Kimberly C. Kirby

Fluoxetine is ineffective for treatment of cocaine dependence or concurrent opiate and cocaine dependence: Two placebo-controlled, double-blind trials

Cocaine dependence has proved difficult to treat, whether occurring alone or in combination with opiate dependence. No medication has been demonstrated to be uniquely effective. Fluoxetine was examined as a candidate in two randomized, double-blind, placebo-controlled trials, one with cocaine-dependent patients (study 1) and the other with patients both cocaine and opiate dependent (study 2). It was selected for known specific action, antidepressant effects, minimum side effects, and data showing reduced cocaine effect and self-administration. Clinic visit frequency requirement, a variable with implications for treatment and cost, was also examined in study 1. A total of 228 patients in study 1 and 21 patients in study 2 completed consent and intake procedures. Patients with serious medical or DSM-III-R diagnoses other than cocaine dependence (study 1) or opiate and cocaine dependence (study 2) were excluded. Study 1 patients were assigned to one of two visit frequency schedules (2 or 5 days/week) and one of three medication doses (0, 20, or 40 mg of fluoxetine/day). Study 2 patients received placebo or 20 mg of fluoxetine and 65 to 80 mg of methadone and attended the clinic 5 days/week. All patients participated in individual therapy sessions. Urine screens were conducted twice weekly. A fluoxetine dose response relationship emerged in study 1 for retention with groups from best to worst being placebo, 20 mg, and 40 mg. Dose effect order was the same for both visit conditions. Cocaine use persisted in all groups. The two visits/week condition was correlated with better retention than the five visits/week condition. A significant interaction emerged between intake urine and visit frequency; patients with benzoylecognine screens at intake used cocaine significantly less in the 5 days/week condition, while exhibiting no reduction in the 2 days/week condition. Patients cocaine positive at intake were better retained with infrequent visits. In study 2, a transient reduction in benzoylecognine-positive drug screens emerged for the fluoxetine group. These complementary studies demonstrate that fluoxetine is ineffective in reducing cocaine use or craving. Study 1 also points to setting conditions modulating treatment outcome.

Behavioral and Emotional Problems Among Children of Cocaine‐ and Opiate‐Dependent Parents

OBJECTIVE To test associations between parental drug abuse and childrens problems, children of cocaine- and opiate-dependent parents were compared with demographically matched referred and nonreferred children. METHOD Cocaine- and opiate-dependent parents in treatment completed the Child Behavior Checklist for 410 children (218 boys, 192 girls) from ages 2 through 18 years (mean = 7.9 years). Children of drug abusers (CDAs) were demographically matched to referred (RCs) and nonreferred children (NRCs). RESULTS RCs scored lower than CDAs and NRCs on most competence scales, and higher than CDAs and NRCs on all problem scales. CDAs scored lower than NRCs on most competence scales, and higher than NRCs on Withdrawn, Thought Problems, Delinquent Behavior, Aggressive Behavior, Internalizing, Externalizing, and Total Problems. Group status also predicted clinical range scores on most competence and all problem scales. CONCLUSIONS CDAs showed more internalizing and externalizing psychopathology relative to matched NRCs, but they showed significantly less psychopathology than shown by matched RCs. CDAs are an important group to target for preventive interventions.

Schedule of voucher delivery influences initiation of cocaine abstinence

This study examined whether voucher delivery arrangements affect treatment outcome. First, 90 cocaine-dependent adults were randomly assigned to behavioral counseling or counseling plus vouchers for cocaine-free urine samples. The value of each voucher was low at the beginning but increased as the patient progressed (Voucher Schedule 1). Voucher Schedule 1 produced no improvements relative to counseling only. Next, 23 patients received vouchers on either Voucher Schedule 1 or Voucher Schedule 2. Voucher Schedule 2 began with high voucher values, but requirements for earning vouchers increased as the patient progressed. Average durations of cocaine abstinence were 6.9 weeks on Voucher Schedule 2 versus 2.0 weeks on Voucher Schedule 1 (p = .02). This confirms that vouchers can assist in initiating abstinence and that voucher delivery arrangements are critical.

From telephone to office: intake attendance as a function of appointment delay.

In the present study, 116 clients calling an outpatient cocaine treatment clinic were randomly assigned to intake appointments scheduled either the same day, 1 day, 3 days, or 7 days later. Significantly more subjects scheduled 1 day later attended their intake appointments (72%), compared to those scheduled 3 days (41%) or 7 days (38%) later. Odds ratios indicate that subjects offered intake appointments approximately 24 h following their initial contact are more than four times as likely to attend their intakes as those scheduled later. This accelerated intake procedure allows clinics to reach more patients in need of services.

Technology transfer through performance management: the effects of graphical feedback and positive reinforcement on drug treatment counselors’ behavior

After drug treatment counselors at a community-based methadone treatment clinic were trained in implementing a contingency management (CM) intervention, baseline measures of performance revealed that, on average, counselors were meeting the performance criteria specified by the treatment protocol about 42% of the time. Counselors were exposed to graphical feedback and a drawing for cash prizes in an additive within-subjects design to assess the effectiveness of these interventions in improving protocol adherence. Counselor performance measures increased to 71% during the graphical feedback condition, and to 81% during the drawing. Each counselors performance improved during the intervention conditions. Additional analyses suggested that counselors did not have skill deficits that hindered implementation. Rather, protocol implementation occurred more frequently when consequences were added, thereby increasing the overall proportion of criteria met. Generalizations, however, may be limited due to a small sample size and possible confounding of time and intervention effects. Nonetheless, present results show promise that feedback and positive reinforcement could be used to improve technology transfer of behavioral interventions into community clinic settings.

Impact of Comorbid Personality Disorders and Personality Disorder Symptoms on Outcomes of Behavioral Treatment for Cocaine Dependence

Studies have revealed a significant adverse impact of comorbid personality disorders on treatment tenure and outcome in a variety of psychiatric and substance abuse populations. We investigated whether this negative relationship also exists among 137 urban, poor, cocaine abusers in behaviorally oriented treatment. Axis II diagnoses were generated categorically using the SCID-II as well as dimensionally using numbers of SCID-II symptoms within diagnostic categories. Contrary to expectations, there were no significant differences between subjects with and without various categorical personality disorders on any outcome measures. Categorical Axis II diagnoses were also minimally correlated with drug use severity, depression, and anxiety at intake, indicating that these were not potential coveriates of outcome. However, dimensional analyses of personality symptoms generated from the SCID-II accounted for substantial proportions of variance in treatment outcomes. Implications of these data for Axis II assessment and drug treatment planning are discussed.

Effectiveness of abstinence-based incentives: interaction with intake stimulant test results.

Intake urinalysis test result (drug positive vs. negative) has been previously identified as a strong predictor of drug abuse treatment outcome, but there is little information about how this prognostic factor may interact with the type of treatment delivered. The authors used data from a multisite study of abstinence incentives for stimulant abusers enrolled in outpatient counseling treatment (N. M. Petry, J. M. Peirce, et al., 2005) to examine this question. The first study urine was used to stratify participants into stimulant negative (n = 306) versus positive (n = 108) subgroups. Abstinence incentives significantly improved retention in those testing negative but not in those testing positive. Findings suggest that stimulant abusers presenting to treatment with a stimulant-negative urine benefit from abstinence incentives, but alternative treatment approaches are needed for those who test stimulant positive at intake.

Shaping smoking cessation in hard-to-treat smokers.

OBJECTIVE Contingency management (CM) effectively treats addictions by providing abstinence incentives. However, CM fails for many who do not readily become abstinent and earn incentives. Shaping may improve outcomes in these hard-to-treat (HTT) individuals. Shaping sets intermediate criteria for incentive delivery between the present behavior and total abstinence. This should result in HTT individuals having improving, rather than poor, outcomes. We examined whether shaping improved outcomes in HTT smokers (never abstinent during a 10-visit baseline). METHOD Smokers were stratified into HTT (n = 96) and easier-to-treat (ETT [abstinent at least once during baseline]; n = 50) and randomly assigned to either CM or CM with shaping (CMS). CM provided incentives for breath carbon monoxide (CO) levels <4 ppm (approximately 1 day of abstinence). CMS shaped abstinence by providing incentives for COs lower than the 7th lowest of the participants last 9 samples or <4 ppm. Interventions lasted for 60 successive weekday visits. RESULTS Cluster analysis identified 4 groups of participants: stable successes, improving, deteriorating, and poor outcomes. In comparison with ETT, HTT participants were more likely to belong to 1 of the 2 unsuccessful clusters (odds ratio [OR] = 8.1, 95% CI [3.1, 21]). This difference was greater with CM (OR = 42, 95% CI [5.9, 307]) than with CMS, in which the difference between HTT and ETT participants was not significant. Assignment to CMS predicted membership in the improving (p = .002) as compared with the poor outcomes cluster. CONCLUSION Shaping can increase CMs effectiveness for HTT smokers.

Decline in self-reported dysphoria after treatment entry in inner-city cocaine addicts.

This study examined self-reported dysphoria in 82 consecutive admissions to intensive outpatient treatment for cocaine abuse on whom data for the Beck scales for depression, anxiety, and hopelessness were available for intake and 4 subsequent weeks with no more than 1 missing data point. Mean scores on the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) decreased significantly between intake and Week 1, with no further significant changes from Weeks 1-4. Similar drops in the rate of clinically significant BDI and BAI scores also were observed. Scores on the Beck Hopelessness Scale (BHS) showed no significant changes. By Week 4, rates of clinically significant depression, anxiety, and hopelessness were similar (17%, 13%, and 16%, respectively). These findings suggest that assessing depression and anxiety using the BDI and BAI in this population should be postponed for at least 1 week after intake and that intake levels of self-reported mood may be inappropriate baseline measures for evaluating treatment effects.

Toward an explicit analysis of generalization: A stimulus control interpretation

Producing generality of treatment effects to new settings has been a critical concern for applied behavior analysts, but a systematic and reliable means of producing generality has yet to be provided. We argue that the principles of stimulus control and reinforcement underlie the production of most generalized effects; therefore, we suggest interpreting generalization programming in terms of stimulus control. The generalization programming procedures identified by Stokes and Baer (1977) are discussed in terms of both the stimulus control tactics explicitly identified and those that may be operating but are not explicitly identified. Our interpretation clarifies the critical components of Stokes and Baer’s procedures and places greater emphasis on planning for generalization as a part of training procedures.