A multi-site, double-blind, placebo-controlled pilot clinical trial to evaluate the efficacy of buspirone as a relapse-prevention treatment for cocaine dependence

Objective—To evaluate the potential efficacy of buspirone as a relapse-prevention treatment for cocaine dependence. Method—A randomized, double-blind, placebo-controlled, 16-week pilot trial conducted at six clinical sites between August 2012 and June 2013. Adult crack cocaine users meeting DSM-IVTR criteria for current cocaine dependence scheduled to be in inpatient/residential substance use disorder (SUD) treatment for 12–19 days when randomized, and planning to enroll in local outpatient treatment through the end of the active treatment phase were randomized to buspirone titrated to 60 mg/day (n=35) or to placebo (n=27). All participants received psychosocial treatment as usually provided by the SUD treatment programs in which they were enrolled. Outcome measures included maximum days of continuous cocaine abstinence (primary), proportion of cocaine use days, and days-to-first-cocaine-use during the outpatient treatment phase (study weeks 4–15) as assessed by self-report and urine drug screens. Results—There were no significant treatment effects on maximum continuous days of cocaine abstinence or days to first cocaine use. In the females (n=23), there was a significant treatment-bytime interaction effect (X2 (1)=6.06, p=.01), reflecting an increase in cocaine use by the buspirone, relative to placebo, participants early in the outpatient treatment phase. A similar effect was not detected in the male participants (n=39; X2 (1)=0.14, p=.70). Conclusions—The results suggest that buspirone is unlikely to have a beneficial effect on preventing relapse to cocaine use and that buspirone for cocaine-dependent women may worsen their cocaine-use outcomes. Trial Registration—Clinical Trials.gov http://www.clinicaltrials.gov; Identifier: NCT0164115

Motivational enhancement therapy to improve treatment utilization and outcome in pregnant substance users

Pregnant substance users can benefit significantly from substance abuse treatment but treatment retention can be challenging. Two hundred pregnant substance users entering outpatient substance abuse treatment at 1 of 4 treatment programs were randomized to receive either 3 individual sessions of Motivational Enhancement Therapy for pregnant substance users (MET-PS) or the first 3 individual sessions normally provided by the program. All participants were encouraged to participate in all other treatment offered by the program. Outcome measures included treatment utilization according to clinic records, qualitative urine toxicology measures, and self-report of substance use. One hundred and sixty two participants (i.e., 81%) completed the 1 month active phase. Participants attended 62% of scheduled treatment on average and reported decreased substance use during the first month of treatment, with no differences between MET-PS and treatment as usual participants. There was some evidence that the efficacy of MET-PS varied between sites and that MET-PS might be more beneficial than TAU in decreasing substance use in minority participants. These results suggest that MET-PS is not more effective than treatment as usual for pregnant substance users in general but that there might be particular subgroups or treatment programs for which MET-PS might be more or less effective than treatment as usual

Impulsivity as a vulnerability factor for poor addiction treatment outcomes: A review of neurocognitive findings among individuals with substance use disorders

The support of the Special Research Fund of Ghent University (Belgium) is gratefully acknowledged.With the current review, we explore the hypothesis that individual differences in neurocognitive aspects of impulsivity (i.e., cognitive and motor disinhibition, delay discounting and impulsive decision-making) among individuals with a substance use disorder are linked to unfavorable addiction treatment outcomes, including high drop-out rates and difficulties in achieving and maintaining abstinence. A systematic review of the literature was carried out using PubMed, PsycINFO and Web of Knowledge searches. Twenty-five unique empirical papers were identified and findings were considered in relation to the different impulsivity dimensions. Although conceptual/methodological heterogeneity and lack of replication are key limitations of studies in this area, findings speak for a prominent role of cognitive disinhibition, delay discounting and impulsive decision-making in the ability to successfully achieve and maintain abstinence during and following addiction treatment. In contrast, indices of motor disinhibition appear to be unrelated to abstinence levels. Whereas the relationship between impulsivity and treatment retention needs to be examined more extensively, preliminary evidence suggests that impulsive/risky decision-making is unrelated to premature treatment drop-out among individuals with a substance use disorder. The reviewed findings are discussed in terms of their clinical implications.Special Research Fund of Ghent University (Belgium

Incentives for smoking cessation

Background Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes. Objectives To determine the long‐term effect of incentives and contingency management programmes for smoking cessation. Search methods For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018. Selection criteria We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed‐population setting (e.g. community, work‐, clinic‐ or institution‐based), and also studies in pregnant smokers. Data collection and analysis We used standard Cochrane methods. The primary outcome measure in the mixed‐population studies was abstinence from smoking at longest follow‐up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow‐up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel‐Haenzel random‐effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster‐randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations. Main results Thirty‐three mixed‐population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty‐four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow‐up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I2 = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long‐term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I2 = 36%), suggesting the impact of incentives continues for at least some time after incentives cease. Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self‐deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self‐deposits. We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow‐up (up to 24 weeks post‐partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I2 = 41%), in favour of incentives. Authors' conclusions Overall there is high‐certainty evidence that incentives improve smoking cessation rates at long‐term follow‐up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow‐up occurs after the withdrawal of incentives. There is also moderate‐certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post‐partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self‐incentives (deposits), within a variety of smoking populations