Theresa Babuscio

Computer-Assisted Delivery of Cognitive-Behavioral Therapy for Addiction: A Randomized Trial of CBT4CBT

OBJECTIVES This study evaluated the efficacy of a computer-based version of cognitive-behavioral therapy (CBT) for substance dependence. METHOD This was a randomized clinical trial in which 77 individuals seeking treatment for substance dependence at an outpatient community setting were randomly assigned to standard treatment or standard treatment with biweekly access to computer-based training in CBT (CBT4CBT) skills. RESULTS Treatment retention and data availability were comparable across the treatment conditions. Participants assigned to the CBT4CBT condition submitted significantly more urine specimens that were negative for any type of drugs and tended to have longer continuous periods of abstinence during treatment. The CBT4CBT program was positively evaluated by participants. In the CBT4CBT condition, outcome was more strongly associated with treatment engagement than in treatment as usual; furthermore, completion of homework assignments in CBT4CBT was significantly correlated with outcome and a significant predictor of treatment involvement. CONCLUSIONS These data suggest that CBT4CBT is an effective adjunct to standard outpatient treatment for substance dependence and may provide an important means of making CBT, an empirically validated treatment, more broadly available.

Mindfulness training for smoking cessation: Results from a randomized controlled trial

BACKGROUND Cigarette smoking is the leading cause of preventable death in the world, and long-term abstinence rates remain modest. Mindfulness training (MT) has begun to show benefits in a number of psychiatric disorders, including depression, anxiety and more recently, in addictions. However, MT has not been evaluated for smoking cessation through randomized clinical trials. METHODS 88 treatment-seeking, nicotine-dependent adults who were smoking an average of 20cigarettes/day were randomly assigned to receive MT or the American Lung Associations freedom from smoking (FFS) treatment. Both treatments were delivered twice weekly over 4 weeks (eight sessions total) in a group format. The primary outcomes were expired-air carbon monoxide-confirmed 7-day point prevalence abstinence and number of cigarettes/day at the end of the 4-week treatment and at a follow-up interview at week 17. RESULTS 88% of individuals received MT and 84% of individuals received FFS completed treatment. Compared to those randomized to the FFS intervention, individuals who received MT showed a greater rate of reduction in cigarette use during treatment and maintained these gains during follow-up (F=11.11, p=.001). They also exhibited a trend toward greater point prevalence abstinence rate at the end of treatment (36% vs. 15%, p=.063), which was significant at the 17-week follow-up (31% vs. 6%, p=.012). CONCLUSIONS This initial trial of mindfulness training may confer benefits greater than those associated with current standard treatments for smoking cessation.

Mindfulness Training and Stress Reactivity in Substance Abuse: Results from a Randomized, Controlled Stage I Pilot Study

ABSTRACT Stress is important in substance use disorders (SUDs). Mindfulness training (MT) has shown promise for stress-related maladies. No studies have compared MT to empirically validated treatments for SUDs. The goals of this study were to assess MT compared to cognitive behavioral therapy (CBT) in substance use and treatment acceptability, and specificity of MT compared to CBT in targeting stress reactivity. Thirty-six individuals with alcohol and/or cocaine use disorders were randomly assigned to receive group MT or CBT in an outpatient setting. Drug use was assessed weekly. After treatment, responses to personalized stress provocation were measured. Fourteen individuals completed treatment. There were no differences in treatment satisfaction or drug use between groups. The laboratory paradigm suggested reduced psychological and physiological indices of stress during provocation in MT compared to CBT. This pilot study provides evidence of the feasibility of MT in treating SUDs and suggests that MT may be efficacious in targeting stress.

Enduring effects of a computer-assisted training program for cognitive behavioral therapy: A 6-month follow-up of CBT4CBT ☆ ☆☆

OBJECTIVES To evaluate the durability of effects of a computer-assisted version of cognitive behavioral therapy (CBT) as treatment for substance dependence through a 6-month follow-up. METHODS Following a randomized clinical trial in which 73 individuals seeking outpatient treatment for substance dependence in an outpatient community setting were randomized to either standard treatment-as-usual (TAU) or TAU with 8 weeks of biweekly access to computer-based training for CBT (CBT4CBT), participants were interviewed 1, 3, and 6 months after the termination of study treatments. RESULTS Sixty of the 73 participants were reached for follow-up (82%); follow-up rates and availability of data were comparable across treatment conditions. Random regression analyses of use across time indicated significant differences between groups, such that those assigned to TAU increased their drug use across time while those assigned to CBT4CBT tended to improve slightly. The durability of the CBT4CBT effect remained even after controlling for treatment retention, treatment substance use outcomes, and exposure to other treatment during the follow-up period. CONCLUSIONS Computerized CBT4CBT appears to have both short-term and enduring effects on drug use.

Contingency management to enhance naltrexone treatment of opioid dependence: a randomized clinical trial of reinforcement magnitude.

Fifty-five detoxified opioid-dependent individuals were randomly assigned to 1 of 3 treatments delivered over 12 weeks: standard naltrexone maintenance, standard naltrexone plus low-value contingency management (CM), or standard naltrexone plus high-value CM. Results suggest that (a) assignment to either CM condition was associated with significant reductions in opioid use over time compared with standard naltrexone treatment; (b) contrasts of high- versus low-value reinforcement magnitude were not significant, suggesting no relative benefit of higher over lower value incentives in this population; (c) participants assigned to either CM group reported significant reductions in readiness to change compared with participants assigned to standard naltrexone treatment. These findings suggest that targeted behavioral therapies can play a substantial role in broadening the utility of available pharmacotherapies.

d-Cycloserine attenuates reactivity to smoking cues in nicotine dependent smokers: A pilot investigation

Increasing evidence indicates that smoking cues contribute to nicotine self-administration and attenuating conditioned reactivity to smoking cues may aid abstinence of smoking and prevention of smoking relapse in individuals with nicotine dependence. Based on prior studies showing that the partial N-methyl-D-aspartate (NMDA) agonist D-cycloserine (DCS) facilitates extinction of learned fear during behavioral exposure therapy in humans and facilitates extinction of cocaine-induced conditioned place preference in animals, we evaluated whether DCS would have potential for reducing reactivity to smoking cues when combined with cue exposure treatment in humans with nicotine dependence. In this double-blind placebo-controlled pilot laboratory study, 25 smokers were recruited from the general community and randomized to DCS or placebo, plus cue exposure therapy. DCS significantly attenuated smoking cue reactivity in response to in-vivo smoking cues based on physiological reactivity and subjective urge-to-smoke ratings and led to a significantly smaller expired carbon monoxide (CO) level at the one-week follow-up compared to placebo, although exploratory analyses indicated no effect on smoking behavior overall. These findings provide promising support for DCS combined with cue exposure therapy in attenuating conditioned reactivity to smoking cues.

Cognitive Function and Treatment Response in a Randomized Clinical Trial of Computer-Based Training in Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT), because of its comparatively high level of cognitive demand, is likely to be challenging for substance users with limitations in cognitive function. However, it is not known whether computer-assisted versions of CBT will be particularly helpful (e.g., allowing individualized pace and repetition) or difficult (e.g., via complexity of computerized delivery) for such patients. In this secondary analysis of data collected from a randomized clinical trial evaluating computer-assisted CBT, four aspects of cognitive functioning were evaluated among 77 participants. Those with higher levels of risk taking completed fewer sessions and homework assignments and had poorer substance use outcomes.

Combining Cognitive Behavioral Therapy with Contingency Management for Smoking Cessation in Adolescent Smokers: A Preliminary Comparison of Two Different CBT Formats

This pilot study evaluated the optimal format of cognitive behavioral therapy (CBT) to combine with contingency management (CM) in a four-week, high school-based smoking cessation program. Thirty-four adolescent smokers received a standard weekly version of CBT or a frequent brief behavioral intervention. Results indicate a trend toward a higher seven-day point prevalence end-of-treatment abstinence rate and percent days abstinent during treatment in the CBT condition. In addition, significantly more participants in the CBT group completed treatment. These preliminary results suggest that when combined with CM, the standard weekly format of CBT is more acceptable to adolescent smokers.

Toward empirical identification of a clinically meaningful indicator of treatment outcome: features of candidate indicators and evaluation of sensitivity to treatment effects and relationship to one year follow up cocaine use outcomes.

BACKGROUND Selection of an appropriate indictor of treatment response in clinical trials is complex, particularly for the various illicit drugs of abuse. Most widely used indicators have been selected based on expert group recommendation or convention rather than systematic empirical evaluation. Absence of an evidence-based, clinically meaningful index of treatment outcome hinders cross-study evaluations necessary for progress in addiction treatment science. METHOD Fifteen candidate indicators used in multiple clinical trials as well as some proposed recently are identified and discussed in terms of relative strengths and weaknesses (practicality, cost, verifiability, sensitivity to missing data). Using pooled data from five randomized controlled trials of cocaine dependence (N=434), the indicators were compared in terms of sensitivity to the effects of treatment and relationship to cocaine use and general functioning during follow-up. RESULTS Commonly used outcome measures (percent negative urine screens; percent days of abstinence) performed relatively well in that they were sensitive to the effects of the therapies evaluated. Others, including complete abstinence and reduction in frequency of use, were less sensitive to effects of specific therapies and were very weakly related to cocaine use or functioning during follow-up. Indicators more strongly related to cocaine use during follow-up were those that reflected achievement of sustained periods of abstinence, particularly at the end of treatment. CONCLUSIONS These analyses did not demonstrate overwhelming superiority of any single indicator, but did identify several that performed particularly poorly. Candidates for elimination included retention, complete abstinence, and indicators of reduced frequency of cocaine use.

Contingency Management to reduce substance use in individuals who are homeless with co-occurring psychiatric disorders.

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.