Guide Better Late Than Never: The Reparative Therapeutic Relationship in Regression to Dependence

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If you would like us to have a bookstand at your meeting, please contact Dermot at dermot clarendonmedical. Follow us on Facebook. All rights reserved. Save wishlist Add to comparison chart View Comparison Chart. Two subsequent trials examining the efficacy of relapse prevention have been reported. One compared it to case management in a randomized design with cocaine-dependent patients Carroll et al. Each failed to observe significant differences between treatment groups in retention, but rates were somewhat higher in relapse prevention than in the comparison treatments in both trials. Pharmacological Interventions Two placebo-controlled, randomized trials were identified in which a pharmacotherapy for cocaine abuse significantly improved treatment retention see table 1.

The first was a 6-week trial comparing desipramine hydrochloride 2.

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All subjects also received once-weekly individual, interpersonal psychotherapy. Subjects assigned to desipramine remained in treatment for an average of Each of these positive trials is countered by negative trials in which desipramine or fluoxetine failed to improve retention. Five randomized, controlled trials have been reported in which desipramine failed to improve retention Carroll et al.

All patients participated in individual cognitive behavior therapy sessions once per week.

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The study included a 2-week stabilization period followed by a week trial. It merits mention that preliminary results from an ongoing, randomized trial suggest that desipramine and flupenthixol decanoate may increase treatment retention in cocaine abusers compared to placebo when the medications are administered in an outpatient setting in which minimal psychotherapy is provided Khalsa et al. For two Higgins et al.

In one of the two trials mentioned above comparing the multicomponent behavioral treatment and drug abuse counseling Higgins et al. Similarly, in the trial described above comparing the behavioral treatment with versus without the voucher program Higgins et al. In both trials, the differential rates of aftercare entry appeared to follow directly from the differences in retention rates observed across the treatments; that is, those treatments that engendered higher retention rates were also more likely to have patients enter aftercare.

That logic does not hold for the third trial relevant to this section, which is the day hospital program versus inpatient treatment comparison described above Alterman et al. Twenty-five 45 percent patients assigned to day hospital versus 17 31 percent patients assigned to inpatient treatment entered aftercare N.

Interestingly, significant treatment differences in the number of treatment completers who entered aftercare emerged favoring the day hospital group. Thus, while less effective in retaining patients in treatment, the day hospital treatment was more effective than inpatient treatment in fostering aftercare participation in treatment completers.


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No published reports noting positive outcomes of pharmacotherapies on aftercare entry were identified, although preliminary results from an ongoing trial suggested that desipramine may facilitate transition from inpatient care to outpatient aftercare when the blood levels of the medication are in the therapeutic range Hall et al.

Abstinence data were not reported in the trial examining accelerated intakes and thus there is no way to know how that practice relates to cocaine abstinence Festinger et al. Abstinence data were included in seven of the eight reports shown in table 1 regarding retention in treatment the exception being Hughes et al. Significantly greater cocaine abstinence was documented in the treatment groups with superior retention in five of those seven reports Batki et al.

The exception was the Alterman and colleagues' study in which inpatient treatment was more effective in retaining patients during the initial treatment period while day hospital treatment was more effective in getting completers to enter aftercare. No significant treatment group differences were discerned in abstinence levels assessed at 7-month followup.

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In the two other trials in which there were treatment group differences in the number of patients who entered aftercare, significantly more abstinence was observed in the treatment groups with greater aftercare participation Higgins et al. Strategies can be devised to improve retention between the initial clinic contact and intake interview, during the treatment episode, and between completion of treatment and entry into aftercare.


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The efficacy of accelerated intakes is encouraging in that it illustrates how a relatively minor change in clinic policy can substantially alter attrition rates Festinger et al. Reported attendance rates at the initial intake interview in the work by Festinger and colleagues in press increased 1. The comparable retention rates observed during treatment in that study suggest that accelerated procedures do not necessarily result in the admission of a larger proportion of individuals who are unmotivated for treatment relative to standard admission procedures.

Results from one controlled and two uncontrolled studies also support the efficacy of accelerated intake procedures. In a controlled trial conducted with a mixed sample of different types of drug abusers 35 percent primary cocaine abusers , consecutive callers to an urban outpatient drug abuse clinic were randomly assigned to either a condition wherein they had the option to come to the clinic immediately or were provided an intake appointment that on average was scheduled 9.

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Having the option to come immediately significantly increased attendance relative to the scheduled appointment. However, during- treatment dropout rates were higher in those provided the immediate option than the standard appointment, suggesting that there are instances where accelerated intake procedures can increase subsequent attrition rates. Before undertaking the experimental study described above, Festinger and colleagues Festinger et al.

The best predictor of whether a client would attend the intake session was whether the appointment was scheduled on the same day as the initial contact. Retention data were not reported in that study. Results were reported as retention rates during months 2 to 5 after admission.

Moving from a practice of completing intakes on 2 designated days per week to conducting them on the same day as the initial contact significantly increased the proportion of patients retained during the 4-month observation period. The accelerated and standard groups both evidenced a steady dropout rate across the observation period.

However, there were no differences between the groups on that measure, which is consistent with the findings of Festinger and colleagues in press that those entered via accelerated procedures are no less likely to remain in treatment than those admitted via standard procedures. In summary, then, the efficacy of accelerated procedures for increasing attendance at the intake interview is consistent across four studies in cocaine and other types of drug abusers, and during-treatment dropout rates were comparable across the accelerated and standard admission procedures in two of the three studies in which that information was reported.

Briefly, there is another study using a mixed sample of drug abusers 31 percent primary cocaine abusers that merits mention Stark and Kane As with the accelerated intake work, it also illustrates an effective strategy for combating the high rates of attrition associated with the intake process using an intervention involving minimal clinical effort. Applicants for outpatient treatment were randomly assigned to one of four conditions immediately following their intake interview: 1 minute general orientation regarding what to expect from psychotherapy, 2 minute specific orientation regarding what to expect from psychotherapy for drug abuse, 3 minute general drug education, or 4 a no-treatment control.

The specific orientation to psychotherapy for drug abuse significantly increased the proportion of patients who returned for a second visit by 19 to 40 percent compared to the other treatment groups. Considerable dropout was observed in all groups during the subsequent 90 days. However, all groups were comparable on that measure, suggesting that the advantage of the specific orientation procedure was not nullified by a subsequent higher dropout rate.

Because results from cocaine abusers were not described separately in this report, the efficacy of this procedure in that population remains unclear. However, considering the minimal effort involved and the large effects observed, it certainly merits further investigation in cocaine abusers. The studies by Higgins and colleagues do address that challenge, and demonstrate that providing a structured, behavioral intervention that includes incentives can improve treatment completion rates by as much as fivefold compared to drug abuse counseling, and almost twofold compared to the same behavioral treatment without incentives Higgins et al.

At this time, the efficacy of that approach for retaining cocaine abusers during treatment has more empirical support than any other strategy.


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Each of the three trials demonstrating the efficacy of this treatment for increasing retention was conducted in the same clinic, which is located in a small metropolitan area with an almost exclusively caucasian population. Thus, replications in other settings are needed, especially clinics located in large urban areas with minority populations. However, the generality of the incentive program used in that treatment to urban clinics and to minority patients has been demonstrated in two trials examining effects on cocaine abstinence Silverman et al.

Both trials were conducted in methadone maintenance clinics, which precluded assessing effects on treatment retention. However, considering that the incentives improved cocaine abstinence in both trials, there is evidence that they are efficacious in those settings and thus may increase retention as well. An obvious concern regarding the use of incentives in any setting is cost. While such extra costs pale when considered against the costs of inpatient hospitalizations for substance abuse Alterman et al.

Hence, strategies for making incentives available for use in community clinics that require no additional financial expenditure on the part of the clinic are needed. Using access to public resources such as athletic or cultural facilities or requesting local businesses to donate retail items for use as incentives have been suggested previously Higgins et al. When the potential therapeutic benefits of incentives are considered, such strategies certainly appear to merit exploration.

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The initial trial by Carroll and colleagues suggested that relapse prevention may be an effective intervention for improving retention during outpatient treatment for cocaine abuse. However, that was less clear in the two subsequent trials in which relapse prevention was associated with somewhat higher retention rates than comparison treatments, but those differences were not statistically significant Carroll et al. Nevertheless, considering the significant challenge that retaining cocaine abusers during treatment represents, and the positive trends evident across trials, relapse prevention certainly warrants further evaluation.

The finding that retention of cocaine-abusing mothers during residential treatment is improved by allowing their children to reside with them lends empirical support to a strategy that makes a great deal of practical sense Hughes et al. Of course, this was only a single study. Thus, further information will be necessary to evaluate the value of this particular strategy.

However, this study focuses attention on the more general issue of practical barriers to treatment completion.