psychosocial problems, negative emotional states, anxiety, self-efficacy, psychopathological comorbidity, addictive severity, and several variables related to the treatment process. Knowledge about the relapse process has increased considerably in recent years, but although the influence of certain factors on relapse in cocaine use now seems clear, specific research is still scarce and inconclusive.

Adding voucher-based incentives to community reinforcement approach improves outcomes during treatment for cocaine dependence.

This study compares the efficacy of the Community Reinforcement Approach (CRA) with and without an incentive program for cocaine-dependent patients in Spain. A total of 58 patients were randomly assigned to the CRA or CRA plus vouchers condition. In the CRA plus vouchers group, mean percentage of cocaine-negative samples was 97.07%, versus 79.76% in the no-voucher group. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the CRA condition. The present results show that treatment outcome is better if incentives are delivered contingent upon the submission of cocaine-free urine specimens.

Urine testing during treatment predicts cocaine abstinence.

The objective of this study was to analyze the influence of the variables that predict cocaine abstinence on an outpatient program for the treatment of addiction to this substance. Participants were 80 patients (85% men and 15% women) selected at random from those receiving treatment at a Spanish health service outpatient unit. For detecting the predictor variables the authors carried out a chi-square automatic interaction detection (CHAID) analysis. Logistic regression analysis and discriminant analysis were performed to estimate the probability of abstinence according to/using the predictor variables detected by CHAID analysis. Abstinence rate after six months of treatment was 37.5%. The variable that best predicted abstinence was number of urine tests carried out over the course of treatment. The rest of the variables used did not have statistically significant influence. The mathematical model used correctly classified 80% of cases. A total of 31 tests were necessary for a probability of over 0.75 of being abstinent at six months. Regular screening for abstinence by means of objective tests helps to improve abstinence rates on cocaine-addiction treatment programs.

[Treatment dropout in cocaine addicts]. / Abandono del tratamiento en adictos a la cocaína.

The high rate of dropout from treatment programs is one of the most serious problems in the field of drug dependence. Early identification of predictors of dropout risk can provide useful information on the specific treatment needs of these types of patient. The aim of this study was to identify predictors of premature cessation of an outpatient treatment program for cocaine addicts. The study was carried out at public healthcare units in a Spanish city. Participants were 91 cocaine addicts admitted for treatment for their addiction, assessed by means of interview and various self-report measures. For identifying predictive variables the researchers used a factor analysis, a cluster analysis and a CHAID analysis. The variables that obtained predictive capacity were the MAST scores and the combined alcohol and drugs scores on the EuropASI. These three variables were grouped in a single factor which was called addictive severity. The predictive analysis showed that this factor had some degree of capacity for the prediction of dropout, but that it was not completely determinant. The results suggest the advantage of detecting at the admission stage those patients who might require more attention to their motivational aspects, greater treatment control and intensity, or the provision of complementary interventions.

Addictive severity in cocaine addicts measured with the EuropASI: differences between composite scores and severity ratings.

In this study we present the addiction severity profile in a sample of 202 cocaine addicts, using the composite scores for each area of the EuropASI (European version of the ASI), which are compared with the severity ratings obtained through interviewers' subjective assessments. The results showed that the areas of the EuropASI which reflected the greatest severity according to the composite scores were, in the following order: employment/support, family/social situation, use of alcohol and psychiatric state. The results obtained with the composite scores show discrepancies with those obtained from the severity rating. Statistically significant differences were found in the areas of alcohol (Z = -6.205; p < 0.001), drugs (Z = -11.902; p < 0.001), family/social (Z = -6.915; p < 0.001) and psychiatric status (Z = -6.651; p < 0.001). The results call into question the reliability and validity of severity ratings obtained through interviewers' subjective assessments. For diagnosis and research, a more objective appraisal is recommended, using composite scores, since severity ratings depend totally on the interviewer's judgement, and do not appear to constitute a sound measure for estimating therapeutic change.

Contingency management improves outcomes in cocaine-dependent outpatients with depressive symptoms.

Despite depressive symptoms being very common among patients seeking treatment for cocaine dependence, few studies have examined the effects of depressive symptoms on cocaine outpatient treatment outcomes, and there is even less research in the context of Contingency Management (CM). The purpose of this study was to assess the main and interactive effects of co-occurring depressive symptoms on CM outcomes. Cocaine-dependent individuals (N = 108) were randomized to Community Reinforcement Approach (CRA) or CRA plus CM in two outpatient community clinical settings. Participants were categorized according to depression symptoms, self-reported by means of the BDI at treatment entry. Outcome measures included treatment retention and documented cocaine abstinence over a 6-month treatment period. Depressive symptoms were more commonly found in females and in unemployed participants, and were associated with more drug-related, social, and psychiatric problems at treatment entry. Individuals with baseline depressive symptoms had poorer treatment outcomes than patients without depressive symptoms. The addition of CM to CRA made the program more effective than with CRA alone, regardless of depressive symptoms. CM was associated with better abstinence treatment outcomes, while the interaction between unemployment and depressive symptoms was associated with negative retention treatment outcomes. This study supports the efficacy of CM for cocaine-dependent outpatients with and without depressive symptoms, and highlights its importance for improving treatment for unemployed and depressed cocaine-dependent individuals.

Contingency management is effective across cocaine-dependent outpatients with different socioeconomic status.

Contingency management (CM) has demonstrated its efficacy for treating cocaine dependence, but there is still some controversy with regard to its dissemination. Understanding how individual differences affect CM outcomes is important for detecting barriers to its dissemination. The aim of this study is to examine the impact of socioeconomic variables in cocaine-dependent outpatients on the effectiveness of CM in a community setting. Cocaine-dependent outpatients (N=118) were randomized to community reinforcement approach (CRA) treatment or a CRA plus vouchers program. The impact of baseline economic variables, alone and in combination with treatment conditions, on abstinence and retention outcomes after 6 months of treatment was assessed. Results showed that income had no effect on retention or abstinence outcomes after 6 months of treatment in either treatment condition. The addition of a CM component was beneficial for individuals with any socioeconomic status. These results support the generalizability of CM strategies with patients of different socioeconomic status in community settings.

Community Reinforcement Approach (CRA) for cocaine dependence in the Spanish public health system: 1 year outcome.

INTRODUCTION AND AIMS: The development and dissemination of effective treatments for cocaine dependence is an important public health priority in Europe, and especially in Spain, given the increase in treatment demand over recent years. The aim of this study was to determine the effectiveness of the Community Reinforcement Approach (CRA) for cocaine dependents at an outpatient clinic within the Spanish public health system. DESIGN AND METHODS: A total of 82 cocaine-dependent patients were randomly assigned to one of two treatment conditions: Standard Treatment (n = 35) or CRA (n = 47). Dependent variables were treatment retention, cocaine abstinence and composite scores from the European version of the Addiction Severity Index at 12 month follow up. RESULTS: Of the patients who received CRA, 55% completed 6 months of treatment, versus 40% who received Standard Treatment. At the 12 month follow up, patients assigned to the CRA condition achieved higher rates of abstinence (95.2%) by comparison with Standard Treatment (69.2%). In the CRA group, 27% of the patients achieved continuous cocaine abstinence, versus 21% in the Standard Treatment group. The CRA group also obtained lower scores than the Standard Treatment group in all Addiction Severity Index composite scores. DISCUSSION AND CONCLUSIONS: This study showed that CRA is a feasible treatment for cocaine addiction in a public community setting in Spain.

Community reinforcement approach plus vouchers among cocaine-dependent outpatients: twelve-month outcomes.

The aims of this study were to assess the effectiveness of the Community Reinforcement Approach (CRA) plus vouchers treatment in a cohort of Spanish cocaine-dependent outpatients, and to examine the maintenance of treatment effects after the voucher intervention was discontinued. Sixty-four adult outpatients were randomly assigned to one of two treatment conditions, CRA plus vouchers or standard care. The vouchers program was implemented from weeks 1 to 24. Among patients assigned to the CRA plus vouchers condition, 65.5% completed 12 months of treatment versus 28.6% of those assigned to the standard care condition (p = .003). At the 12-month assessment, 58.6% of patients assigned to the CRA plus vouchers condition were abstinent, compared with 25.7% in the standard care condition (p = .008); furthermore, 34.5% of patients assigned to the CRA plus vouchers condition achieved twelve months of continuous cocaine abstinence, versus 17.1% in the standard care condition. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the standard care condition. Overall, these results reveal an extension of the effectiveness of the CRA plus vouchers treatment to a community sample of cocaine-dependent outpatients, while also supporting the maintenance of treatment effects for 6 months after completion of the voucher program.

Individual characteristics and response to Contingency Management treatment for cocaine addiction.

Voucher-based contingency management (CM) research has demonstrated efficacy for treating cocaine addiction, but few studies have examined associations between individual baseline characteristics and response to CM treatments. The aim of this study, involving 50 cocaine outpatients receiving CM for cocaine addiction, was to assess the impact of baseline characteristics on abstinence outcomes after six months of treatment. Patients who were abstinent after six months of treatment accounted for 58% of the sample. Patients with higher scores on the Alcohol area of the EuropASI and patients that were non-abstinent during the first month of treatment were less likely to achieve abstinence. These outcome predictors have implications both for treatment research and for clinical practice. Patients who do not respond early to treatment may need a more intensive intervention, and concomitant problematic alcohol use should be detected and treated. The remaining baseline variables examined were not statistically significant predictors of abstinence. This finding is important for the generalizability of CM across the range of individual characteristics of treatment-seeking cocaine abusers.