An adaptive approach for identifying cocaine dependent patients who benefit from extended continuing care

Abstract

Objective: Study tested whether cocaine dependent patients using cocaine or alcohol at intake or in the first few weeks of intensive outpatient treatment would benefit more from extended continuing care than patients abstinent during this period. The effect of incentives for continuing care attendance was also examined.

Method: Participants (N = 321) were randomized to treatment as usual (TAU), TAU and telephone monitoring and counseling (TMC), or TAU and TMC plus incentives (TMC+). The primary outcomes were (a) abstinence from all drugs and heavy alcohol use and (b) cocaine urine toxicology. Follow-ups were at 3, 6, 9, 12, 18, and 24 months.

Results: Cocaine and alcohol use at intake or early in treatment predicted worse outcomes on both measures (ps ≤ .0002). Significant effects favoring TMC over TAU on the abstinence composite were obtained in participants who used cocaine (odds ratio [OR] = 1.95 [1.02, 3.73]) or alcohol (OR = 2.47 [1.28, 4.78]) at intake or early in treatment. A significant effect favoring TMC+ over TAU on cocaine urine toxicology was obtained in those using cocaine during that period (OR = 0.55 [0.31, 0.95]). Conversely, there were no treatment effects in participants abstinent at baseline and no overall treatment main effects. Incentives almost doubled the number of continuing care sessions received but did not further improve outcomes.

Conclusion: An adaptive approach for cocaine dependence in which extended continuing care is provided only to patients who are using cocaine or alcohol at intake or early in treatment improves outcomes in this group while reducing burden and costs in lower risk patients.

Figure 1

Consort Diagram

Figure 2

Moderating effect of baseline cocaine use on abstinence composite outcomes. Solid lines indicated cocaine use in 30 days prior to baseline, dashed lines indicate no cocaine use in that period. In patients with recent cocaine use, TMC produced higher rates of abstinence than TAU (p< .05), whereas the comparisons of TMC+ vs. TAU (p= .14) and TMC+ vs. TMC (p= .53) were not significant. There were no significant treatment group differences in patients cocaine abstinent in the 30 days prior to baseline.

Figure 3

Moderating effect of baseline cocaine use on cocaine urine toxicology outcomes. Solid lines indicated cocaine use in 30 days prior to baseline, dashed lines indicate no cocaine use in that period. In patients with recent cocaine use, TMC+ produced higher rates of abstinence than TAU (p< .05), whereas the comparisons of TMC vs. TAU (p= .22) and TMC+ vs. TMC (p= .48) were not significant. There were no significant treatment group differences in patients cocaine abstinent in the 30 days prior to baseline.

Figure 4

Moderating effect of baseline alcohol use on abstinence composite outcomes. Solid lines indicated alcohol use in 30 days prior to baseline, dashed lines indicate no alcohol use in that period. In patients with recent alcohol use, TMC produced higher rates of abstinence than TAU (p< .01), whereas the comparisons of TMC+ vs. TAU (p= .09) and TMC+ vs. TMC (p= .28) were not significant. There were no significant treatment group differences in patients alcohol abstinent in the 30 days prior to baseline.