Epstein David H, Schmittner John, Umbricht Annie, Schroeder Jennifer R, Moolchan Eric T, Preston Kenzie L
Treatment Section, Clinical Pharmacology & Therapeutics Branch, Intramural Research Branch of the National Institute on Drug Abuse, 251 Bayview Blvd., Suite 200, Baltimore, MD 21224, USA.
Drug Alcohol Depend. 2009 Apr 1;101(1-2):92-100. doi: 10.1016/j.drugalcdep.2008.11.006. Epub 2008 Dec 19.
To test whether a combination of contingency management and methadone dose increase would promote abstinence from heroin and cocaine, we conducted a randomized controlled trial using a 2 x 3 (dosexcontingency) factorial design in which dose assignment was double-blind. Participants were 252 heroin- and cocaine-abusing outpatients on methadone maintenance. They were randomly assigned to methadone dose (70 or 100mg/day, double-blind) and voucher condition (noncontingent, contingent on cocaine-negative urines, or "split"). The "split" contingency was a novel contingency that reinforced abstinence from either drug while doubly reinforcing simultaneous abstinence from both: the total value of incentives was "split" between drugs to contain costs. The main outcome measures were percentages of urine specimens negative for heroin, cocaine, and both simultaneously; these were monitored during a 5-week baseline of standard treatment (to determine study eligibility), a 12-week intervention, and a 10-week maintenance phase (to examine intervention effects in return-to-baseline conditions). DSM-IV criteria for ongoing drug dependence were assessed at study exit. Urine-screen results showed that the methadone dose increase reduced heroin use but not cocaine use. The split 100mg group was the only group to achieve a longer duration of simultaneous negatives than its same-dose noncontingent control group. The frequency of DSM-IV opiate and cocaine dependence diagnoses decreased in the active intervention groups. For a split contingency to promote simultaneous abstinence from cocaine and heroin, a relatively high dose of methadone appears necessary but not sufficient; an increase in overall incentive amount may also be required.
为了测试应急管理与美沙酮剂量增加相结合是否会促进海洛因和可卡因戒断，我们采用2×3（剂量×应急）析因设计进行了一项随机对照试验，其中剂量分配采用双盲法。研究对象为252名接受美沙酮维持治疗的海洛因和可卡因滥用门诊患者。他们被随机分配到美沙酮剂量组（70或100毫克/天，双盲）和代金券条件组（非应急、可卡因尿液阴性时应急或“拆分”）。“拆分”应急是一种新颖的应急方式，它强化对任何一种药物的戒断，同时加倍强化对两种药物的同时戒断：激励措施的总价值在两种药物之间“拆分”以控制成本。主要结局指标是海洛因、可卡因以及两者同时呈阴性的尿液样本百分比；在标准治疗的5周基线期（以确定研究资格）、12周干预期和10周维持期（以检查在恢复到基线条件下的干预效果）对这些指标进行监测。在研究结束时评估持续性药物依赖的DSM-IV标准。尿液筛查结果显示，美沙酮剂量增加减少了海洛因使用，但未减少可卡因使用。100毫克“拆分”组是唯一比同剂量非应急对照组实现更长同时阴性持续时间的组。在积极干预组中，DSM-IV阿片类和可卡因依赖诊断的频率降低。对于“拆分”应急措施要促进可卡因和海洛因的同时戒断，相对高剂量的美沙酮似乎是必要的，但并不充分；可能还需要增加总体激励金额。
