Wednesday, February 15, 2006

Drug Voucher Programs

Kevin, MD recently wrote about drug voucher programs. In these programs, drug addicts get vouchers that are exchangeable for consumer goods in return for clean urine samples. This study, from the Archives of General Psychiatry, found that Bupropion (Wellbutrin) combined with vouchers (contingency management) reduced cocaine use in opioid addicts maintained on methadone:
Six-Month Trial of Bupropion With Contingency Management for Cocaine Dependence in a Methadone-Maintained Population
James Poling, PhD; Alison Oliveto, PhD; Nancy Petry, PhD; Mehmet Sofuoglu, MD, PhD; Kishorchandra Gonsai, MD; Gerardo Gonzalez, MD; Bridget Martell, MD; Thomas R. Kosten, MD
Arch Gen Psychiatry. 2006;63:219-228.
Context No effective pharmacotherapies exist for cocaine dependence, although contingency management (CM) has demonstrated efficacy.
Objective To compare the efficacy of bupropion hydrochloride and CM for reducing cocaine use in methadone hydrochloride–maintained individuals.
Design This 25-week, placebo-controlled, double-blind trial randomly assigned participants to 1 of 4 treatment conditions: CM and placebo (CMP), CM and 300 mg/d of bupropion hydrochloride (CMB), voucher control and placebo (VCP), or voucher control and bupropion (VCB).
Setting Outpatient clinic at the Veterans Affairs Connecticut Healthcare System.
Participants A total of 106 opiate-dependent, cocaine-abusing individuals.
Interventions All study participants received methadone hydrochloride (range, 60-120 mg). Participants receiving bupropion hydrochloride were given 300 mg/d beginning at week 3. In the CM conditions, each urine sample negative for both opioids and cocaine resulted in a monetary-based voucher that increased for consecutively drug-free urine samples during weeks 1 to 13. Completion of abstinence-related activities also resulted in a voucher. During weeks 14 to 25, only completion of activities was reinforced in the CM group, regardless of sample results. The voucher control groups received vouchers for submitting urine samples, regardless of results, throughout the study.
Main Outcome Measure Thrice-weekly urine toxicologic test results for cocaine and heroin.
Results Groups did not differ in baseline characteristics or retention rates. Opiate use decreased significantly, with all treatment groups attaining equivalent amounts of opiate use at the end of the study. In the CMB group, the proportion of cocaine-positive samples significantly decreased during weeks 3 to 13 (P<.001) relative to week 3 and remained low during weeks 14 to 25. In the CMP group, cocaine use significantly increased during weeks 3 to 13 (P<.001) relative to week 3, but then cocaine use significantly decreased relative to the initial slope during weeks 14 to 25 (P<.001). In contrast, by treatment end, the VCB and VCP groups showed no significant improvement in cocaine use.
Conclusion These findings suggest that combining CM with bupropion for the treatment of cocaine addiction may significantly improve outcomes relative to bupropion alone.
Author Affiliations: Yale University School of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven (Drs Poling, Sofuoglu, Gonsai, Gonzalez, Martell, and Kosten); University of Arkansas for Medical Sciences, Little Rock (Dr Oliveto); and University of Connecticut School of Medicine, Farmington (Dr Petry).
This Month in Archives of General PsychiatryArch Gen Psychiatry. 2006;63:124.


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